Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0349, written 21 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Sep 2023 |
|---|---|
| Reference | 2023-0349 |
| Deceased | Chantelle Reed |
| Coroner | Samantha Goward |
| Coroner area | Cambridgeshire and Peterborough |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
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: 1. The Royal College of Emergency Medicine 2. The Royal College of Radiologists 3. NHS England 1. CORONER I am Samantha Goward, Assistant Coroner for the coroner area of Cambridgeshire and Peterborough. 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. Coroners and Justice Act 2009 (legislation.gov.uk) The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) 3. INVESTIGATION and INQUEST On 14 January 2021 an investigation into the death of Chantelle Reed was commenced. Chantelle died on 29 October 2020. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion of the inquest was: Medical Cause of Death: 1a. Haemopericardium 1b. Type A aortic dissection Conclusion – Natural causes, namely an undiagnosed acute aortic dissection, a rare condition, even more so in light of Chantelle’s age and lack of relevant medical history. 4. CIRCUMSTANCES OF THE DEATH 1. Chantelle Reed was a 33 year old lady who had no history of any significant medial conditions. 2. On 27 October 2020 Chantelle began to experience back and neck pain and feeling of breathlessness. She described the pain as worse than contractions. The pain was sufficient that she felt unable to drive and she was driven to the Emergency Department at Peterborough City Hospital. 3. On arrival Chantelle described having throat spasms/back pain. When she was seen by a doctor she advised that her symptoms had resolved and indicated a desire to leave as she did not wish to waste the department’s time. At that time she did not advise of any chest pain or breathlessness. Chantelle also advised she had experienced similar back spasms before following an epidural. The doctor did however complete a physical assessment and arrange for 4. blood tests to be performed. Based on the findings at that time, a working diagnosis of musculoskeletal pain was made and Chantelle was discharged with a prescription for diazepam. 5. Chantelle did not have any medical history that would cause concern for this condition. Given her age and presentation, I heard expert evidence that “acute thoracic aortic dissection in these circumstances in a young woman to be highly unusual making it so rare that it would not be considered a differential diagnosis without strong clinical evidence”. 6. While the expert gave evidence that on 27 October, the abrupt onset of central chest pain radiating to back and throat was consistent with a dissection, he stated that Chantelle had a normal ECG, completely normal physical observation, no abnormality on examination and normal blood tests. He therefore stated this would reassure a responsible emergency physician and it was therefore reasonable, without the benefit of hindsight, to discharge her at that time. 7. Overnight on 28 October Chantelle became breathless and developed chest pain and in the early hours of 29 October, after a 111 call, an ambulance was called and Chantelle was taken again to hospital arriving at around 0450 hours. She was complaining of sudden onset chest pain, which was worse on inspiration, vomiting and fever. 8. the length of the delay was not one outside the realm of the usual wait nationwide, particularly in the context of the covid pandemic. There was a delay in Chantelle seeing a doctor after she was triaged, but 9. Various tests were carried out following assessment and she was managed for suspected pulmonary embolism (PE). A chest x-ray was performed and reviewed by the ED clinician and no concerns were noted. A CT pulmonary Angiogram (CTPA) and echocardiogram were requested, but this was later overruled by a Medical Consultant. We heard evidence from that Consultant who felt that Chantelle did not have a PE and likely had an infection and provided antibiotics and indicated she was fit for discharge. Chantelle was moved to the ambulatory majors area of ED when she was noted to be unconscious by another patient who alerted staff. She was rushed to the resuscitation room, but sadly did not survive. 10. I heard expert evidence that when Chantelle represented to the ED on 29 October, based upon what was known at that time, and Chantelle’s presentation, the suspicion of a PE was reasonable, as was starting treatment for this with anticoagulants in accordance with national guidance, while awaiting the scan results. However, his evidence was that it was not appropriate to decide not to carry out the further investigations requested by the ED Registrar. The expert’s evidence was that Chantelle’s presentation did not fit fully fit with infection, although this should have remained as a differential diagnosis. She should therefore have been admitted and given the antibiotics as an inpatient, where she could be monitored due to the ongoing tachycardia and the raised troponin t, so that the nature of any infection could be established to ensure she was on the correct antibiotics, and also the investigations to confirm or rule out a PE could be undertaken. 11. I am mindful that the investigations ordered were not to consider aortic dissection, and the expert was not critical of this, but that the CTPA if undertaken could have shown the dissection as an incidental finding and this was also agreed by an expert Cardio Thoracic Surgeon. 12. Further, the chest x-ray undertaken on 29 October was subsequently reported as abnormal. The ED expert was not critical of the fact that the ED clinicians did not correctly interpret this and advised that the subtle signs may have been missed by them, especially as it is only with the benefit of hindsight that signs of a dissection would be specifically considered. They were however spotted by the reporting Radiologist, but sadly they did not review and report until after Chantelle’s death and the evidence was that this is nationally not an unusual timescale for such a report. Had the chest x-ray been reported by a Radiologist sooner, the diagnosis would have been made sooner. 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: 1. The evidence of the independent expert in Emergency Medicine, was that “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. Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain. The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further”. The expert felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms. 2. The evidence also indicated that the timescale for a Radiologist to review the chest x-ray (2 days) was not unusual and that often the timescale is longer and this is due to a national shortage of Radiologists. The concern is that, to a trained Radiologist, the possibility of an aortic dissection was immediately recognised, but the review did not take place until after Chantelle had died. In an emergency situation such as this one, this delay represents on ongoing risk of future deaths. 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 You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 November 2023. 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: 1. Chantelle’s family 2. North West Anglia NHS Foundation Trust (Peterborough City Hospital) I have also sent it to the following who may find it useful or of interest. 3. Secretary of State for Health 4. HSIB 5. Aortic Dissection Awareness UK & Ireland 6. Heart Research UK (‘think aorta’ campaign) 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. Dated 21/09/2023 Signed: Samantha GOWARD, Assistant Coroner for Cambridgeshire and Peterborough
2 responses 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.
Samantha Goward
Cambridgeshire & Peterborough Coroner’s Service
Lawrence Court
Princes Street
Huntington
PE29 3PA
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
16 November 2023
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Chantelle Reed who died
on 29 October 2020.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21
September 2023 concerning the death of Chantelle on 29 October 2020. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Chantelle’s family and loved ones. NHS England are keen to
assure the family and the coroner that the concerns raised about Chantelle’s care have
been listened to and reflected upon.
In your Report, you raise the concern that there was a lack of awareness of aortic
dissection amongst Urgent & Emergency Care (UEC) and acute medicine health
professionals.
In recent years, significant work has been undertaken to raise awareness within acute
care settings of the indicators of acute aortic dissection, following recommendations
made by the Healthcare Safety Investigations Branch (HSIB) in January 2020 on the
culmination of an investigation into delayed recognition of acute aortic dissection and
an acknowledgement that there have been challenges in frontline staff diagnosis and
treatment of acute aortic dissection. This included the Manchester Triage International
Reference Group updating the Manchester Triage System (MTS) in 2020 to include
‘aortic pain’ as a discriminator for chest pain and to raise awareness of acute aortic
dissection as a potential cause. The MTS is a clinical risk management tool commonly
used in Emergency Departments to enable clinicians to safely manage patient flow,
by assigning a clinical priority to patients based on presenting signs and symptoms to
ensure life threatening injuries and illnesses are identified.
In November 2021, the Royal College of Radiologists and the Royal College of
Emergency Medicine (RCEM) published their guidance on the diagnosis of thoracic
aortic dissection within emergency departments on their respective websites:
Diagnosis_of_Thoracic_Aortic_dissection.pdf (rcem.ac.uk). I realise that this guidance
was published after Chantelle’s death, but I hope this provides some assurance that
that actions are being taken to address the issues raised in your Report. Awareness
raising has also been undertaken via the Think Aorta campaign, a global campaign
focused on misdiagnosis and delay in acute Aortic Dissection which provides
accredited learning resources for first responders, emergency medicine and radiology
teams.
NHS England’s Getting It Right First Time (GIRFT) Programme also includes the
possibility of aortic dissection in its chest pain pathway for acute settings: Chest-Pain-
Pathway-FINAL-V2-July-2023.pdf (gettingitrightfirsttime.co.uk). GIRFT is a national
programme designed to improve the treatment and care of patients through in-depth
review of services, benchmarking and wide-ranging data analysis and is part of an
aligned set of programmes within NHS England input into by senior clinicians.
NHS England has been sighted on the response to you from the RCEM and the Royal
College of Radiologists. NHS England notes their position that they do not believe
there is sufficient evidence to support the suggestion that chest pain radiating to the
neck or jaw should mandate the investigation for Thoracic Aortic Dissection or that
Computed Tomography of the Aorta should be performed in all such cases.
NHS England’s national Patient Safety Team are linked into the RCEM’s Patient
Safety Committee and so will be aware of any future work in this area. We will of
course support wherever necessary.
Your Report also raises the concern that there is a national shortage of Radiologists
and that this can lead to delays in reviewing x-rays, which, in this case, may have led
to the timely diagnosis of acute aortic dissection in Chantelle.
NHS England published the Image report turnaround time guidance in August 2023,
available here: NHS England » Diagnostic imaging reporting turnaround times. The
guidance sets out the maximum turnaround times from acquisition to image reports,
with a 4-hour maximum for acutely unwell patients in Accident & Emergency (A&E)
during routine hours of working.
The guidance incudes caveats for sufficient availability of workforce as the numbers
of reporting staff (radiologists and reporting radiographers) are not increasing in line
with demand. We are supporting Trusts to increase reporting capacity by increasing
the number of reporting radiographers and radiologist trainees per financial year,
international recruitment initiatives and workforce demand and capacity planning tools.
In June 2023, NHS England also published the NHS Long Term Workforce Plan, in
response to the current lack of sufficient workforce. The plan sets out how we will train,
retain and reform healthcare staff across the NHS over the next fifteen years, and is
underpinned by the biggest recruitment drive in NHS history.
I would also like to provide further assurances on national NHS England work taking
place around the Reports to Prevent Future Deaths. All reports received are discussed
by the Regulation 28 Working Group, comprising Regional Medical Directors, and
other clinical and quality colleagues from across the regions. This ensures that key
learnings and insights around preventable deaths are shared across the NHS at both
a national and regional level and helps us pay close attention to any emerging trends
that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Samantha Goward Assistant Coroner for Cambridgeshire and Peterborough Regulation 28 Report to Prevent Future Deaths: C Reed 21.09.2023 Further to your prevention of Future Deaths Notice following the conclusion of your inquest (06.09.2023) into the death of Chantelle Reed who died on 29th October 2020, we would like to extend our sympathy and condolences to the family and friends of Ms Reed. You have asked us to address two specific areas of concern, the first of which was the nature of the chest pain which was described as radiating to the neck and jaw and whether this should have raised the possibility of Thoracic Aortic Dissection (TAD). Unfortunately chest pain which radiates to the neck or jaw is not specific for TAD and this description is much more likely to be in keeping with other pathology such as acute coronary syndrome (heart attacks and angina); in fact acute coronary syndrome is 100-200 times more common than TAD [1]. The most discriminating description of the chest pain that is experience in TAD that is evidence based is described as sudden onset with its worst severity being at its onset [2,3]. As noted in your report, TAD in a woman of Ms Reed’s age is highly unusual and we would consider this a rare occurrence in the absence of any other risk factors. We neither feel that there is sufficient evidence to support the suggestion that chest pain radiating to the neck or jaw should mandate the investigation for TAD (Computed Tomography of the Aorta) nor that there is sufficient evidence to suggest that the balance of risk and benefit is in favour of performing Computed Tomography of the Aorta (CTA) in all such cases. The risks associated with performing CTA for all patients presenting chest pain radiating to the neck or jaw will include a high rate of negative scans and consequent unnecessary exposure to the risks of ionising radiation (eg. cancer) as well as a significant radiological workload that is likely to negatively impact on patients who do have significant injury or illness. Unfortunately there is currently no combination of presenting features or blood tests or radiographic changes on a chest X-ray that are able to exclude the diagnosis of TAD with certainty, this can only be done by CTA. The second area of concern that you asked us to address related to the timescale for a radiologist to review a chest x-ray and provide a report on relevant findings. The Royal College of Radiologists (RCR), together with the Society and College of Radiographers, contributed to and support guidance published in August 2023 by NHS England on diagnostic imaging turnaround times [4]. Turnaround time (TAT) is the interval between an imaging examination and a verified report being made available to the referring clinician, and keeping TATs as short as possible is essential for timely diagnosis and treatment of patients. The guidance recognises the current workforce crisis in diagnostic imaging: achieving or exceeding the recommended TATs is based on there being full staffing in place to deliver them. For context, the RCR’s most recent workforce census [5] highlighted a current 29% shortfall of clinical radiologists, which inevitably has an impact on the quality of care that consultants are able to provide. The recommended maximum TAT for urgent inpatient referrals is 12 hours, or less than 4 inpatients. hours post-acquisition of images for Emergency Department or acutely unwell Departments are encouraged to explore alternative solutions, including outsourcing agreements with third-party teleradiology providers and cross-network collaboration to address efficiency gaps. The rapid diagnosing of TAD continues to be of great concern to both organisations and we have worked with aortic dissection charities to highlight to frontline clinical staff the available guidance and the need to consider the diagnosis of TAD in patients who present to the emergency department with chest pain. The clinical features of TAD are diverse, making diagnosis difficult and currently there is no validated clinical decision rule to aid clinicians. Both our organisations are committed to continuing to work together to promote evidence based best practice in the diagnosis of TAD. Yours, The Royal College of Radiologists Medical Director Professional Practice, Clinical Radiology Royal College of Emergency Medicine Chair, Quality Emergency Care Committee References 1. Diagnosis of Thoracic Aortic Dissection in the Emergency Department. Royal College of Radiologists & Royal College of Emergency Medicine, 2021. https://res.cloudinary.com/studio- republic/images/v1638376591/Diagnosis_of_Thoracic_Aortic_dissection/Diagnosis_of_Thoracic_Aortic_dissection.pdf?_i=AA. Accessed 18.10.2023. 2. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Isselbacher EM et al. Circulation. 2022; 146 (24): e334–e482. https://www.ahajournals.org/doi/epub/10.1161/CIR.0000000000001106. Accessed 18.10.2023. 3. European Society Cardiology Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal 2014, 35; 2873-2926 4. Diagnostic imaging reporting turnaround times. NHS England, 2023. https://www.england.nhs.uk/long-read/diagnostic-imaging- reporting-turnaround-times/. Accessed 19.10.2023. 5. RCR Clinical Radiology Workforce Census 2022. The Royal College of Radiologists, 2023. https://www.rcr.ac.uk/clinical-radiology/rcr- clinical-radiology-workforce-census-2022. Accessed 19.10.2023. Please direct any further queries regarding this joint RCR/RCEM response via in the first instance.
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