Ischaemic heart disease

Negligence verdict backs wider use of CT aortogram for diagnosis of aortic dissection

A Victorian hospital has been found negligent for not offering abdominal CT aortogram for diagnosis of aortic dissection to a man who died from the condition after being discharged from the emergency department.

In a case heard at the Supreme Court of Victoria, Peninsular Health was found to have failed in its duty of care to Mr Ronald Boxell in October 2013 when he presented with chest pain at the Frankston Hospital.

Doctors at the hospital found no cause for Mr Boxell’s pain, and he was discharged without a diagnosis. He died at home the following day as a result of acute aortic dissection causing haemopericardium and cardiac tamponade.

The hospital was sued by his family, who claimed that emergency department doctors had failed to consider and exclude aortic dissection as a cause of Mr Boxell’s chest pain, and failed to perform a CT aortogram.

Expert witnesses for the hospital argued that the patient’s presenting history, physical examination and investigation results provided no clinical basis for performing a CT aortogram.

Professor Peter Cameron, Academic Director of the Emergency and Trauma Centre at The Alfred Hospital, said a patient had to have symptoms consistent with aortic dissection to justify ordering a CT aortogram, “because it is a test with side effects which you cannot do every time someone has a twinge of chest pain.”

His view was backed by cardiologist Professor Richard Harper told the court that CT aortogram was not justified in a patient who did not show the three key diagnostic features of AD, namely,

  • abrupt onset of a severe ripping-type chest pain radiating through to the back;
  • widened mediastinum or widened aortic contour on the chest x-ray; and
  • differential pulse strength and blood pressures in the arms.

“Given the rarity of AD, and the fact that Mr Boxell had no features pointing to that diagnosis, an emergency department would have to do many hundreds, perhaps thousands, of CT aortograms to pick up one dissection. It is just not feasible to do a CT aortogram with every patient who presents with chest pain,” the court was told.

However the judge said he preferred to rely on the evidence of other emergency medicine specialist witnesses, who he said had more familiarity with the patient’s case and in particular the presenting history of the onset and character of chest pain.

Although the patient had atypical symptoms there were still red flags that should have triggered further investigation and consideration of CT aortogram, he said.

“The Hospital did not consider the diagnosis of [aortic dissection] with a high level of suspicion at any stage of Mr Boxell’s presentation, carefully tease out the pain history, or reconsider the diagnosis before discharge,” Justice Andrew Keogh said in his analysis.

“Because the Hospital did not take the steps to which I have referred, it cannot be concluded that its conduct satisfied a standard of competent professional practice.

The judge also said that concerns about overuse of CT aortogram and the cost implications were overstated, as the alternative options such as  discharging chest pain patients with a recommendation for outpatient stress test, would also lead to high rates of health care utilisation and adverse patient outcomes.

“Reasonable care required that the Hospital confirm or exclude AD by performing a [CT aortogram] before Mr Boxell was discharged on that day. Because it failed to do so the defendant was negligent,” he concluded.

Court orders on matters such as costs will be made a later date.

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