Sentinel 4F Delayed access to Investigation way. emergency treatment in remote site prior to urgent transfer resulting in patient death. Serious 3 Retained surgical Investigation under way. instrument (clamp) following gastric bypass surgery requiring subsequent surgical removal. Sentinel 4A Misdiagnosis resulting The patient’s presenting complaint A process to enable consultant in patient discharge was of back pain. Misdiagnosis involvement in decision making and subsequent death and discharge occurred despite regarding discharge from the due to rupture of major thorough examination. Emergency Department (ED). abdominal artery in radiology reporting which Establish a process to ensure timely (aorta). may have identified the condition. review of X-ray findings for ED patients. Current back pain proforma does not include rupture of abdominal Consider adding rupture of aorta as part of the diagnosis as it abdominal artery to the current is a rare cause. proforma with guidance on potential for misdiagnosis.
Sentinel 4F Delayed access to emergency treatment in remote site prior to urgent transfer resulting in patient death. Investigation way. Serious 3 Retained surgical instrument (clamp) following gastric bypass surgery requiring subsequent surgical removal. Investigation under way. Sentinel 4A Misdiagnosis resulting in patient discharge and subsequent death due to rupture of major abdominal artery (aorta). The patient’s presenting complaint was of back pain. Misdiagnosis and discharge occurred despite thorough examination. in radiology reporting which may have identified the condition. Current back pain proforma does not include rupture of abdominal aorta as part of the diagnosis as it is a rare cause. A process to enable consultant involvement in decision making regarding discharge from the Emergency Department (ED). Establish a process to ensure timely review of X-ray findings for ED patients. Consider adding rupture of abdominal artery to the current proforma with guidance on potential for misdiagnosis.
SSE_cases_2010_11_FINALv1.docx