Case 15 A woman with chest pain

Mrs Wilkinson, a 78-year-old widow, presents to the Emergency Department at 5.30 on a Tuesday morning with a three-hour history of central chest pain accompanied by shortness of breath. The pain was initially extremely severe. She has a history of diffuse coronary disease on a background of diabetes. She says that her cardiologist had informed her that she was for ‘medical management’. The chest pain is of a different character to previous episodes – she usually experiences discomfort in the jaw and left arm accompanied by mild nausea, brought on by moderate exercise (70–80 metres on the flat).

She continues to smoke and flew back from a three week Caribbean cruise four days ago.

On examination, Mrs Wilkinson continues to have some central chest discomfort and an ache between her shoulders. The pain has reduced in intensity since its onset. Her vital signs demonstrate a tachycardia (130 irregular), tachypnoea of 24 breaths per minute and an oxygen saturation of 92% on air. Breath sounds are present throughout the lung fields with no added sounds.

What would you do now?

Dr Ahmed, an FY2 doctor, applies supplemental oxygen and administers 300 mg aspirin. She requests an electrocardiogram which demonstrates left bundle branch block and atrial fibrillation. She accesses an electronic discharge summary from eight months earlier which attests to an ECG with LBBB pattern and sinus rhythm at that time. A routine panel of blood tests are sent by the nursing staff including a Troponin I. Mrs Wilkinson’s pain seems to be settling.

What is your differential diagnosis?

The FY2’s diagnosis is one of Acute Coronary Syndrome precipitated by a tachyarrhythmia. In addition to the aspirin and oxygen, she prescribes single doses of low molecular weight heparin and clopidogrel, and an oral loading dose of digoxin for rate control.

After two hours, she reviews Mrs Wilkinson again. She is now pain free although still short of breath. She has a heart rate of 110 per minute (AF) and oxygen saturations of 94% on air. She has been able to mobilize to the toilet and back without any worsening in symptoms. Baseline blood results are now available which are normal apart from a modestly elevated troponin I (0.6 ng/ml). Thyroid function test results will be available in 24 hours. A chest X-ray reveals clear lung fields, a small left pleural effusion and borderline cardiomegaly.

What would you do now?

Dr Ahmed talks on the telephone to the Cardiology Registrar who agrees that this ischaemic episode may have been rate-related and confirms that Mrs Wilkinson has severe multi-vessel disease with poor distal vessels: she is a candidate for neither angiographic nor surgical intervention.

Dr Ahmed remains comfortable with her diagnosis and given that the tachycardia seems to be responding to digoxin and the chest pain has resolved, she decides to discharge Mrs Wilkinson with digoxin (a further loading dose followed by a maintenance dose) and advice to see her GP on Thursday that week for review and results of her thyroid function tests.

On Thursday morning, Mrs Wilkinson fails to attend her GP appointment. After morning surgery, the GP asks the district nurse to make contact with Mrs Wilkinson as she is usually very reliable. The district nurse is unable to contact Mrs Wilkinson by telephone and makes a home visit. She is able to see Mrs Wilkinson on the floor through the sitting room window. The police are called to gain entry to the house and Mrs Wilkinson is confirmed dead.

A coroner’s post-mortem examination reveals a type B dissection of the aorta which has ruptured intra-thoracically.

Mrs Wilkinson’s son is concerned that his mother had been discharged from the Emergency Department within 24 hours of her death and he writes to the hospital seeking an explanation.

What approach should the clinical director take when responding to this letter?

Expert opinion

An elevation in serum troponin is not 100% specific for myocardial infarction due to coronary disease. In the case described, misdiagnosis was driven by the assumption that the troponin rise was driven by rate related ischaemia. The history might also have suggested initially a diagnosis of pulmonary embolism and consideration should have been given to performing a CTPA.

Even in the context of the Dr Ahmed’s working diagnosis, further errors were made: Dr Ahmed was perhaps lulled in to a false sense of security by the conservative approach advocated by the cardiology registrar, although the registrar’s comments were quite focused rather than recommending an overall management plan, and he did not see the patient himself. Even in the absence of interventional options, a patient with myocardial damage regardless of cause would typically be observed in hospital for 24–48 hours. This course of action – appropriate on the basis of the Dr Ahmed’s working diagnosis – may have prevented Mrs Wilkinson’s death and offered further opportunities to reach the correct diagnosis.

There were a number of clues in Mrs Wilkinson’s history that this was not simple acute coronary syndrome – the character and initial severity of the pain, and the presence of a pleural effusion.

Legal comment

Mrs Wilkinson’s son has written a letter of complaint; he is not currently seeking any form of recompense. A complaint response should be sent in line with the formal NHS Complaints Process. Using the Department of Health’s complaint grading matrix, this letter is likely to be graded as a serious (red) complaint. In accordance with the Being Open and Honest NHS Policy the Clinical Director’s response should be exactly that.

The patient’s death also triggered the Serious Incident Requiring Investigation (SIRI) process by the NHS Trust, with an action plan and final report to be shared with the family.

Mrs Wilkinson’s death within 24 hours of discharge from hospital required a referral to the coroner, from which the coroner’s post-mortem followed. The coroner’s officer liaised with the Trust’s legal team in order to obtain a copy of the healthcare records and statements from Trust staff to assist the coroner establish cause of death. Where, as in this case, there has been an SIRI investigation, the report is shared with the coroner as evidence of organizational learning. Where the coroner has significant concerns about patient safety, he has it in his power to write a Rule 43 Letter to the Chief Executive of the Trust (with a copy to the Ministry of Justice) requesting specific reassurance that steps have been taken that would assist to prevent a similar fatality in the future.

Mrs Wilkinson’s son would have three years from her date of death to bring a clinical negligence claim (under the ‘primary limitation period’). Whilst breach of duty may be established, for the deceased’s estate to make a claim for damages under the Law Reform (Miscellaneous) Provisions Act 1934, or any dependents to make a claim under the Fatal Accidents Act 1976, they will also need to establish causation, i.e. would require that the actions or omissions of healthcare professionals had directly resulted in Mrs Wilkinson’s death. The coroner’s verdict may give greater clarification of the factual cause of death (although the coroner can make no assessment of liability).

If following the coroner’s Inquest hearing and response under the complaints process, Mrs Wilkinson’s son decides to bring legal action, the Trust would have to notify the NHS Litigation Authority under the Clinical Negligence Scheme for Trusts (CNST) reporting protocol for an evaluation of liability and quantum. There is a litigation risk to the Trust and early expert advice on liability would assist the decision to defend or to reach a settlement. As causation is arguable, this may assist to reach a discounted settlement without an admission of liability. In the absence of a large dependency claim, it is unlikely that the cost benefit analysis of this case would permit it to be run to trial.

If such a legal action was to be brought, it is possible that the NHSLA, the Trust and the individual doctors involved may have differing views on the best form of defence and indeed, whether to actively seek a settlement. For this reason, medical practitioners should make their views known to the Trust’s legal team so that these can be considered by the Trust and NHSLA.

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