Chantelle Reed
PFD Report
All Responded
Ref: 2023-0349Deceased
All 2 responses received
· Deadline: 16 Nov 2023
Coroner's Concerns (AI summary)
Emergency medicine guidelines lack emphasis on specific chest pain symptoms indicating acute aortic dissection, and national radiologist shortages cause critical delays in reviewing urgent scans.
View full coroner's concerns
1. The evidence of the independent expert in Emergency Medicine, was that “the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection. Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain. The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further”. The expert felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms.
2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists. The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died. In an emergency situation such as this one, this delay represents on ongoing risk of future deaths.
2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists. The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died. In an emergency situation such as this one, this delay represents on ongoing risk of future deaths.
Responses
Disputed
The Royal College of Radiologists disputes that chest pain radiating to the neck or jaw should mandate investigation for Thoracic Aortic Dissection. However, they commit to working with the Royal College of Emergency Medicine to promote evidence-based best practice in diagnosis. (AI summary)
The Royal College of Radiologists disputes that chest pain radiating to the neck or jaw should mandate investigation for Thoracic Aortic Dissection. However, they commit to working with the Royal College of Emergency Medicine to promote evidence-based best practice in diagnosis. (AI summary)
View full response
Samantha Goward Assistant Coroner for Cambridgeshire and Peterborough
Regulation 28 Report to Prevent Future Deaths: C Reed 21.09.2023
Further to your prevention of Future Deaths Notice following the conclusion of your inquest (06.09.2023) into the death of Chantelle Reed who died on 29th October 2020, we would like to extend our sympathy and condolences to the family and friends of Ms Reed.
You have asked us to address two specific areas of concern, the first of which was the nature of the chest pain which was described as radiating to the neck and jaw and whether this should have raised the possibility of Thoracic Aortic Dissection (TAD). Unfortunately chest pain which radiates to the neck or jaw is not specific for TAD and this description is much more likely to be in keeping with other pathology such as acute coronary syndrome (heart attacks and angina); in fact acute coronary syndrome is 100-200 times more common than TAD [1]. The most discriminating description of the chest pain that is experience in TAD that is evidence based is described as sudden onset with its worst severity being at its onset [2,3]. As noted in your report, TAD in a woman of Ms Reed’s age is highly unusual and we would consider this a rare occurrence in the absence of any other risk factors.
We neither feel that there is sufficient evidence to support the suggestion that chest pain radiating to the neck or jaw should mandate the investigation for TAD (Computed Tomography of the Aorta) nor that there is sufficient evidence to suggest that the balance of risk and benefit is in favour of performing Computed Tomography of the Aorta (CTA) in all such cases. The risks associated with performing CTA for all patients presenting chest pain radiating to the neck or jaw will include a high rate of negative scans and consequent unnecessary exposure to the risks of ionising radiation (eg. cancer) as well as a significant radiological workload that is likely to negatively impact on patients who do have significant injury or illness. Unfortunately there is currently no combination of presenting features or blood tests or radiographic changes on a chest X-ray that are able to exclude the diagnosis of TAD with certainty, this can only be done by CTA.
The second area of concern that you asked us to address related to the timescale for a radiologist to review a chest x-ray and provide a report on relevant findings. The Royal College of Radiologists (RCR), together with the Society and College of Radiographers, contributed to and support guidance published in August 2023 by NHS England on diagnostic imaging turnaround times [4]. Turnaround time (TAT) is the interval between an imaging examination and a verified report being made available to the referring clinician, and keeping TATs as short as possible is essential for timely diagnosis and treatment of patients. The guidance recognises the current workforce crisis in diagnostic imaging: achieving or exceeding the recommended TATs is based on there being full staffing in place to deliver them. For context, the RCR’s most recent workforce census [5] highlighted a current 29% shortfall of clinical radiologists, which inevitably has an impact on the quality of care that consultants are able to provide. The recommended maximum TAT for urgent inpatient referrals is 12 hours, or less than 4 hours post-acquisition of images for Emergency Department or acutely unwell inpatients.
Departments are encouraged to explore alternative solutions, including outsourcing agreements with third-party teleradiology providers and cross-network collaboration to address efficiency gaps.
The rapid diagnosing of TAD continues to be of great concern to both organisations and we have worked with aortic dissection charities to highlight to frontline clinical staff the available guidance and the need to consider the diagnosis of TAD in patients who present to the emergency department with chest pain. The clinical features of TAD are diverse, making diagnosis difficult and currently there is no validated clinical decision rule to aid clinicians. Both our organisations are committed to continuing to work together to promote evidence based best practice in the diagnosis of TAD.
Yours,
The Royal College of Radiologists Royal College of Emergency Medicine Medical Director Professional Practice, Chair, Quality Emergency Care Clinical Radiology Committee
References
1. Diagnosis of Thoracic Aortic Dissection in the Emergency Department. Royal College of Radiologists & Royal College of Emergency Medicine, 2021. https://res.cloudinary.com/studio- republic/images/v1638376591/Diagnosis_of_Thoracic_Aortic_dissection/Diagnosis_of_Thoracic_Aortic_dissection.pdf?_i=AA. Accessed
18.10.2023.
2. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Isselbacher EM et al. Circulation. 2022; 146 (24): e334–e482.
3. European Society Cardiology Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal 2014, 35; 2873-2926
4. Diagnostic imaging reporting turnaround times. NHS England, 2023. https://www.england.nhs.uk/long-read/diagnostic-imaging- reporting-turnaround-times/. Accessed 19.10.2023.
5. RCR Clinical Radiology Workforce Census 2022. The Royal College of Radiologists, 2023. https://www.rcr.ac.uk/clinical-radiology/rcr- clinical-radiology-workforce-census-2022. Accessed 19.10.2023.
Please direct any further queries regarding this joint RCR/RCEM response via in the first instance.
Regulation 28 Report to Prevent Future Deaths: C Reed 21.09.2023
Further to your prevention of Future Deaths Notice following the conclusion of your inquest (06.09.2023) into the death of Chantelle Reed who died on 29th October 2020, we would like to extend our sympathy and condolences to the family and friends of Ms Reed.
You have asked us to address two specific areas of concern, the first of which was the nature of the chest pain which was described as radiating to the neck and jaw and whether this should have raised the possibility of Thoracic Aortic Dissection (TAD). Unfortunately chest pain which radiates to the neck or jaw is not specific for TAD and this description is much more likely to be in keeping with other pathology such as acute coronary syndrome (heart attacks and angina); in fact acute coronary syndrome is 100-200 times more common than TAD [1]. The most discriminating description of the chest pain that is experience in TAD that is evidence based is described as sudden onset with its worst severity being at its onset [2,3]. As noted in your report, TAD in a woman of Ms Reed’s age is highly unusual and we would consider this a rare occurrence in the absence of any other risk factors.
We neither feel that there is sufficient evidence to support the suggestion that chest pain radiating to the neck or jaw should mandate the investigation for TAD (Computed Tomography of the Aorta) nor that there is sufficient evidence to suggest that the balance of risk and benefit is in favour of performing Computed Tomography of the Aorta (CTA) in all such cases. The risks associated with performing CTA for all patients presenting chest pain radiating to the neck or jaw will include a high rate of negative scans and consequent unnecessary exposure to the risks of ionising radiation (eg. cancer) as well as a significant radiological workload that is likely to negatively impact on patients who do have significant injury or illness. Unfortunately there is currently no combination of presenting features or blood tests or radiographic changes on a chest X-ray that are able to exclude the diagnosis of TAD with certainty, this can only be done by CTA.
The second area of concern that you asked us to address related to the timescale for a radiologist to review a chest x-ray and provide a report on relevant findings. The Royal College of Radiologists (RCR), together with the Society and College of Radiographers, contributed to and support guidance published in August 2023 by NHS England on diagnostic imaging turnaround times [4]. Turnaround time (TAT) is the interval between an imaging examination and a verified report being made available to the referring clinician, and keeping TATs as short as possible is essential for timely diagnosis and treatment of patients. The guidance recognises the current workforce crisis in diagnostic imaging: achieving or exceeding the recommended TATs is based on there being full staffing in place to deliver them. For context, the RCR’s most recent workforce census [5] highlighted a current 29% shortfall of clinical radiologists, which inevitably has an impact on the quality of care that consultants are able to provide. The recommended maximum TAT for urgent inpatient referrals is 12 hours, or less than 4 hours post-acquisition of images for Emergency Department or acutely unwell inpatients.
Departments are encouraged to explore alternative solutions, including outsourcing agreements with third-party teleradiology providers and cross-network collaboration to address efficiency gaps.
The rapid diagnosing of TAD continues to be of great concern to both organisations and we have worked with aortic dissection charities to highlight to frontline clinical staff the available guidance and the need to consider the diagnosis of TAD in patients who present to the emergency department with chest pain. The clinical features of TAD are diverse, making diagnosis difficult and currently there is no validated clinical decision rule to aid clinicians. Both our organisations are committed to continuing to work together to promote evidence based best practice in the diagnosis of TAD.
Yours,
The Royal College of Radiologists Royal College of Emergency Medicine Medical Director Professional Practice, Chair, Quality Emergency Care Clinical Radiology Committee
References
1. Diagnosis of Thoracic Aortic Dissection in the Emergency Department. Royal College of Radiologists & Royal College of Emergency Medicine, 2021. https://res.cloudinary.com/studio- republic/images/v1638376591/Diagnosis_of_Thoracic_Aortic_dissection/Diagnosis_of_Thoracic_Aortic_dissection.pdf?_i=AA. Accessed
18.10.2023.
2. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Isselbacher EM et al. Circulation. 2022; 146 (24): e334–e482.
3. European Society Cardiology Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal 2014, 35; 2873-2926
4. Diagnostic imaging reporting turnaround times. NHS England, 2023. https://www.england.nhs.uk/long-read/diagnostic-imaging- reporting-turnaround-times/. Accessed 19.10.2023.
5. RCR Clinical Radiology Workforce Census 2022. The Royal College of Radiologists, 2023. https://www.rcr.ac.uk/clinical-radiology/rcr- clinical-radiology-workforce-census-2022. Accessed 19.10.2023.
Please direct any further queries regarding this joint RCR/RCEM response via in the first instance.
Noted
NHS England notes the concerns and highlights national work to raise awareness of aortic dissection and improve image reporting turnaround times. They also mention the NHS Long Term Workforce Plan and the Regulation 28 Working Group. (AI summary)
NHS England notes the concerns and highlights national work to raise awareness of aortic dissection and improve image reporting turnaround times. They also mention the NHS Long Term Workforce Plan and the Regulation 28 Working Group. (AI summary)
View full response
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Chantelle Reed who died on 29 October 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 September 2023 concerning the death of Chantelle on 29 October 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Chantelle’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Chantelle’s care have been listened to and reflected upon.
In your Report, you raise the concern that there was a lack of awareness of aortic dissection amongst Urgent & Emergency Care (UEC) and acute medicine health professionals.
In recent years, significant work has been undertaken to raise awareness within acute care settings of the indicators of acute aortic dissection, following recommendations made by the Healthcare Safety Investigations Branch (HSIB) in January 2020 on the culmination of an investigation into delayed recognition of acute aortic dissection and an acknowledgement that there have been challenges in frontline staff diagnosis and treatment of acute aortic dissection. This included the Manchester Triage International Reference Group updating the Manchester Triage System (MTS) in 2020 to include ‘aortic pain’ as a discriminator for chest pain and to raise awareness of acute aortic dissection as a potential cause. The MTS is a clinical risk management tool commonly used in Emergency Departments to enable clinicians to safely manage patient flow, by assigning a clinical priority to patients based on presenting signs and symptoms to ensure life threatening injuries and illnesses are identified.
In November 2021, the Royal College of Radiologists and the Royal College of Emergency Medicine (RCEM) published their guidance on the diagnosis of thoracic aortic dissection within emergency departments on their respective websites: Diagnosis_of_Thoracic_Aortic_dissection.pdf (rcem.ac.uk). I realise that this guidance was published after Chantelle’s death, but I hope this provides some assurance that that actions are being taken to address the issues raised in your Report. Awareness raising has also been undertaken via the Think Aorta campaign, a global campaign focused on misdiagnosis and delay in acute Aortic Dissection which provides accredited learning resources for first responders, emergency medicine and radiology teams. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16 November 2023
NHS England’s Getting It Right First Time (GIRFT) Programme also includes the possibility of aortic dissection in its chest pain pathway for acute settings: Chest-Pain- Pathway-FINAL-V2-July-2023.pdf (gettingitrightfirsttime.co.uk). GIRFT is a national programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking and wide-ranging data analysis and is part of an aligned set of programmes within NHS England input into by senior clinicians.
NHS England has been sighted on the response to you from the RCEM and the Royal College of Radiologists. NHS England notes their position that they do not believe there is sufficient evidence to support the suggestion that chest pain radiating to the neck or jaw should mandate the investigation for Thoracic Aortic Dissection or that Computed Tomography of the Aorta should be performed in all such cases.
NHS England’s national Patient Safety Team are linked into the RCEM’s Patient Safety Committee and so will be aware of any future work in this area. We will of course support wherever necessary.
Your Report also raises the concern that there is a national shortage of Radiologists and that this can lead to delays in reviewing x-rays, which, in this case, may have led to the timely diagnosis of acute aortic dissection in Chantelle.
NHS England published the Image report turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from acquisition to image reports, with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E) during routine hours of working. The guidance incudes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools. In June 2023, NHS England also published the NHS Long Term Workforce Plan, in response to the current lack of sufficient workforce. The plan sets out how we will train, retain and reform healthcare staff across the NHS over the next fifteen years, and is underpinned by the biggest recruitment drive in NHS history.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Chantelle Reed who died on 29 October 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21 September 2023 concerning the death of Chantelle on 29 October 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Chantelle’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Chantelle’s care have been listened to and reflected upon.
In your Report, you raise the concern that there was a lack of awareness of aortic dissection amongst Urgent & Emergency Care (UEC) and acute medicine health professionals.
In recent years, significant work has been undertaken to raise awareness within acute care settings of the indicators of acute aortic dissection, following recommendations made by the Healthcare Safety Investigations Branch (HSIB) in January 2020 on the culmination of an investigation into delayed recognition of acute aortic dissection and an acknowledgement that there have been challenges in frontline staff diagnosis and treatment of acute aortic dissection. This included the Manchester Triage International Reference Group updating the Manchester Triage System (MTS) in 2020 to include ‘aortic pain’ as a discriminator for chest pain and to raise awareness of acute aortic dissection as a potential cause. The MTS is a clinical risk management tool commonly used in Emergency Departments to enable clinicians to safely manage patient flow, by assigning a clinical priority to patients based on presenting signs and symptoms to ensure life threatening injuries and illnesses are identified.
In November 2021, the Royal College of Radiologists and the Royal College of Emergency Medicine (RCEM) published their guidance on the diagnosis of thoracic aortic dissection within emergency departments on their respective websites: Diagnosis_of_Thoracic_Aortic_dissection.pdf (rcem.ac.uk). I realise that this guidance was published after Chantelle’s death, but I hope this provides some assurance that that actions are being taken to address the issues raised in your Report. Awareness raising has also been undertaken via the Think Aorta campaign, a global campaign focused on misdiagnosis and delay in acute Aortic Dissection which provides accredited learning resources for first responders, emergency medicine and radiology teams. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16 November 2023
NHS England’s Getting It Right First Time (GIRFT) Programme also includes the possibility of aortic dissection in its chest pain pathway for acute settings: Chest-Pain- Pathway-FINAL-V2-July-2023.pdf (gettingitrightfirsttime.co.uk). GIRFT is a national programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking and wide-ranging data analysis and is part of an aligned set of programmes within NHS England input into by senior clinicians.
NHS England has been sighted on the response to you from the RCEM and the Royal College of Radiologists. NHS England notes their position that they do not believe there is sufficient evidence to support the suggestion that chest pain radiating to the neck or jaw should mandate the investigation for Thoracic Aortic Dissection or that Computed Tomography of the Aorta should be performed in all such cases.
NHS England’s national Patient Safety Team are linked into the RCEM’s Patient Safety Committee and so will be aware of any future work in this area. We will of course support wherever necessary.
Your Report also raises the concern that there is a national shortage of Radiologists and that this can lead to delays in reviewing x-rays, which, in this case, may have led to the timely diagnosis of acute aortic dissection in Chantelle.
NHS England published the Image report turnaround time guidance in August 2023, available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times from acquisition to image reports, with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E) during routine hours of working. The guidance incudes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools. In June 2023, NHS England also published the NHS Long Term Workforce Plan, in response to the current lack of sufficient workforce. The plan sets out how we will train, retain and reform healthcare staff across the NHS over the next fifteen years, and is underpinned by the biggest recruitment drive in NHS history.
I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Sent To
- NHS England
- Royal College of Emergency Medicine
- Royal College of Radiologists
Response Status
Linked responses
2 of 3
56-Day Deadline
16 Nov 2023
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14 January 2021 an investigation into the death of Chantelle Reed was commenced. Chantelle died on 29 October 2020. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion of the inquest was: Medical Cause of Death: 1a. Haemopericardium 1b. Type A aortic dissection Conclusion – Natural causes, namely an undiagnosed acute aortic dissection, a rare condition, even more so in light of Chantelle’s age and lack of relevant medical history.
Circumstances of the Death
1. Chantelle Reed was a 33 year old lady who had no history of any significant medial conditions.
2. On 27 October 2020 Chantelle began to experience back and neck pain and feeling of breathlessness. She described the pain as worse than contractions. The pain was sufficient that she felt unable to drive and she was driven to the Emergency Department at Peterborough City Hospital.
3. On arrival Chantelle described having throat spasms/back pain. When she was seen by a doctor she advised that her symptoms had resolved and indicated a desire to leave as she did not wish to waste the department’s time. At that time she did not advise of any chest pain or breathlessness. Chantelle also advised she had experienced similar back spasms before following an epidural.
4. The doctor did however complete a physical assessment and arrange for blood tests to be performed. Based on the findings at that time, a working diagnosis of musculoskeletal pain was made and Chantelle was discharged with a prescription for diazepam.
5. Chantelle did not have any medical history that would cause concern for this condition. Given her age and presentation, I heard expert evidence that “acute thoracic aortic dissection in these circumstances in a young woman to be highly unusual making it so rare that it would not be considered a differential diagnosis without strong clinical evidence”.
6. While the expert gave evidence that on 27 October, the abrupt onset of central chest pain radiating to back and throat was consistent with a dissection, he stated that Chantelle had a normal ECG, completely normal physical observation, no abnormality on examination and normal blood tests. He therefore stated this would reassure a responsible emergency physician and it was therefore reasonable, without the benefit of hindsight, to discharge her at that time.
7. Overnight on 28 October Chantelle became breathless and developed chest pain and in the early hours of 29 October, after a 111 call, an ambulance was called and Chantelle was taken again to hospital arriving at around 0450 hours. She was complaining of sudden onset chest pain, which was worse on inspiration, vomiting and fever.
8. There was a delay in Chantelle seeing a doctor after she was triaged, but the length of the delay was not one outside the realm of the usual wait nationwide, particularly in the context of the covid pandemic.
9. Various tests were carried out following assessment and she was managed for suspected pulmonary embolism (PE). A chest x-ray was performed and reviewed by the ED clinician and no concerns were noted. A CT pulmonary
5. Angiogram (CTPA) and echocardiogram were requested, but this was later overruled by a Medical Consultant. We heard evidence from that Consultant who felt that Chantelle did not have a PE and likely had an infection and provided antibiotics and indicated she was fit for discharge. Chantelle was moved to the ambulatory majors area of ED when she was noted to be unconscious by another patient who alerted staff. She was rushed to the resuscitation room, but sadly did not survive.
10. I heard expert evidence that when Chantelle represented to the ED on 29 October, based upon what was known at that time, and Chantelle’s presentation, the suspicion of a PE was reasonable, as was starting treatment for this with anticoagulants in accordance with national guidance, while awaiting the scan results. However, his evidence was that it was not appropriate to decide not to carry out the further investigations requested by the ED Registrar. The expert’s evidence was that Chantelle’s presentation did not fit fully fit with infection, although this should have remained as a differential diagnosis. She should therefore have been admitted and given the antibiotics as an inpatient, where she could be monitored due to the ongoing tachycardia and the raised troponin t, so that the nature of any infection could be established to ensure she was on the correct antibiotics, and also the investigations to confirm or rule out a PE could be undertaken.
11. I am mindful that the investigations ordered were not to consider aortic dissection, and the expert was not critical of this, but that the CTPA if undertaken could have shown the dissection as an incidental finding and this was also agreed by an expert Cardio Thoracic Surgeon.
12. Further, the chest x-ray undertaken on 29 October was subsequently reported as abnormal. The ED expert was not critical of the fact that the ED clinicians did not correctly interpret this and advised that the subtle signs may have been missed by them, especially as it is only with the benefit of hindsight that signs of a dissection would be specifically considered. They were however spotted by the reporting Radiologist, but sadly they did not review and report until after Chantelle’s death and the evidence was that this is nationally not an unusual timescale for such a report. Had the chest x-ray been reported by a Radiologist sooner, the diagnosis would have been made sooner.
2. On 27 October 2020 Chantelle began to experience back and neck pain and feeling of breathlessness. She described the pain as worse than contractions. The pain was sufficient that she felt unable to drive and she was driven to the Emergency Department at Peterborough City Hospital.
3. On arrival Chantelle described having throat spasms/back pain. When she was seen by a doctor she advised that her symptoms had resolved and indicated a desire to leave as she did not wish to waste the department’s time. At that time she did not advise of any chest pain or breathlessness. Chantelle also advised she had experienced similar back spasms before following an epidural.
4. The doctor did however complete a physical assessment and arrange for blood tests to be performed. Based on the findings at that time, a working diagnosis of musculoskeletal pain was made and Chantelle was discharged with a prescription for diazepam.
5. Chantelle did not have any medical history that would cause concern for this condition. Given her age and presentation, I heard expert evidence that “acute thoracic aortic dissection in these circumstances in a young woman to be highly unusual making it so rare that it would not be considered a differential diagnosis without strong clinical evidence”.
6. While the expert gave evidence that on 27 October, the abrupt onset of central chest pain radiating to back and throat was consistent with a dissection, he stated that Chantelle had a normal ECG, completely normal physical observation, no abnormality on examination and normal blood tests. He therefore stated this would reassure a responsible emergency physician and it was therefore reasonable, without the benefit of hindsight, to discharge her at that time.
7. Overnight on 28 October Chantelle became breathless and developed chest pain and in the early hours of 29 October, after a 111 call, an ambulance was called and Chantelle was taken again to hospital arriving at around 0450 hours. She was complaining of sudden onset chest pain, which was worse on inspiration, vomiting and fever.
8. There was a delay in Chantelle seeing a doctor after she was triaged, but the length of the delay was not one outside the realm of the usual wait nationwide, particularly in the context of the covid pandemic.
9. Various tests were carried out following assessment and she was managed for suspected pulmonary embolism (PE). A chest x-ray was performed and reviewed by the ED clinician and no concerns were noted. A CT pulmonary
5. Angiogram (CTPA) and echocardiogram were requested, but this was later overruled by a Medical Consultant. We heard evidence from that Consultant who felt that Chantelle did not have a PE and likely had an infection and provided antibiotics and indicated she was fit for discharge. Chantelle was moved to the ambulatory majors area of ED when she was noted to be unconscious by another patient who alerted staff. She was rushed to the resuscitation room, but sadly did not survive.
10. I heard expert evidence that when Chantelle represented to the ED on 29 October, based upon what was known at that time, and Chantelle’s presentation, the suspicion of a PE was reasonable, as was starting treatment for this with anticoagulants in accordance with national guidance, while awaiting the scan results. However, his evidence was that it was not appropriate to decide not to carry out the further investigations requested by the ED Registrar. The expert’s evidence was that Chantelle’s presentation did not fit fully fit with infection, although this should have remained as a differential diagnosis. She should therefore have been admitted and given the antibiotics as an inpatient, where she could be monitored due to the ongoing tachycardia and the raised troponin t, so that the nature of any infection could be established to ensure she was on the correct antibiotics, and also the investigations to confirm or rule out a PE could be undertaken.
11. I am mindful that the investigations ordered were not to consider aortic dissection, and the expert was not critical of this, but that the CTPA if undertaken could have shown the dissection as an incidental finding and this was also agreed by an expert Cardio Thoracic Surgeon.
12. Further, the chest x-ray undertaken on 29 October was subsequently reported as abnormal. The ED expert was not critical of the fact that the ED clinicians did not correctly interpret this and advised that the subtle signs may have been missed by them, especially as it is only with the benefit of hindsight that signs of a dissection would be specifically considered. They were however spotted by the reporting Radiologist, but sadly they did not review and report until after Chantelle’s death and the evidence was that this is nationally not an unusual timescale for such a report. Had the chest x-ray been reported by a Radiologist sooner, the diagnosis would have been made sooner.
Copies Sent To
2. North West Anglia NHS Foundation Trust (Peterborough City Hospital) the following
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