Finding into death of Iman Kassis

46y · Female·hemopericardium secondary to dissection of the thoracic aorta

Iman Kassis, a 46-year-old woman with Ehlers-Danlos Syndrome Type 4 and known severe aortic regurgitation with dilated ascending aorta, presented to the ED on 8 October 2008 with sudden-onset severe throat pain, bradycardia, and right arm weakness. She was discharged after 4 hours observation with a diagnosis of gastro-oesophageal reflux disease. She died at home hours later from hemopericardium secondary to thoracic aortic dissection. The coroner found her death preventable: aortic dissection should have been explicitly considered and documented as a differential diagnosis before settling on a benign explanation. Best practice requires clinicians to convincingly exclude aortic dissection in patients with chest pain, particularly those with predisposing connective tissue disorders. Poor documentation of her observation period and vital signs after 2pm hampered assessment of clinical decision-making. With timely diagnosis and treatment, Ms Kassis had a reasonable chance of survival.