Zoe Knight
PFD Report
All Responded
Ref: 2020-0168
All 1 response received
· Deadline: 5 Jan 2021
Coroner's Concerns (AI summary)
Acute aortic dissection is difficult to diagnose due to symptom overlap. A critical recommendation to add "aortic pain" to the Manchester Triage System to improve awareness and earlier diagnosis has not been implemented.
View full coroner's concerns
1. I heard from Dr , a Consultant Cardiologist at Tameside general Hospital that aortic dissection is a well-recognised, but rare condition. It has some characteristic symptoms, but these are by no means definitively diagnostic.
2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event.
3. Dr was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066: “It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.”
4. It does not appear that this recommendation has been implemented.
5. Dr ’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage.
2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event.
3. Dr was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066: “It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.”
4. It does not appear that this recommendation has been implemented.
5. Dr ’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage.
Responses
Noted
NICE acknowledges the concerns and notes that existing guidance (CG95) flags points where healthcare professionals should consider aortic dissection. They note that topic experts decided against including more detailed guidance, but that they will engage with professional bodies to improve use of their guidelines. (AI summary)
NICE acknowledges the concerns and notes that existing guidance (CG95) flags points where healthcare professionals should consider aortic dissection. They note that topic experts decided against including more detailed guidance, but that they will engage with professional bodies to improve use of their guidelines. (AI summary)
View full response
Dear Mr Farrow,
I write in response to your Regulation 28 Report, dated 4 September 2020, regarding the tragic death of Zoe Amanda Knight.
We have considered the circumstances surrounding Ms Knight’s death and the matters of concern raised in your report, including concerns about awareness of aortic dissection and implementation of recommendations on this topic.
NICE guidance relevant to aortic dissection
NICE has published a guideline on recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95). Several recommendations in this guideline flag various points at which healthcare professionals should consider the possibility that a person presenting with recent onset chest pain of suspected cardiac origin may have aortic dissection:
• Recommendation 1.2.1.13 advises that, if an acute coronary syndrome (ACS) is not suspected, other causes of chest pain be considered, some of which may be life-threatening.
• Recommendation 1.2.2.8 says that if clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely to consider other acute conditions, specifically citing aortic dissection as an example.
• Recommendation 1.2.4.2 states that a physical examination should be carried out to determine factors including signs of non-coronary causes of acute chest pain, such as aortic dissection.
• Recommendation 1.2.6.2 advises that, when a raised troponin level is observed in people with suspected ACS, that other causes for raised
troponins be considered, specifically citing aortic dissection as an example.
• Recommendation 1.2.6.7 states that early chest CT only be considered to rule out other diagnoses, again specifically citing aortic dissection as an example.
Reviewing this guideline
This guideline underwent a surveillance review in 2019, to determine whether any new evidence indicated that it needed to be updated. Ultimately, no additional evidence was identified with potential impact on these existing recommendations.
During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.
Topic experts were consulted on this issue, including experts in emergency medicine. While intelligence was considered relating to the inclusion of further guidance on the diagnosis of aortic dissection , the majority view was that this would not be appropriate. The decision was therefore made that the guideline would not be updated in this regard. During the surveillance review process, it was noted that there are several existing non-NICE guidelines and educational resources for acute aortic syndrome.
Encouraging best practice
In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.
To help support the implementation of our guideline CG95, a range of externally- produced resources can be accessed from the tools and resources section of our website.
I do hope this response indicates that we have investigated this issue thoroughly, and will work with partners to encourage a change in practice.
I write in response to your Regulation 28 Report, dated 4 September 2020, regarding the tragic death of Zoe Amanda Knight.
We have considered the circumstances surrounding Ms Knight’s death and the matters of concern raised in your report, including concerns about awareness of aortic dissection and implementation of recommendations on this topic.
NICE guidance relevant to aortic dissection
NICE has published a guideline on recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95). Several recommendations in this guideline flag various points at which healthcare professionals should consider the possibility that a person presenting with recent onset chest pain of suspected cardiac origin may have aortic dissection:
• Recommendation 1.2.1.13 advises that, if an acute coronary syndrome (ACS) is not suspected, other causes of chest pain be considered, some of which may be life-threatening.
• Recommendation 1.2.2.8 says that if clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely to consider other acute conditions, specifically citing aortic dissection as an example.
• Recommendation 1.2.4.2 states that a physical examination should be carried out to determine factors including signs of non-coronary causes of acute chest pain, such as aortic dissection.
• Recommendation 1.2.6.2 advises that, when a raised troponin level is observed in people with suspected ACS, that other causes for raised
troponins be considered, specifically citing aortic dissection as an example.
• Recommendation 1.2.6.7 states that early chest CT only be considered to rule out other diagnoses, again specifically citing aortic dissection as an example.
Reviewing this guideline
This guideline underwent a surveillance review in 2019, to determine whether any new evidence indicated that it needed to be updated. Ultimately, no additional evidence was identified with potential impact on these existing recommendations.
During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.
Topic experts were consulted on this issue, including experts in emergency medicine. While intelligence was considered relating to the inclusion of further guidance on the diagnosis of aortic dissection , the majority view was that this would not be appropriate. The decision was therefore made that the guideline would not be updated in this regard. During the surveillance review process, it was noted that there are several existing non-NICE guidelines and educational resources for acute aortic syndrome.
Encouraging best practice
In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.
To help support the implementation of our guideline CG95, a range of externally- produced resources can be accessed from the tools and resources section of our website.
I do hope this response indicates that we have investigated this issue thoroughly, and will work with partners to encourage a change in practice.
Sent To
- National Institute for Health and Care Excellence
Response Status
Linked responses
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56-Day Deadline
5 Jan 2021
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 30th July 2019, an inquest was opened into the death of Zoe Amanda Knight, who died at Tameside General Hospital on 15th July 2019 at the age of 43 years. The investigation concluded with an inquest which I heard on 28th August 2020. The conclusion was Narrative: Died as a result of a rare, naturally occurring Aortic Dissection which ruptured before the condition could be diagnosed.
Circumstances of the Death
Mrs Knight woke in the early hours of the morning with chest pain. She had no medical history of any cardiac disorder. She experienced paraesthesia of her right leg and episodes of vomiting and diarrhoea.
Having been taken by ambulance to hospital, she was under investigation for ischaemic heart disease and pulmonary embolism, but suffered a brief seizure. Having been referred to the radiology department for a CT head scan and a chest X-ray, Mrs Knight’s condition quickly deteriorated and extensive efforts to resuscitate her were unsuccessful.
Whilst the doctor assessing Mrs Knight in the Emergency Department was aware of aortic dissection, his focus was on ischaemic heart disease and pulmonary embolism and the origin of the seizure.
She was in hospital for about 7 hours.
A post mortem examination concluded that Ms Chapman died as a consequence of: 1a) Dissecting aneurysm of thoracic aorta; and
2) Renal transplant (2006)
Having been taken by ambulance to hospital, she was under investigation for ischaemic heart disease and pulmonary embolism, but suffered a brief seizure. Having been referred to the radiology department for a CT head scan and a chest X-ray, Mrs Knight’s condition quickly deteriorated and extensive efforts to resuscitate her were unsuccessful.
Whilst the doctor assessing Mrs Knight in the Emergency Department was aware of aortic dissection, his focus was on ischaemic heart disease and pulmonary embolism and the origin of the seizure.
She was in hospital for about 7 hours.
A post mortem examination concluded that Ms Chapman died as a consequence of: 1a) Dissecting aneurysm of thoracic aorta; and
2) Renal transplant (2006)
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.