Introduction
This article explores whether the new best practice guidelines (RCEM, 2021) on the diagnosis of aortic dissection are more of a hinderance than help. Aortic dissection, although classified as a rare condition, kills more than 2000 people in the UK each year, (Tees Law, 2021), which is more than those killed in road traffic accidents (Think Aorta, 2022). Despite this startling statistic, there is insufficient awareness on this topic, and calls for reform on both the awareness and diagnosis of aortic dissection have been longstanding. However, despite new clinical best practice guidelines being published in 2021 by the Royal College of Emergency Medicine, with the aim to provide more clarity and cohesiveness in the diagnosis and treatment of aortic dissections, it seems that the potential effects could involve defensive medicine techniques employed by clinicians, arising out of a fear of malpractice litigation.
What is aortic dissection?
Aortic dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, and when ruptured, can have catastrophic and in many cases, fatal consequences. The primary issue surrounding fatalities arising out of aortic dissection is the difficulty in diagnosis. It has been noted that doctors do indeed have the necessary tools available to make such diagnoses, however the problem lies in the awareness, education and swift access to the tools necessary in order to do so. (Coroner's Report of Chloe Lumb, 2021). Access to CT aortagrams are crucial when seeking to diagnose an aortic dissection, and without these scans being conducted swiftly, it can lead to the misdiagnosis and death of many victims.
The effects of late/misdiagnosis can be seen in practice. One such case is of Ms. Chloe Lumb, a 24-year-old mother of two, who died of an aortic dissection. The coroner’s report stated that her death was indeed ‘preventable’ had she been swiftly diagnosed (Coroner's Report of Chloe Lumb, 2021) and highlighted the fact that there was no clear mechanism in place for the procedure that should be invoked when a suspected aortic dissection presents. Moreover, the coroner called for reform in this area, asking for a guidance document to be achieved via the NHS Patient Safety Network.
The call for reform in the diagnosis of this illness was once again referred to in another Coroner’s report, following the death of Paul Satori. (Coroner's Report of Paul Sartori, 2021) Here, the Coroner warns that there is ‘a risk that future deaths could occur unless action was taken’. It was clear that changes needed to be made with regard to the swift diagnosis of aortic dissection if lives were to be saved.
The long-awaited change
With no cohesive guidelines in place for clinicians to deal with a suspected aortic dissection, patients were not receiving the necessary scans and timely diagnosis, and innocent lives were being lost. Subsequently, more medical negligence cases arose as a result of misdiagnosis.
In November 2021, it seemed that the cries to the calls for reform were answered, when the Royal College of Emergency Medicine published their best practice guidelines. This body was responsible for developing an evidence-based process to detect and manage patients with acute aortic dissection who presented to emergency departments (HSIB, 2020).
The national guidelines note the difficulty in diagnosis of aortic dissection and stress the need for CT aortograms in cases of suspected thoracic aortic dissections. Although the guidelines allow for each emergency department to have agreed protocols between themselves and their radiology departments in the request of such aortograms, the guidelines highlight that rapid access to such scans are necessary in these suspected cases, in order to make a diagnosis.
At first glance, these guidelines seem to provide the clarity for clinicians that was much sought after. From a medico-legal perspective, these guidelines initially have great benefit, as they provide a pathway to early diagnosis of aortic dissection, which in turn may prevent a misdiagnosis/medical negligence case in the future. However, these guidelines should not and cannot be viewed as a panacea to the issues that were prevalent before.
The Legal Position of Such Guidelines
Although the guidelines are not legally enforceable and are not legally binding on clinicians, this does not mean that defensive medicine techniques will not be used by clinicians for fear of litigation. The potential for this to occur can be seen in litigation, whereby the plaintiff’s family were taking a clinical negligence case due to a fatality from aortic dissection, with the hope that ‘aortagrams will be seen as fundamental’ in the future diagnosis and treatment of aortic dissection. (Tees Law, 2021) The invocation of these new guidelines seems to realise their goal, as aortagrams are held as primary and monumental to the diagnosis of this medical emergency. Moreover, to many victims, these guidelines may now signify the starting point for a misdiagnosis claim.
Although the Royal College of Emergency Medicine have not stated that clinicians are mandated to follow these guidelines, the General Medical Council has noted that doctors should ‘normally follow guidelines (Hurwitz, 2004)’ meaning that doctors should undoubtedly take heed of the new aortic dissection guidance. Moreover, it has been noted that civil litigators often see guidelines as attractive, as they can form a starting point for negligence claims, if the doctor did not follow such guidelines. Guidelines, although they are just that, are highly influential to the way doctors practice medicine and are held accountable.
These new guidelines by the Royal College of Emergency Medicine will only be successful if their goal is to raise awareness, and not be used or strong-armed for litigation. The guidelines are vague in the sense that they do not provide a step-by-step process for diagnosis, however they are specific enough to highlight the importance and the need for aortagrams in the diagnosis of aortic dissection. This means that there is potential for litigation in the event that an aortagram is not carried out, and it later transpires that the victim suffered an aortic dissection. Although it can be argued the Bolam defence is available to a clinician who departed from guidelines and can prove that acceptable practice was still carried out, this does not mean that it will be the reality. To prevent a claim of malpractice or threat of litigation, doctors may send patients for aortagrams anyway, just to show that they have followed the guidelines, and can safely rule out both a diagnosis for aortic dissection, and any subsequent claim that they did not follow the guidelines.
For patients, or lay people, this may not seem significant, and if patients are sent for such scans to rule out aortic dissection, then this can only be a good thing. However, in reality, this is not the case. Firstly, and importantly, doctors should have the autonomy to make decisions based on their clinical expertise, experience, and judgement, rather than making decisions and referrals in anticipation of negligence claims down the road. Doctors should not fear litigation when carrying out their duties, but if the clinical guidelines on aortic dissection are seen as currency in which civil litigators can trade in and ultimately cash in on, then they will have the effect of increasing defensive medicine within medicine. Moreover, if doctors send patients for aortagrams out of fear, then this will inevitably lead to an increase in the waiting times for such scans, and will ultimately be in conflict with the main goal of the guidelines, which was to ensure swift access to such CT scans to ensure a timely diagnosis, and
to save lives.
Although the guidelines are useful, and are welcomed by clinicians in this area of medicine, they should remain in use for the purpose intended; which is to raise awareness of aortic dissection and enable a cohesive process of diagnosis and treatment. Awareness of this illness and the new guidelines cannot, and should not be viewed as simply another avenue for medical negligence claims, because if they are, then the only legacy that these guidelines will leave behind is a new realm of defensive medicine for clinicians, and a fear of litigation for doctors, rather than a helpful set of guidelines to assist with the diagnosis and treatment.
The guidelines are just guidelines, and this should be borne in mind by clinicians and litigators alike. Doctors can employ the new guidelines to ensure that no more victims die unnecessarily at the hands of this medical emergency, and litigators should welcome these guidelines, with the hope of saving lives, rather than the aim of cashing in on new claims.
Concluding Remarks
Both patients and clinicians concede that more awareness needs to be made in the area of aortic dissection; however this awareness should not be at the expense of clinicians’ fear of litigation. Although from a litigators perspective, these guidelines may serve as a pathway to court, this is not what the guidelines are designed to do. The guidelines should be informative for clinicians, and should not be viewed as a back door to sue a doctor, or the starting point for negligence.
Although the national guidelines are welcomed by all, as they provide clarity, and cohesive advice on the diagnosis of aortic dissection; they are not law, and should not be treated as so, and both patients and plaintiff clinical negligence litigators would do well to note this.
Bibliography:
[1] RCEM Diagnosis of Thoracic Aortic dissection in the Emergency Department, 2021 https://rcem.ac.uk/wp-content/uploads/2021/12/Diagnosis_of_Thoracic_Aortic_dissection.pdf [Accessed 11 November 2022].
[2] Coroner's Report of Chloe Lumb, 2021. Report to Prevent Future Deaths, London: Walthamstow Coroner's Court.
[3] Coroner's Report of Paul Sartori, 2021. Coroner's Report of Paul Sartori, London: Walthamstow Coroner's Court.
[4] HSIB, 2020. Patient Safety Learning. [Online] Available at: https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/investigation-reports/hsib-investigations/hsib-investigation-into-delayed-recognition-of-acute-aortic-dissection-23-january-2020-r1375/ [Accessed 20 October 2022].
[5] Hurwitz, B., 2004. How does evidence based guidance influence determinations of medical negligence?. British Medical Journal, 329(7473).
[6] Tees Law , 2021. Aortic Dissection Medical Negligence Claims. [Online] Available at: https://www.teeslaw.com/case-studies/aortic-dissection-medical-negligence-claims/ [Accessed 20 October 2022].
[7] Think Aorta , 2022. Think Aorta: Media Release. [Online]
Available at: https://www.thinkaorta.net/_files/ugd/e855b1_91fe2bfab8b44bcf8dd1204fa1d34ae5.pdf [Accessed 20 October 2022].
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