Finding into death of Sununtha Suttha
Deceased
SUNUNTHA SUTTHA
Demographics
57y, female
Date of death
2017-02-24
Finding date
2018-10-11
Cause of death
Haemopericardium complicating ascending thoracic aortic dissection
AI-generated summary
A 57-year-old woman presenting to the ED with sudden-onset sharp mid-back pain, syncope, shortness of breath, and lower limb neurological symptoms was diagnosed with musculoskeletal back pain and discharged after normal troponin serial testing. She died five days later from haemopericardium due to ascending thoracic aortic dissection. Multiple red flags for aortic dissection were documented but not recognised. The coroner found the diagnosis was missed due to lack of medical knowledge in the treating registrar and inadequate senior supervision. Key lessons: aortic dissection must remain in differential diagnosis for acute back pain even with normal troponins; structured supervision and cognitive de-biasing strategies are essential; adequate senior staffing is critical, particularly after-hours.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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
- 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
- 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
- Northern Health management ensure adequate senior staffing to allow adequate supervision of junior staff, with staffing levels reflecting workload
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