Missed aortic dissection diagnosis due to atypical presentation
Royal College of Emergency Medicine received 3 coroners' reports about this hazard between 3 Apr 2020 and 21 Sept 2023.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
Original on judiciary.uk ↗ Royal College of Emergency Medicine responded.Response (PDF) ↗Response (PDF) ↗
- 1 year 1 month laterClosely relatedConfidence 0.90 · higha different coroner
“During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection.”
Original on judiciary.uk ↗ Repeated from the earlier report:diagnosisaorticdissection
Royal College of Emergency Medicine responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The guidance was reviewed on 18" May 2021 by Clinical and Operational leads in NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on gh June 2021.”
Stated timescale: 30 June 2021
“The Royal College of Emergency Medicine is in the process of finalising a Guideline, based on the limited evidence that is available on the selection of patients for CT scanning. This will be circulated to our 10,000+ members and published on our website for public viewing. It is planned that this will be endorsed by the Royal College of Radiologists, to raise awareness amongst Radiologists.”
- 2 years 5 months later
Raised again · 2nd time
Chantelle Reed↗
21 Sept 2023 · Samantha Goward · Cambridgeshire and Peterborough
Closely relatedConfidence 0.86 · higha different coroner“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.”
Original on judiciary.uk ↗ Repeated from the earlier report:chestaorticdissection
Royal College of Emergency Medicine responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Royal College of Emergency Medicine
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2020 → 2021Paul Sartori1 year 1 month after Andrew Wing · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight missed diagnosis of aortic dissection due to insufficient information or awareness among clinicians.
Andrew Wing · 3 Apr 2020
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
Original on judiciary.uk ↗ Paul Sartori · 29 Apr 2021
“During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection.”
Original on judiciary.uk ↗ 2020 → 2023Chantelle Reed3 years 6 months after Andrew Wing · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight failures in recognizing aortic dissection that lead to delayed or omitted appropriate imaging.
Andrew Wing · 3 Apr 2020
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
Original on judiciary.uk ↗ Chantelle Reed · 21 Sept 2023
“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.”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
Stated action · timescale: 30 June 2021
“The guidance was reviewed on 18" May 2021 by Clinical and Operational leads in NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on gh June 2021.”
Stated action
“The Royal College of Emergency Medicine is in the process of finalising a Guideline, based on the limited evidence that is available on the selection of patients for CT scanning. This will be circulated to our 10,000+ members and published on our website for public viewing. It is planned that this will be endorsed by the Royal College of Radiologists, to raise awareness amongst Radiologists.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Royal College of Emergency Medicine at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2020 → 2021 | 0.74 | 0.21 | Closely related · 0.90 | different |
| 2020 → 2023 | 0.70 | 0.18 | Closely related · 0.86 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.