Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0168, written 4 Sep 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Sep 2020 |
|---|---|
| Reference | 2020-0168 |
| Deceased | Zoe Knight |
| Coroner | Adrian Farrow |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Director, National Institute for Health and Care Excellence 1 CORONER I am Adrian Farrow, Assistant Coroner for South Manchester 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 3 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. 4 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: 1 1a) Dissecting aneurysm of thoracic aorta; and 2) Renal transplant (2006) 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 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 (Healthcare Safety was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection 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.” this recommendation has been that 4. It does not appear 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE 2 You are under a duty to respond to this report within 56 days of the date of this report, namely by 30th October 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Mr deceased, on behalf of the family. , husband of the I have also sent a copy of my report to the Clinical Director, Tameside and Glossop NHS Foundation Trust, as it may be of interest to them. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Adrian Farrow HM Assistant Coroner 04.09.2020 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
19 October 2020 Adrian Farrow HM Assistant Coroner Coroner’s Court 1 Mount Tabor Street Stockport SK1 3AG Your ref: Our ref: 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. Yours sincerely, Professor Chief Executive
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