Finding into death of Salvatore Accardo

47y · Male·pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm due to Marfan's syndrome

Salvatore Accardo, a 47-year-old with previously diagnosed Marfan syndrome, died from pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm. He presented to Austin Hospital ED on 22 February 2008 with chest pain, diaphoresis, and weakness, but was misdiagnosed with gastroenteritis. Critical clinical information documenting his cardiac risk factors was documented by paramedics and nursing staff but not incorporated into Dr R.'s clinical decision-making. While the coroner found no departure from accepted standards warranting adverse findings, she identified the flow of clinical information in the ED as problematic and noted the diagnosis was preventable had aortic dissection been considered. Key lessons: ensure clinically relevant documented information reaches the decision-making clinician; in patients with known predisposing conditions presenting with atypical symptoms, actively seek and integrate information from all available sources; maintain clinical vigilance for rare but catastrophic conditions in appropriate risk groups.