Chloe Lumb
PFD Report
Historic (No Identified Response)
Ref: 2022-0050
Coroner's Concerns (AI summary)
The Emergency Department lacked a clinical pathway for suspected aortic dissection and a system to flag patients with genetic predispositions, leading to missed critical diagnostic steps.
View full coroner's concerns
The MATTERS OF CONCERNS ate as follows:
There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition. When the Emergency Department were contacted by Ms Lumb on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP The trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called 'Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection'. Additionally they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag Copies of both documents are attached
There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition. When the Emergency Department were contacted by Ms Lumb on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP The trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called 'Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection'. Additionally they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag Copies of both documents are attached
Sent To
- Department of Health and Social Care
Response Status
Linked responses
0 of 1
56-Day Deadline
13 Apr 2022
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On Fourteenth January 2021 I commenced an investigation into the death of Chloe May LUMB aged 24. The investigation concluded at the end of the inquest on 111n February 2022 and established that Mrs Lumb died at in Redcar on a1n January 2021. She was known to have a genetic risk of aortic dissection that was being monitored. She presented to James Cook University Hospital Middlesbrough (South Tees NHS Foundation Trust) on 4111 January 2021 when a diagnosis of aortic dissection should have been made because of her clinical symptoms and imagining that was carried out. When she contacted the hospital on 5111 January 2021 because of ongoing symptoms (having been discharged earlier that day) she should have been asked to return. A diagnosis ofaortic dissection and appropriate treatment would have prevented her death. The cause of death was I a Acute Hemopericardium due to I b Ruptured Ascending Aortic Dissection due to I c Cystic Medial Necrosis My conclusion was that Mrs Lumb died as a result of an undiagnosed and therefore untreated aortic dissection
Circumstances of the Death
Chloe May Lumb died a , Redcar on 8th January 2021. She was known to have a genetic risk ofaortic dissection. She presented 'at hospital on 4th January 2021 when a diagnosis ofaortic dissection should have been made and she should have been asked to return to the hospital on the 5th January 2021. A diagnosis of aortic dissection and appropriate surgical treatment would have prevented death. j
Action Should Be Taken
In my opinion action should be taken to prevent Mure deaths and I believe you (and/or your organisation) have the power to take such action. All Trusts within England should be made aware of the circumstances of this case and particularly the necessity to have in place a similar guidance or pathway document and standard operating policy to be achieved via the nhs patient safety framework
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.