Andrew Wing
3 Apr 2020 · Coroner Caroline Topping · Surrey
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. failure to order CT Aorta for suspected aortic dissection
“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. Plain X rays are not diagnostic of aortic dissections. The consultant radiographer who reviewed the X ray remotely on the 14th January 2019 reported it as normal but had not been made aware of the differential diagnosis of aortic dissection. If he had been made aware of this”
2. inadequate clinical information for radiographers
“It is common practice for reviews of X rays to be undertaken by radiographers. The clinical information provided to them is sparse. More detailed and specific information would assist them in undertaking their reviews.”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“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.”
Later report
“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.”
Closely relatedConfidence 0.86 · high
This report
“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.”
Later report
“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.”
Responses
2020-0089-Response-from-the-General-Medical-Council_Redacted.pdf ↗· General Medical Council
2020-0089-Response-from-the-Society-of-Radiographers_Redacted.pdf ↗· College and Society of Radiographers