Coroner highlights ‘systemic’ lack of education amongst healthcare professionals on deadly condition

The Coroner to an inquest into the death of a man who died after he was sent away from A&E by medical staff has issued 2 Prevention of Future Deaths (‘PFD’) reports as well as a narrative conclusion with criticisms of a series of omissions and failures by North East London NHS Foundation Trust and Barts Health NHS Trust, a leading aortic specialist centre.

Paul Sartori was just 38 years old when he died from a type A aortic dissection in October 2019. The aorta, the main artery carrying oxygenated blood out of the heart to the body, is composed of three layers and an aortic dissection occurs when a tear develops in one of the three layers and this layer dissects away from the others, allowing blood to enter. The blood then separates the inner and outer layers leading to a rupture with fatal consequences.

Around 3,800 patients in the UK suffer from aortic dissection each year, of which 49% do not survive to get to hospital for treatment. Medical literature estimates that about a third of patients are treated for the wrong diagnosis. In the UK, around 500 patients a year die from acute type A aortic dissections due to delayed or failed diagnoses.

Crucially, the mortality of aortic dissection increases by about 1-2% per hour from the time of the initial tear, which presents as pain spreading through the chest and into the back.

Nadia Persaud, area coroner for East London, made her reports following the inquest into Paul’s death which concluded on 22 April 2021. Ms Persaud concluded that the response that Paul received from A&E was ‘incomplete’, as the A&E triage nurse had failed to record a full set of medical observations and had failed to take a full medical history prior to diverting Mr Sartori away from A&E. She also concluded that a full medical examination should have been undertaken which included bilateral blood pressures and a CT scan.

Rosie McKechnie, Paul’s fiancée said:

“Paul’s death has left us all completely devastated. My life and the lives of our children, his parents and sister have been shattered. Knowing that he could still be alive if basic triage standards had been followed is incredibly difficult to process.”

The PFD reports also identified a lack of awareness around aortic dissection as a matter of concern. Despite A&E departments having available tools to make a correct diagnosis, insufficient education on the condition was highlighted as a ‘very common problem’.

Paul Sartori, from Walthamstow, was a father to 2 young children and he and Rosie were planning their wedding ceremony. His family describe him as a wonderfully caring and compassionate individual. He worked as Head of Analytics at a web analytics company where was using his ‘acute social conscience’ to direct the company’s adoption of ethical principles.

Paul first complained of feeling unwell on 23 October 2019, describing a pain shooting down his arms. In the early hours of the 24th, Paul woke up with severe chest, jaw, arm and back pain with numbness in his hand and burping. ‘Scared for his life’, Paul thought he was having a heart attack and phoned an ambulance. The paramedics took 2 sets of standard physical observations, including pain scores, and a mobile electrocardiogram (ECG), but questioned whether it was likely Paul was having a panic attack. Paul was taken to hospital via ambulance.

Unable to walk properly, Paul was taken into Whipps Cross Hospital A&E (managed by Barts Health NHS Trust) in a wheelchair. There, basic physical observations were repeated, however there was no pain score taken, the nurse didn’t do another ECG and, despite Paul’s complaints of feeling sweaty, didn’t take his temperature. There was no record of any further triage assessment or patient or family history. These observations were written on a loose piece of paper and handed to the paramedics and Paul was directed and triaged away from A&E to the Urgent Care Centre (managed by North East London NHS Foundation Trust). He was seen by a streaming nurse who took the verbal handover and the documents from the paramedics, but his physical observations were not repeated, which was not normal practice. He was seen by a GP contracted urgent care doctor working in the UCC who briefly listened to his chest and lungs after Paul described his severe and spreading chest pain and shortness of breath. Again, there was no pain score documented and no recent personal or family history taken. The GP did not consider Paul’s pain was cardiac in nature and concluded an impression of costochondritis, an inflammation of the cartilage and muscles of the chest wall, with advice to seek medical advice if the pain did not improve.

Despite the hospital being quiet, Paul was told he was ‘wasting hospital time’. He told Rosie he was made to feel ‘humiliated and guilty’ by the hospital treatment and didn’t believe he was being taken seriously. Paul was discharged from A&E after only 30 minutes without having any blood tests, further physical observations or CT scan.

Over the following days, Paul continued to experience chest, jaw, arm, and back pain. On 26 October, he told Rosie that his symptoms had worsened but that he was hesitant about phoning 999 for fear of being criticised of wasting hospital time again.

By the 27 October, Paul’s condition had deteriorated severely again. The pain in his chest and back had intensified, he was short of breath, and was feeling nauseous. He spoke to a 111 operator who said they would send an ambulance. Soon after, and while on the phone to Rosie, Paul screamed out in pain, collapsed and became unresponsive. Rosie called 999 to report what had happened and to rush the ambulance. After 20 minutes she called 999 again to get an update. They confirmed an ambulance had now been dispatched and it arrived after 45 minutes, by which time Paul had sadly died.

The Coroner instructed an independent expert, Mr Stephen Large, Consultant Cardiothoracic Surgeon, to assist the Court with the medical evidence in the case. The Inquest heard that costochondritis and a panic attack were diagnoses of exclusion and such diagnoses could not be reached without a full history of present and past condition and family history being taken. Mr Large stated that someone presenting to A&E with serious chest pain needs differential diagnoses considered, including aortic dissection, and after a full history is taken, lethal causes of the pain should be excluded with a CT scan. Mr Large stated that an ECG should have been repeated and a troponin test done, a blood test that helps diagnose a heart attack. If these were still normal, the doctors should then consider other lethal, non-cardiac causes of pain, such as pulmonary embolisms or aortic dissections, as set out in the NICE guidelines.

Mr Large stated that had a CT scan been carried out on 24 October 2019, it is likely to have revealed an aortic aneurysm with probable aortic dissection. Had the CT scan been done then, it is likely that Paul’s death could have been avoided.

The Coroner gave a narrative conclusion and stated that no specific investigations were undertaken to rule out potentially lethal causes of the acute chest pain when Paul presented to A&E on 24 October 2019, and had bilateral blood pressures and a CT scan been carried out, it is likely that Paul’s death could have been avoided.

Rosie McKechnie added: “When you seek help from medical professionals, you put your trust in their ability to do all within their professional capacity to keep you safe. You trust that they will have the clinical competence that befits their role, you trust that they will have undergone sufficient training, you trust that they will understand guidelines and safe practice protocols, and you trust that they will listen to you and show you care and compassion. Paul was feeling so severely unwell he was scared for his life and he put his trust in Whipps Cross staff to help him. He was failed by those whose job it was to do that. He was met by minimal intervention and inattentive care at each stage of his rushed journey through the emergency and urgent care pathway.

“Aortic dissection is a lethal condition, but one that can be identified using simple, brief and readily available diagnostic tools. Taking a blood pressure reading from each arm could have indicated the condition and saved his life. Paul had two young children, one of whom was just a baby when he died and will never know his father. We hope that critical lessons will now be learnt from Paul’s death and no family will ever have to go through the same pain we are suffering.”

Emma-Jayne Rudland, Solicitor at Hodge Jones & Allen, who represented Paul’s family during the inquest, said: “Paul’s tragic death has sadly highlighted that although there appear to be educational resources available regarding the recognition and diagnosis of aortic dissections, the training and knowledge isn’t embedded enough in the healthcare setting. This is a serious fatal condition, but with prompt diagnosis and rapid transfer to specialist centres, patients have a much higher chance of survival. We need greater awareness of the condition amongst healthcare professionals if we’re to prevent further deaths. The Coroner’s reports on these issues are fundamental and welcomed by the Family as a route to changing this.”

The inquest into Paul’s death came shortly after the death of another young man who attended Whipps Cross A&E with chest and abdominal pain and was sent home after an aortic dissection was misdiagnosed.

The Coroner’s 2 Prevention of Future Deaths reports were as follows:

• One PFD report, sent to Barts Health NHS Trust and North East London Foundation Trust, highlighted the need for streaming guidance to be updated following Paul’s death and proper record keeping when triaging patients. It also urged the following and embedding of guidance from “THINK AORTA”, a campaign launched in 2018 by the patient-led Aortic Dissection Awareness association, the Royal College of Emergency Medicine and others, designed to save lives and educate healthcare professionals.
• The second PFD report, issued to the Royal College of Emergency Medicine, outlined the coroner’s concerns with regards to the systemic issues about awareness of aortic dissections in emergency departments and questioned whether the current guidance and risk scoring tools require review and revision to address the issue of widespread misdiagnosis of thoracic aortic dissections.

The Family were also represented by counsel Rob Harland of 5 Essex Court.

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