Sharon's aortic dissection patient story

Sharon Goddard was a Medical Secretary at the Bristol Children’s Hospital and a member of the Rheumatology Team. She had worked for the NHS for many years and had received a 30-year service award.

On the 18th December 2022 she suffered an acute Aortic Dissection. Sharon was 53 years old and had Loeys-Dietz syndrome, with a dilated aortic root which was being monitored annually. This condition carries an increased risk of Aortic Dissection.

Returning from a family holiday abroad, during the descent into Gatwick Airport, Sharon experienced pain in her chest, radiating up to her neck and down her left arm. Sharon felt she was going to pass out. She expressed increasingly severe pain, saying “I have never felt pain like this” as her breathing became shallow and erratic.

The fire service boarded the plane and two medically trained members carried out an assessment and basic observations. Sharon described her pain level as 10/10. The family made the fire service medics aware of her condition.

A paramedic with an assistant/trainee boarded the plane, carried out more observations and an ECG. The paramedic was informed about Sharon’s Loeys-Dietz Syndrome (LDS) diagnosis, along with the explanation that this was a genetic condition, inherited from her father, who had undergone an Aortic valve replacement as a result of this condition. None of the medical team had heard of LDS, so Sharon’s daughter’s provided a Google explanation and said it was similar to Marfan Syndrome, of which they were aware. 

After palpating Sharon’s chest, the paramedic made a diagnosis of musculoskeletal damage from deep coughing. Sharon replied “No it’s not muscular, it hurts more than that. I know what that feels like, it’s deeper than that.” The ambulance crew then took Sharon to East Surrey and Sussex Hospital. They did not pre-alert the hospital, which was exceptionally busy that morning, with over 120 patients in the ED, compared with its capacity of 50. Doctors were seeing four or five patients at the same time. The CT scanner in the department was also broken.

The Paramedic handed over to the ED Matron who was not familiar with LDS, but said she was aware of Marfan Syndrome. Sharon was left in a corridor and not seen again until 2pm, three hours after arriving. Eventually she was reviewed by a Physician Associate, who took her history and elicited that Sharon had an Aortic dilatation, which caused her concern for a possible Aortic Dissection.

At 2.50pm, an electronic request for an emergency CT scan of Sharon’s Aorta was sent. 40 minutes later, the Physician Associate realised the scan had still not been performed. At 5pm, Sharon was informed that she was about to go for the scan, but at this point her condition suddenly deteriorated. Her blood pressure dropped and she was moved to the resuscitation area, which was full, so she was placed in the same cubicle as another patient. 

Once Sharon was stabilised there were further delays, because the CT scanner was not working. Patients needed to be transferred to the main hospital for a scan, but the ED staff were unable to find a portable monitor to go with her. At 6pm a CT scan was performed, three hours after it was requested. It revealed an acute Aortic Dissection. The Aortic centre at St. George’s Hospital were called, but had no capacity. Kings College Hospital had capacity and asked for Sharon to be blue lighted to them, but no-one called an ambulance.

At 8.20pm the doctor realised that an ambulance had not been called and was told that the call was being managed as a category 2. During this delay, the opening at Kings was taken by another patient. By 10pm the Aortic service at St Bartholomew’s Hospital had agreed to accept Sharon for surgery, but the ambulance requested at 8.22 pm had still not arrived. A nurse called the ambulance service again and asked for the request to be upgraded to category 1, but this was refused. Later still, an ambulance worker who was in the ED telephoned to press for an ambulance as soon as possible, saying that Sharon may die in the department. An ambulance arrived at 11.45pm, 3 hours and 20 minutes after it had been requested.

The Operating Unit Manager said the delay was due to a high level of demand at that time and that the service was under a “Major Surge”. He said that the system was not working as it was designed to work and it was not working effectively to keep people safe.

Sharon was transferred to Barts, a journey expected to take about an hour. This was an unusual destination for the ambulance crew and they ended up at the public entrance, but were unable to gain entry. They had to drive for another 10 minutes to the correct entrance. When they arrived, no-one was waiting for them and the hospital was all locked-up. After another 35-minute delay and a lot of confusion and frantically looking for the surgical team and the operating theatre, the ambulance crew eventually handed Sharon over. She arrived in theatre at 1.30am on 19th of December 2022. 

Sadly, Sharon suffered a cardiac arrest during anaesthesia and could not be saved. 

From presenting to emergency services at 9.40am on the 18th of December to reaching theatre at 1.30am the following day, there was a period of almost 16 hours. 

At Sharon’s Inquest, the Coroner concluded that if surgery had commenced prior to her deterioration, as it ought to have done, Sharon would have had an 80 to 88% chance of survival. Her death would probably have been avoided if she had reached theatre in a timely manner. 

Sharon was a loving and much-loved wife, mother, daughter, sister and friend. She has left behind three beautiful daughters.