Case settled following fatal missed diagnosis of acute aortic dissection

We have settled a tragic case involving the sudden and unexpected death of our client’s husband from undiagnosed acute aortic dissection (AAD) whilst in hospital. Aortic dissection is a medical emergency. If misdiagnosed or missed, it can have devastating consequences. Our client’s husband was a well-respected police constable and left behind a widow and two young boys. 

What is an aortic dissection?

The aorta is the largest blood vessel in the body. It carries oxygenated blood from the heart through the chest and abdomen. An aortic dissection occurs where the innermost layer of the aorta tears, allowing blood to leak between the layers of the artery. Aortic dissection is a rare but serious condition and can be fatal, as this case sadly shows. Symptoms can include:

• sudden, severe chest pain that feels like ripping or tearing;
• pain spreading to the back, neck, shoulder, arms, jaw or abdomen;
• shortness of breath;
• faintness or dizziness.

A definitive diagnosis usually requires a CT scan.

Our client’s story

On the weekend of 15 December 2018, our client’s husband attended his brother’s stag do in Birmingham, which involved axe throwing, dinner out and then a concert. She received a call from him at around 22:00 to tell her that he had returned to his hotel room because of a migraine. This was the last time our client spoke to her husband.

Following the concert, his brother returned to the same hotel room, and went to sleep. He was woken up in the early hours of 16 December 2018 by our client’s husband, who was pacing around the hotel room complaining of a very painful headache, chest pain, diarrhoea and vomiting. An ambulance was called at 00:51.

The paramedics arrived and it was noted that he was unwell and had complained of rectal bleeding as well as severe chest, abdominal and head pain. He reported that the chest pain was the most severe and was in the upper centre of his chest.

The paramedics took observations and gave him morphine for the pain. There was a discrepancy between the first and second blood pressure readings (taken on the right arm) and the third blood pressure reading (taken on the left). It was our client’s case that this was an indicator of acute aortic dissection (AAD). Discrepant blood pressures between the upper limbs associated with chest pain of sudden onset are characteristic signs of AAD.

The paramedics felt that the cause of his pain was cardiac in nature and he was taken to Birmingham City Hospital emergency department. He was accompanied by his sister who had also attended the stag do.

The ambulance arrived at the hospital at 02:12 and a handover took place. Two ECGs were performed in the emergency department. The first at 02:48 showed non-specific T-wave abnormalities and was classified as a borderline ECG. A second ECG was performed at 03:26 and noted again a non-specific T-wave abnormality, but also abnormal rhythm. It was our client’s case that no consideration was given to the second abnormal ECG.

Our client’s husband was triaged and the first set of observations appear to have been taken at 02:17. Respiratory rate was noted as 16-20, oxygen saturation as >96, and temperature 36°C. The blood pressure was unclear but appears to have been stated as 125/55. Heart rate was recorded as 85. The NEWS score was 0. The pain score was 5/10, as he had been given morphine in the ambulance. The triage nurse considered that he appeared to show signs of food poisoning and did not question him about his central chest pain, despite this being the presenting complaint. It was our client’s case that she failed to recognise that her husband was suffering with AAD symptoms and allocated him the incorrect clinical priority. 

A second set of observations appeared to have been taken at 03:30, however the time was unclear. Respiratory rate was noted to be 22, oxygen saturation as 95 on air, and temperature was recorded at 36°C. Blood pressure was 141/60 and heart rate was 75. His pain score had increased to 6/10.

A third set of observations were recorded on the chart but were untimed and not properly documented. The respiratory rate was documented at between 16 and 20. Oxygen saturation was at >96. Temperature was 36°C. The blood pressure reading was unclear but appeared to show a blood pressure of around 130/55. Heart rate was documented at 90. The pain score had increased to 9/10 despite receiving morphine.

At around 04:00, our client received a telephone call from her brother-in-law telling her what had happened and to come to the hospital immediately. At 04:30 he was noted to be in respiratory arrest with no cardiac output. CPR was commenced immediately. He was moved to resuscitation at 04:32. He was intubated and CPR continued. 

Our client arrived at the hospital at around 06:30 and was given the chance to see her husband and to say goodbye. The life support machine and ventilator were switched off at 06:45. His death was verified at 07:00.

A post-mortem took place and found a rupture of the proximal aorta with blood around the heart. The rupture was type A – a tear in the wall of the first part of the ascending aorta.

The cause of death was as follows:
Ia: intrapericardial haemorrhage;
Ib: ruptured dissecting aortic aneurysm;
II: hypertension.

How we investigated 

We investigated our client’s case on behalf of her husband’s estate, and on her own behalf and that of her children as dependants. We obtained supportive evidence from experts in A&E nursing, emergency medicine and cardiothoracic surgery. It was our client’s case that there was a negligent failure to recognise the characteristic symptoms her husband was showing of acute aortic dissection – that of sudden onset pain in the neck, back, chest or abdomen. There should be a high index of suspicion for AAD as it is a life-threatening condition and requires urgent investigation and treatment. He should have been reviewed by a registrar, with an urgent CT scan performed. The scan would have confirmed the diagnosis of AAD, he would have been given medication to reduce blood pressure, and he would have been taken to a tertiary centre to undergo emergency surgery to repair his aorta. Had this taken place, our cardiothoracic surgery expert confirmed that he would have survived.

We presented our findings to the trust, which denied liability. We therefore started court proceedings against the trust. As part of this process, we took witness statements from family members present at the time who witnessed his symptoms and his deterioration whilst in hospital. We also took statements from colleagues and his line manager, who confirmed that he had been on the pathway to promotion to sergeant. 

No admissions of liability were made by the trust; however, we managed to reach a settlement a month before trial. We secured damages for our client to reflect the pain and suffering of her husband whilst in hospital, to compensate her and her sons for their loss, and to secure their future.

His former line manager commented, “He served as a dedicated Response Police Officer. His loss has been felt deeply. He was a lovely, gentle soul. I am still in disbelief as I did not ever think we would lose him.” 

Rosie Nelson, senior associate at Penningtons Manches Cooper, commented: “Despite the various campaigns to spread awareness of AAD and its symptoms, of which all emergency medicine practitioners ought to be aware, it is sad to see that it is still being missed – with devastating consequences. This was a truly tragic case, and it was incredibly brave of our client to pursue it, whilst supporting her young family through their bereavement.”

For more information on AAD, see the THINK AORTA campaign website, which aims to raise awareness and improve diagnosis of aortic dissection worldwide.

Return to case studies