Case 11 A doubly bad outcome

Mrs Benjamin is a 34-year-old woman who has been referred to the medical assessment unit by her GP with a 48-hour history of breathlessness. She is short of breath on minimal exertion but there are no other associated symptoms – specifically no cough or chest pain. Mrs Benjamin is an occasional smoker and has no personal history of respiratory disease. She returned from honeymoon in the Maldives six weeks ago where she had developed a swollen left calf shortly after stepping on some coral. This had improved over a week or so. She is seen in the assessment unit by Dr Talbot, the on-call SHO. Mrs Benjamin seems anxious and remarks to Dr Talbot that her grandfather died in an adjacent bay two years ago.

What is the differential diagnosis and how would you investigate her complaint?

Mrs Benjamin’s respiratory rate at rest is 26 min−1 and oxygen saturations on air are 98%. The chest is clear with breath sounds heard throughout. Dr Talbot feels that it is important to rule out a pulmonary embolus. She sends off a panel of blood tests including a D-dimer and requests a chest radiograph before assessing another acutely unwell patient whilst awaiting results. Half an hour later, Dr Talbot is called by the radiographer who informs her that Mrs Benjamin is tearful and refusing to have a chest radiograph as she is 14/40 pregnant.

How does this new information influence your management plan?

Mrs Benjamin tells Dr Talbot that she became pregnant on her second cycle of IVF and she is terrified of the potential effect of radiation on the pregnancy. Dr Talbot explains that a chest radiograph involves a very modest exposure and the effects of this can be further mitigated by abdominal shielding. Simultaneously, Mrs Benjamin’s blood results are available showing a normal CRP and D-dimer. Dr Talbot and Mrs Benjamin agree that she will have a chest radiograph to rule out the possibility of a pneumothorax but that further ionizing radiation (for example, CTPA) will not be necessary in view of the D-dimer result. Mrs Benjamin’s radiograph is entirely normal and she is discharged home with Dr Talbot’s reassurance.

What are your thoughts upon Dr Talbot’s management plan?

Six days later, Mrs Benjamin collapses at home. An ambulance is called and she is found to be in cardiac arrest. Resuscitation efforts continue en-route to the emergency department. Twenty minutes after arrival there, in the absence of a return of spontaneous circulation, the resuscitation attempt is called off.

A coroner’s inquest is held and although Mrs Benjamin is found to have died from natural causes (pulmonary embolism), the coroner criticizes the Trust for a failure to appropriately investigate Mrs Benjamin during her attendance to the AMU.

Expert opinion

Mrs Benjamin presented with acute shortness of breath with clear tachypnoea and no associated symptoms to suggest an infective aetiology. Even without the history of pregnancy, the presentation along with the history of a long haul flight and leg symptoms made it imperative to rule out venous thrombo-embolism (VTE). A D-dimer was not appropriate given the high probability of thromboembolic disease. The subsequent disclosure of pregnancy and IVF treatment heightens the chances of VTE still further.

Dr Talbot did not achieve the appropriate balance between risks and benefits. Fatal VTE is more common during pregnancy and puerperium than in age matched controls. The consequences of missed or poorly managed VTE are also greater with two lives at risk. Based on the history, Mrs Benjamin should have been counselled that the benefits of a definitive test to confirm or rule out VTE outweighed the risks. Non-ionizing tests including lower limb Doppler and echocardiography could have formed part of the investigative strategy although had they been normal, Mrs Benjamin should have been advised to continue to perfusion scanning or CTPA according to local protocols.

Dr Talbot failed to use the D-dimer test in an evidence-based manner. She failed to enquire as to whether her patient was pregnant prior to requesting the use of ionizing radiation. Dr Talbot also failed to seek expert advice from senior physicians, radiologists or obstetricians. This points to a lack of awareness of her own limitations and competencies, or a systematic problem in the hospital if junior doctors are left to ‘fend for themselves’.

The confidential enquiries into maternal death (CEMD) have long reported avoidable death through VTE. Many of the features of this case – including a well-meaning desire to minimize risk for mother and unborn child – are common to those cases reported in CEMD.

Legal comment

Proceedings in the coroner’s court are governed by the Coroner’s Act 1988 supplemented by the Coroner’s Rules 1984 (as amended). The duty of the coroner is restricted to investigations of certain deaths. He is charged with the duty to make inquiry where there is reasonable cause to suspect that a person’s death was either violent or unnatural, sudden and of unknown cause. Whilst doctors commonly sign a death certificate this document certifies the cause of death only. The registrar of births and deaths issues the actual legal death certificate. There is no obligation on doctors to report deaths to the coroner but it is sensible to do so. A death should be reported to a coroner in the following circumstances:

• The cause of death is unknown.
  
• The doctor has not attended the patient during his last illness.
  
• The doctor neither attended the patient during the last 14 days before death nor saw the patient’s body after death.
  
• Death occurred during an operation or before recovery from the effects of an anaesthetic.
  
• Death was caused by industrial disease or poisoning.
  
• Death was believed to be unnatural or caused by violence, neglect or abortion.

Informal consultation with the coroner is vital to clarify whether or not a patient death should be reported.

The coroner has jurisdiction over a patient’s body once death has been reported. He can order a post-mortem to be undertaken by a practitioner of his choice. When death occurs in the course of medical treatment, particularly if concerns have been expressed about the standard of care, an independent pathologist usually carries out the post-mortem at another location.

The inquest hearing is not a trial and the coroner’s terms of reference are restricted since the coroner only considers questions about who the deceased was, and when, where, and how the deceased came to his/her death.

Where a patient’s death has also resulted in a Serious Incident Requiring Investigation (SIRI) by the NHS Trust it is good practice to share the report and completed action plan with the coroner as evidence of organizational learning. Rule 43 of the Coroner’s Rules 1984 enables a coroner to refer matters to the appropriate authority, if by so doing it may enable changes to be made to prevent repetition of similar fatalities. In the context of the NHS, the coroner would send a Rule 43 letter to the Chief Executive of the NHS Trust and under Rule 43A the Trust is required to provide a written response within 56 days. Any Rule 43 letters issued are automatically copied to the Ministry of Justice and appear in the Ministry of Justice’s Annual Summary Report. The Care Quality Commission also monitors Rule 43 letters with regard to healthcare. The first Ministry of Justice Summary Report was published in September 2011. The report seeks to identify any emerging national trends relating to patient safety.

Against whom would a case be brought – the individual doctor or the NHS Trust? Actions in negligence require there to be a person or persons, who owe a duty of care. Where the patient has received acute NHS care, the NHS Trust is cited as the defendant. Actions against GPs will name the individual doctor as defendant. Similarly, private practitioners are pursued individually or are identified as a co-defendant with the private hospital. Where a doctor is employed by an NHS Trust then the named defendant will be the NHS Trust under the legal principle of vicarious liability.

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