Finding into death of Sununtha Suttha

Contributing factors

• Failure to consider aortic dissection in differential diagnosis despite multiple red flags
• Lack of medical knowledge of treating registrar regarding aortic dissection presentation
• Inadequate supervision of junior staff by senior emergency physician
• Reduced senior staffing on weekend when patient presented
• Brief discussion between junior and senior doctor reinforcing benign diagnosis
• ECG not clearly reviewed by senior doctor
• Cognitive bias towards diagnosis of syncope and musculoskeletal back pain
• History of SLE not weighted appropriately as risk factor for aortic dissection

Coroner's recommendations

1. Ms Suttha's case be discussed at Northern Hospital ED morbidity and mortality meeting highlighting clinical red flags of aortic dissection, cognitive biases and system issues involved, and strategies to combat these
2. Northern Hospital utilise a structured cognitive de-biasing strategy such as NSW Clinical Excellence Commission's 'Take 2, Think Do' for all discussions between junior and senior staff and for transitions in care including handovers and transfers to Short Stay Unit
3. Northern Health management ensure adequate senior staffing to allow adequate supervision of junior staff, with staffing levels reflecting workload