Finding into death of Mrs K
Deceased
Mrs K
Demographics
81y, female
Date of death
2020-03-07
Finding date
2023-02-28
Cause of death
Cardiac tamponade secondary to dissection of ascending aorta
AI-generated summary
An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrome via troponin and ECG, she was discharged with undiagnosed chest pain after a 'chest pain pathway' without further investigation (no chest X-ray or imaging). She re-presented 4 days later with persistent symptoms, was admitted under cardiology with suspected NSTEMI, and died from cardiac tamponade due to aortic dissection rupture while awaiting CTPA. The coroner found that aortic dissection was likely considered but discounted based on absence of 'classic' features (ripping pain, pulse deficits, widened mediastinum). Critical lessons: absent classic features cannot exclude aortic dissection (anterior chest pain is common in Type A); patients discharged from chest pain pathways with persistent undiagnosed symptoms require further investigation; high-quality history-taking is essential; and bedside ultrasound during PEA arrest might have identified reversible causes such as cardiac tamponade.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Hypertension
- Hypercholesterolaemia
- Missed diagnosis of aortic dissection on initial presentation
- Discharge without further investigation despite persistent chest pain
- Discounting of aortic dissection diagnosis based on absence of classic features
- Inadequate consideration of differential diagnoses after ruling out acute coronary syndrome
Coroner's recommendations
- Monash Health should review their approach to patients with significant but undiagnosed chest pain after passing through the chest pain pathway
- Review and improve education of ED and other doctors regarding aortic dissection presentation and diagnosis, particularly the inability of absence of classic features to exclude the diagnosis
- Consider senior ED clinician review of patients who have experienced severe, acute onset chest pain and are being discharged from a short stay unit or chest pain pathway without a clear alternative cause
- Consider implementation of enhanced CTPA protocol ('Dual rule out') to assess both pulmonary embolism and aortic dissection in patients with complex presentations
- Consider routine use of bedside ultrasound early in PEA arrests to identify potentially reversible causes (cardiac tamponade, massive pulmonary embolism, tension pneumothorax, bleeding)
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