The fate of those who die from a misdiagnosis of acute aortic syndromes

This study highlights the urgent need for improved diagnosis and medical education to prevent fatalities due to acute aortic syndromes.


October 2021


Regulation 28 - reports to prevent future deaths

Presented at

RCEM Annual Scientific Conference

The issue of misdiagnosis in the medical field is a subject that necessitates serious scrutiny, especially when the stakes are life and death. Research conducted by the Aortic Dissection Charitable Trust sheds new light on the fate of patients who were misdiagnosed with acute aortic syndromes. The findings raise critical concerns about the need for more accurate diagnosis and improved medical education.

The Study: Data Sources and Methodology

The research study analysed two types of public data: coroner’s Rule 28 reports from 2015 – 2021 and the public AD petition. Rule 28 reports are documents prepared by coroners when they believe that preventative action is needed to avert future deaths. The public petition allows relatives to share personal experiences with acute aortic syndromes. Both sources offer a window into the grim reality of patients who were diagnosed incorrectly.

Misdiagnosis: A Fatal Error

According to the study, 11 out of 17 Rule 28 reports involving acute aortic syndromes were cases of delayed or incorrect diagnosis. For the victims, the types of dissections and aneurysms were varied. The majority had sought medical help, either at a hospital or via paramedics, but were not adequately diagnosed or treated. Tragically, nine patients died at home after being discharged from the hospital, and two died while still in medical care.

Coroner Rule 28 reports on aortic dissection

The Specifics of Misdiagnosis

It’s important to note the varied nature of these misdiagnoses. They range from gastrointestinal issues like diverticulitis and food poisoning to musculoskeletal pain, panic attacks, and even sinusitis. These are common conditions, but they shouldn’t obscure the detection of something as critical as an aortic dissection, which requires immediate and specific treatment. The study demonstrates that when it comes to acute aortic syndromes, misdiagnosis can happen more easily than one might think, and the outcomes can be devastating.

Key Findings

  • High Frequency of Misdiagnosis Necessitates Systemic Change

    The study reveals that out of 17 Rule 28 reports concerning acute aortic syndromes, 11 were cases of misdiagnosis. This high frequency is alarming and suggests that there are systemic issues in diagnosing aortic dissections, warranting immediate changes in how medical personnel are trained and how diagnoses are conducted.

  • A Wide Range of Misdiagnoses Indicates a Lack of Specific Diagnostic Tools

    The study shows that misdiagnoses varied from gastrointestinal issues to panic attacks and musculoskeletal pain. This wide range of incorrect diagnoses indicates a lack of specific diagnostic tools or guidelines for identifying acute aortic syndromes, emphasising the need for specialised training and equipment.

  • High Mortality at Home Signifies Poor Post-Hospital Care

    Nine out of the eleven misdiagnosed patients died at home, suggesting that even after hospital assessment, patients are not provided with the necessary follow-up care or information to seek immediate help if their condition deteriorates.

Imperative for Change

Although the study operates on a small sample size and acknowledges the limitations of selection bias, its findings are highly consequential. It establishes an urgent need for a more rigorous and systematic approach to ruling out aortic dissection when a patient presents symptoms that could possibly relate to it. There is a pressing requirement for further research and education in this domain.

This research was formally presented at the Royal College of Emergency Medicine (RCEM) Annual Scientific Conference in October 2021. This RCEM CPD-accredited event featured scientific updates from emergency medicine experts both from the UK and internationally, highlighting the study’s significance and its contribution to ongoing medical education and policy discussions.

A Compassionate Reminder

The data serves as a poignant reminder of the human lives lost due to misdiagnosis. Each number represents a person who sought help but was tragically failed by the current system. It is essential to understand that timely and accurate diagnosis can mean the difference between life and death for someone experiencing an acute aortic syndrome.

Healthcare providers must exercise heightened diligence and cultivate a deeper awareness of the signs that could indicate an aortic dissection.

Our hope is that this research instigates real change in policy and education, making misdiagnosis a rarity rather than an all-too-common occurrence. Lives depend on it.

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