Case 9 Cry wolf

James O’Connell is a 31 year old man with a long history of cigarette, marijuana, alcohol and opioid drug abuse, who in the last 12 months has attended the emergency department on at least 30 occasions saying he has taken an overdose or that he has severe chest pain and needs to be admitted to hospital. He is known to be infected with hepatitis C and he has an abnormal chest X-ray with pleural thickening at the left base, possibly following chest trauma. His ECG has high ST take off in the anterior leads but is otherwise normal and there is a copy on file in the departmental folder for comparison when he comes in complaining of chest pain.

He is often intoxicated when he arrives late at night but he is never abusive to staff who know him well and he almost always takes his own discharge the next morning after breakfast. Numerous attempts have been made to change his behaviour and the psychiatry liaison team have labelled him as having a personality disorder. In recent weeks his attendances have become less frequent and he seems to be more content since he has been sleeping at the local night shelter.

On Friday night he arrives in the emergency department and tells the nursing sister on duty that he has chest pain and feels very sick and dizzy.

What course of action would be appropriate for the triage nurse?

The sister knows him of old and tells the emergency department registrar that ‘Jimmy’s back’, writing in the notes ‘multiple attender, complaining of chest pain again’. She records the BP at 96/65, heart rate 98, respiratory rate 26, oxygen saturations 91% on air, but she does not register that these are abnormal or that they should trigger prompt investigation.

The registrar, Dr Proudfoot, has met Mr O’Connell previously and after some friendly banter he undertakes a cursory examination. He notes there is dullness at the base of the left lung but when he reviews the old chest X-rays he assumes this is longstanding. Dr Proudfoot tells Mr O’Connell that this time the hospital is very busy and he cannot just come in for a bed for the night. He tells him to go back to the night shelter and moves on to his next patient without writing adequate notes or addressing the obvious physiological abnormalities. Dr Proudfoot simply writes ‘ISQ – not for admission’ in the notes before moving on to the next patient in the queue.

What do you think about Dr Proudfoot’s actions?

Jimmy hangs around the waiting area and continues to complain that he feels dizzy and unwell but no more observations are performed and he is encouraged to leave by the security staff. He returns to the night shelter and next morning he does not get up and staff check on him and find him to be very pale, sweaty and monosyllabic. They wonder if he is withdrawing from alcohol but an experienced volunteer care worker is concerned and arranges an ambulance to take Mr O’Connell back to hospital. When he arrives he is clearly very sick with a blood pressure of 60 mmHg systolic, a heart rate of 140 and unrecordable oxygen saturations. He is given intravenous fluids and antibiotics and is taken to the intensive care unit for inotropic support. Despite intensive support he succumbs to overwhelming staphylococcal infection associated with an infected groin wound where he had been injecting his heroin.

His case is referred to the coroner who is concerned that inadequate care was provided and staff dismissed Mr O’Connell’s complaints because he had ‘cried wolf’ so often.

Expert opinion

Every Acute Medical Unit and Emergency Department will have its cohort of regulars who are very well known to the staff. Some have serious problems which result in frequent exacerbations (e.g. brittle diabetics, asthmatics and patients with COPD and angina) and knowing them well allows prompt action to be taken and early recognition of when they are even more sick than usual. Other frequent attenders have anxiety or personality problems and they are at particular risk of not being taken seriously.

Few doctors respond well to being deliberately misled by people who have different motivations for seeking admission than the average patient, and it is all too easy to allow personal feelings to override a dispassionate professional assessment. That is not to say that every such patient who complains recurrently of chest pain and breathlessness (caused by hyperventilation) should get chest X-rays, and a CTPA – but as in Mr O’Connell’s case you should never ignore clear warning signs that there may be a more serious problem on this occasion.

Always ask yourself ‘how do I explain the low oxygen saturation or the persistent tachycardia?’ and if you cannot logically do so then do not ignore it. It should be no skin off your nose if the next morning when the old notes arrive that you find you have done what the last ten junior doctors did and you admitted someone unnecessarily. You have to take people at face value, particularly when you are inexperienced. The competence and confidence to discharge this group of patients promptly comes with experience – make sure you develop the competence before the confidence. At all times maintain appropriate professional behaviour, examine and assess patients thoroughly, irrespective of their background or past behaviour. A history of previous problematic behaviour does not confer immunity to subsequent serious illness.

Legal comment

In accordance with the Human Rights Act 1998 and NHS policies supporting equality and diversity, a frequent attender is owed the same duty of care as any other patient to have a full clinical assessment of the reasons behind his attendance at the Emergency Department on each occasion that he presents. Such a cursory examination is a breach of duty of care and was compounded by lack of documentation. The decision to discharge was premature and not based on a full clinical assessment of the presenting clinical complaint. The previous or recent past medical history would not provide any adequate defence to a civil litigation claim.

The coroner will be looking at the chronological chain of factual events leading to the patient’s death and as such, the factual evidence of staff under oath, would demonstrate that they had not undertaken a full and proper assessment. To avoid a Rule 43 Letter, or adverse criticism from the coroner, the Trust would need to evidence organizational learning by way of patient pathway protocols which staff should follow with regard to making a diagnosis and seeking a more senior opinion if required.

There are cases when frequent attenders are present on Trust premises with no presenting clinical condition. Any verbal or physical harassment should be documented in accordance with the Trust’s Zero Tolerance Policy since such documentation in the patient’s healthcare records and Incident Report Forms will provide background evidence for the Trust should it wish to take forward prosecution under the Harassment Act 1997, whereby three previous examples of pre-existing behaviour are required. An injunction can be considered if a patient persistently attends Trust premises without a genuine presenting clinical condition but any Injunction Order will make it clear that the patient is still entitled to attend Trust premises for clinically diagnosed emergency treatment. Information sharing with other public health bodies and local authorities may demonstrate that the frequent attender’s behaviour is also having impact on other public authority resources. In these cases joint application to court for an injunction may assist.

Stay updated, free articles. Join our Telegram channel

Join