Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Health and Disability Commissioner Morag McDowell today released a report highlighting the difficulty in diagnosing acute aortic dissection without failsafe diagnostic tools.
A woman in her forties complaining of severe ongoing chest pain was taken to the Emergency Department of her local hospital by ambulance. She was assessed and monitored in ED, where she underwent a range of diagnostic testing and an X-ray. She was given strong pain medication.
The woman was diagnosed with a heart rhythm condition caused by irregular heartbeats, and discharged the same day.
Sadly the woman died later that night from acute aortic dissection. An acute aortic dissection is a tear in the inner layer of the large blood vessels branching off the heart.
The Commissioner considered that the appropriate standard of care was provided by the district health board (DHB).
“It is clear that aortic dissection is a relatively difficult and rare diagnosis for clinicians to make,” said Ms McDowell.
“As a healthcare provider, the DHB is responsible for providing services in accordance with the Code. In this case, no broader system issues at the DHB were identified,” said Ms McDowell.
The Commissioner recommended that the DHB use an anonymised version of this case as an educational tool to be incorporated into staff training, and that the DHB liaise with the Australasian College for Emergency Medicine about the use of the a developing diagnostic tool, for consideration of implementing its use in ED once its usefulness has been proven.
“I hope that the recommendations made will aid in minimising such outcomes for other patients and their whānau,” said Ms McDowell.
The full report on case 20HDC00480 is available on the HDC website.
