Paul Sartori

MISS N PERSAUD 
HER MAJESTY’S CORONER 

EAST LONDON 

Walthamstow Coroner's Court, Queens Road Walthamstow, E17 8QP 

Telephone 020 8496 5000 Email 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS (1) 

Ref: 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

2. 

, Chief Medical Officer, Barts Health NHS Trust, 

Ground Floor, Pathology Block, 80 Newark Street, London, E1 2ES 
Email:

, Medical Director, North East London Foundation Trust, 

Suite 1, Phoenix House, Christopher Martin Road, Basildon, Essex, SS14 3EZ 
Email: 

1 

CORONER 

I am Nadia Persaud area coroner for the coroner area of East London 

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. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On the 7th November 2019 I commenced an investigation into the death of Mr Paul 
Sartori, who was 38 years old. The investigation concluded at the end of the inquest on 
22nd April 2021.  The conclusion of the inquest was a narrative conclusion: 

Paul Sartori died from a dissecting aortic aneurysm on the 27 October 2019.  He sought 
emergency medical assistance for central chest pain on the 24 October 2019.  He was 
taken by ambulance to A&E, but directed away from the A&E department, to the urgent 
care centre by an emergency department nurse.  He underwent an assessment by a 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 general practitioner in the urgent care centre.  The general practitioner formed the 
impression of costochondritis (musculoskeletal chest pain).  Mr Sartori was advised to 
take analgesia and to seek medical advice if pain did not improve or if symptoms 
worsened.  Mr Sartori suffered increasing chest pain on the 27 October 2019.  An 
ambulance attended, but sadly, Mr Sartori did not respond to resuscitation efforts.  No 
specific investigations were undertaken to rule out potentially lethal causes of the acute 
chest pain when Mr Sartori presented to A&E on the 24 October 2019.  Had bilateral 
blood pressures and a CT scan been carried out on the 24 October 2019, it is likely that 
Mr Sartori’s death would have been avoided.    

4.  CIRCUMSTANCES OF THE DEATH 

As can be seen from the narrative conclusion, Paul Sartori sought emergency medical 
assistance for central chest pain on the 24th October 2019.  The previous day he had 
begun to suffer from arm pain.  On the morning of the 24th October 2019 he reported to 
the emergency operator that he had been suffering from clamminess and sweating, 
followed by numbness in his hand.  On attendance of the paramedics at 0630, he had a 
pain score of 7 out of 10 and a raised heart rate of 107 and 108.  The pain score 
reduced at 06:50 to 4 out of 10.  The paramedics determined that he should be taken to 
A & E to investigate the cause of the chest pain. 

Mr Sartori was taken to A & E where an A & E nurse took an incomplete set of 
observations and redirected Mr Sartori to the urgent care centre.  There is no record of 
the A&E nurse’s assessment.   

In the urgent care centre, Mr Sartori was assessed by a GP who made a diagnosis of 
costochondritis.   

Mr Sartori left the hospital without any further investigation or treatment.  He continued 
to suffer from pain which became acutely worse on the morning of the 27th October 
2019.  At this time an ambulance was called but he was found to be unresponsive in his 
home address. Resuscitation efforts were provided but he was pronounced life extinct in 
his address on the 27th October 2019. 

A post-mortem examination found that Mr Sartori had suffered a ruptured dissecting 
aortic aneurysm of the ascending thoracic aorta. 

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 could 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.  The Inquest heard evidence that the streaming guidance in place for Barts 

Health A & E staff and NELFT staff had not been updated to take into account 
the learning from the death of Mr Sartori and to take into account the guidance 
from the THINK AORTA Campaign (launched in 2016). 

2.  The nurse making the decision to re-direct Mr Sartori from A&E did not record a 
full set of observations, to include a pain score, prior to diverting Mr Sartori from 
the A & E department.  The nurse did not document her decision making 
process and rationale for redirecting Mr Sartori from A&E. 

3.  A junior sister who provided evidence at the Inquest was not aware of the 

THINK AORTA campaign.  The Inquest heard that the senior leadership team 
had recently agreed to embed the THINK AORTA learning into practice at all 
levels within the emergency department.  This learning had not been embedded 
at the time of the Inquest hearing. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 6 

ACTION SHOULD BE TAKEN 

In my opinion, action should be taken to prevent future deaths and I believe you and 
your organisation have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 23 June 2021 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 family of the deceased 
(parents and partner) and to the CQC.  I will also send a copy of the report to the 
Director of Public Health who may find it useful or of interest. 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it.   

I may also send a copy of your response to any other person who I believe may find it 
useful or of interest.  

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. 

9 

28 April 2021          [SIGNED BY CORONER]   

3

Patron: HRH Princess Royal 
7-9 Bream’s Buildings   
London 
EC4A 1DT 

                      www.rcem.ac.uk 

MS Nadia Persaud  
HM Coroner, East London 
Walthamstow Coroners Court 
Queens Road, Walthamstow 
London E17 8QP 

Dear Ms Persaud, 

22 July 2021 

Prevention of Future Deaths Report (Mr Paul Michael Sartori) 

The Royal College of Emergency Medicine is responding to the Regulation 28 
Prevention of Future Deaths (PFD) Report issued on 28th April by Ms Nadia Persaud, 
HM Coroner East London.  We wish to express our condolences to Mr Sartori’s family 
during this difficult time. 

The Regulation 28 PFD identifies concerns regarding the management of Aortic 
Dissection in Emergency Department.  The evidence highlighted in the Report raises 
concerns regarding a lack of awareness and education, access to CT scanning, and 
the difficulties in diagnosing aortic dissection.   

Awareness and education 

The Royal College of Emergency Medicine has been working on raising the 
awareness amongst the Emergency Department clinicians regarding aortic 
dissection. The Royal College of Emergency Medicine has worked to increase 
awareness to its members and fellows through the use of communications and safety 
notices as well as developing specific learning modules for members and fellows. The 
College is also developing guidance for the assessment of patients, and 
identification of those that require CT scanning (see below). 

Access to CT scanning 

A Healthcare Safety Investigation Branch (HSIB) investigation recently recommended 
that the Royal College of Emergency Medicine and the Royal College of Radiologists 
work together to increase the awareness of aortic dissection, the accessibility of CT 
scanning to diagnose aortic dissection, and to develop guidance on the 
identification of aortic dissection.  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.  It should be remembered that CT scanning is not without its own 
associated harms (significant radiation exposure and kidney damage). 

                   
 
 
 
      
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Difficulties in diagnosing Aortic Dissection 

As was highlighted in the PFD report, the current clinical decision making tools lack 
sensitivity, and do not have a solid evidence base in support. There are consensus-
derived tools that are based on a suite of risk factors, features in the medical history 
and clinical findings. These require a full assessment of the patient by a clinician. 
Additionally, the College is also aware that clinical findings such as blood pressure 
differential are not sensitive or specific enough on their own to diagnose or exclude 
the presence of aortic dissection.  Unfortunately, there is a limited evidence-base to 
support a specific screening or scoring system.  Patients with thoracic aortic 
dissection generally present with chest pain, in this group of patients a diagnosis 
related to coronary artery disease (eg. heart attack, angina) is approximately 100-
200 times more likely than thoracic aortic dissection, making the decision of which 
patients to scan particularly problematic, given this is not risk free either. 

The Royal College of Emergency Medicine on several occasions has applied to the 
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) for a 
national review of aortic dissection cases to help provide further evidence on this 
area, and is re-submitting this application this year.   

Reading the details of the inquest, it is noted that this patient was seen by a General 
Practitioner who would not be likely to be a member of the Royal College of 
Emergency Medicine, and was seen in an Urgent and Emergency Care centre after 
‘streaming’.  These are not Emergency Departments and often are not linked to 
Emergency Departments.  This highlights the systemic issues that exist beyond the 
Emergency Department and beyond the remit of the Royal College of Emergency 
Medicine, as identified in the PFD. This would include General Practitioners, Urgent 
Care Centres, and the NHS 111 system as a patient with aortic dissection may well 
present to all of these. It is also noted that the patient presented with chest pain and 
the National Guidance from the National Institute of Clinical Excellence on Chest 
Pain of Acute Onset (NICE CG95) does not provide clear guidance regarding 
screening for or consideration of aortic dissection in this group of patients.  The Royal 
College of Emergency Medicine would therefore respectfully suggest that a number 
of organisations with high-level reach and importance such as NICE and NHS 
pathways should also be engaged with the process of raising awareness within the 
whole system. 

Yours sincerely, 

Head of Quality and Policy 
Royal College of Emergency Medicine

NHS

Barts Health
NHS Trust
Trust Executive Office

Ground Floor
Pathology and Pharmacy Building

08 June 2021 The Royal London Hospital
80 Newark Street
PRIVATE & CONFIDENTIAL London E1 2ES

Ms Nadia Persaud
HM Senior Coroner

www.bartshealth.nhs.uk

Dear Ms Persaud
RE: Regulation 28: Report to Prevent Future Deaths

| write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding
the care of Paul Sartori. Please accept this as the final joint response from NELFT and Barts Health.

Paul Sartori attended Whipps Cross Hospital by ambulance on 24 October 2019 with chest pain
and was directed to the Urgent Care Centre by an Emergency Department nurse and then by a
streamer. He was assessed by a GP and discharged with a diagnosis of costochondritis. He
collapsed at home from an aortic dissection on 27" October 2019 and could not be resuscitated.

The matters of concern raised in the Regulation 28 notice were:

1. The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff
and NELFT staff had not been updated to take into account the learning from the death of Mr
Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in
2016).

2. The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of
observations, to include a pain score, prior to diverting Mr Sartori from the A & E department.
The nurse did not document her decision making process and rationale for redirecting Mr Sartori
from A&E.

3. Ajunior sister who provided evidence at the Inquest was not aware of the THINK AORTA
campaign. The Inquest heard that the senior leadership team had recently agreed to embed the
THINK AORTA learning into practice at all levels within the emergency department. This
learning had not been embedded at the time of the Inquest hearing.

Both NELFT and Barts Health are deeply sorry that the diagnosis of aortic dissection was not
adequately considered when Mr Sartori sought our care. We have approached this matter great
seriousness and a mutual determination to learn and improve both our individual processes and the
way we work together.

Regarding the first matter of concern

NHS;

Barts Health
NHS Trust

NELFT and Barts Health have worked closely to review the current streaming guidance and
incorporate the learning from the ‘THINK AORTA’ campaign. 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 gt
June 2021.

Regarding the second matter of concern
Whipps Cross will ensure that the pre-arrival documentation made on CRS when ambulances arrive

includes documentation supporting any decision to divert the patient to the Urgent Care Centre. This
will include vital signs observations and pain score and will be implemented by 15" June. A process
to do this at other Barts Health Emergency Departments is already in place.

NELFT staff are aware and have been instructed that they are to document the rationale for transfer
of care from the Urgent Care Centre to the Emergency Department on the patient electronic system.
Urgent Care staff will also ensure that all observations are rechecked on arrival to the Urgent Care
Centre and documented in the patient's record. This will be randomly manually audited.

Regarding the third matter of concern
As previously described in their letter to you dated 10" May 2021, NELFT have completed and

disseminated a dedicated team learning pack on aortic aneurysm dissection, and this will be
reinforced at monthly clinician team meetings for NELFT urgent care practitioners.

All Barts Health Emergency Departments now display “THINK AORTA” posters in prominent
positions and incorporate the “THINK AORTA” campaign as a recurring topic of education in
departmental multidisciplinary teaching.

A learning piece describing the clinical characteristics of aortic dissection seen in our local population
will be shared in departmental teaching during June and this will be refreshed and shared iteratively
alongside the scheduled “THINK AORTA’ teaching.

The Barts Health Heart Attack Centre feedback template has been updated to prompt exclusion of
aortic dissection as a cause of non-cardiac chest pain.

Thank you for communicating your concerns to us - we believe that our services are safer as a result
of the action we have taken to address them.

Yours sincerely,

Chief Medical Officer
Barts Health NHS Trust

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