Chantelle Reed

I am Samantha Goward, Assistant Coroner for the coroner area of Cambridgeshire and Peterborough.

(legislation.gov.uk)

On 14 January 2021 an investigation into the death of Chantelle Reed was commenced. Chantelle died on 29 October 2020. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion of the inquest was: Medical Cause of Death: 1a. Haemopericardium 1b. Type A aortic dissection Conclusion – Natural causes, namely an undiagnosed acute aortic dissection, a rare condition, even more so in light of Chantelle’s age and lack of relevant medical history.

Chantelle Reed was a 33 year old lady who had no history of any significant medial conditions.

On arrival Chantelle described having throat spasms/back pain. When she was seen by a doctor she advised that her symptoms had resolved and indicated a desire to leave as she did not wish to waste the department’s time. At that time she did not advise of any chest pain or breathlessness. Chantelle also advised she had experienced similar back spasms before following an epidural.

The doctor did however complete a physical assessment and arrange for blood tests to be performed. Based on the findings at that time, a working diagnosis of musculoskeletal pain was made and Chantelle was discharged with a prescription for diazepam.

Chantelle did not have any medical history that would cause concern for this condition. Given her age and presentation, I heard expert evidence that “ acute thoracic aortic dissection in these circumstances in a young woman to be highly unusual making it so rare that it would not be considered a differential diagnosis without strong clinical evidence ”.

While the expert gave evidence that on 27 October, the abrupt onset of central chest pain radiating to back and throat was consistent with a dissection, he stated that Chantelle had a normal ECG, completely normal physical observation, no abnormality on examination and normal blood tests. He therefore stated this would reassure a responsible emergency physician and it was therefore reasonable, without the benefit of hindsight, to discharge her at that time.

During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN ARE:

The evidence of the independent expert in Emergency Medicine, was that “the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection. Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain. The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for those responsible for compiling guidelines to consider including this symptom to raise the profile of possible aortic dissection further”. The expert  felt that this would assist in cases such as Chantelle’s where the presentation did not have many of the usual ‘red flag’ symptoms.

In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.