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A wrong diagnosis but no criticism

30 May 2019

INQUEST

Mr G, 28, was brought into hospital by ambulance following a motorway accident involving multiple casualties. He had been unable to stop in time and had driven into the back of the car in front. Although the force of the collision had been sufficient to deploy the airbag in Mr G’s car, he was fully conscious on arrival at hospital and was able to give a clear account of what had happened.

Mr G was assessed by Dr C in the Emergency Department, who recorded the patient to be fully alert and oriented with GCS 15. She noted a non-tender abdomen, chest clear to auscultation, good air entry on both sides, with no obvious signs of injury. X rays of the cervical spine were deemed unnecessary as Mr G was assessed as meeting the NEXUS criteria and therefore his cervical collar was removed.

Mr G was kept in the resuscitation area and, over the next 60 minutes, he became increasingly anxious, asking repeatedly about the other casualties and wanting to know if his partner who had been travelling with him was safe. They had been, he said, en route to a wedding and were now probably going to miss the ceremony. Mr G mentioned a past history of anxiety attacks and said he’d had counselling, which had helped, and that he was not currently on any medical treatment.

He was reassured by nursing staff, and analgesia in the form of 1g oral paracetamol was administered. Mr G spoke again about the crash and how close he had come to going through the windscreen. He told Dr C that there had been little chance to stop his car in time and that the other vehicle was upon him before he knew anything about it. Throughout the conversation he began to breathe more rapidly and complained of his fingers tingling. Dr C believed that Mr G was having a panic attack so she explained to the patient that he was hyperventilating and, along with the nursing staff, attempted to calm him down. Due to Mr G’s agitation, Dr C asked the nurse to give him 5mg of diazepam.

Notwithstanding this, Mr G complained of feeling claustrophobic and attempted to take off his oxygen mask. At that point his pulse rate was 122/min and regular, his blood pressure was 102/58mmHg and oxygen saturation was 91%. Dr C and the nursing staff continued in their attempt to reassure and calm him, and get him to slow his breathing down. Mr G began to shout and attempted to get up from the trolley and, while they were trying to get him to lie back down, he became limp and lost consciousness. IV access was obtained and cardiac monitoring showed pulseless electrical activity. Despite extensive resuscitation attempts, Mr G died.

A postmortem examination found a splenic rupture and intra-abdominal haemorrhage.

Outcome

The case went to the coroner’s court for an inquest. Dr C was called to give evidence at the inquest and Medical Protection instructed a barrister to individually represent her. In order to prepare for the inquest, a conference with the barrister, the instructed solicitor and a medicolegal consultant was arranged, where Dr C’s notes were reviewed in advance.

Although Dr C had wrongly attributed Mr G’s symptoms to dehydration and anxiety, based on the evidence heard during the inquest from Dr C’s quality note-keeping, the coroner found that this did not necessarily mean her decision-making was flawed.

The coroner recorded a verdict of accidental death, concluding that death was due to the injuries sustained from the car crash.

Learning points

In the context of emergency presentations including trauma, be mindful that agitation may be due to an underlying physical problem (eg hypoxia, hypoglycaemia or hypovolaemia) and these should be excluded before attributing agitation to psychological causes.

As always, good note-keeping is essential – not only for patient care, but in case of any further investigations into a doctor’s actions. In this case, Dr C’s clear, contemporaneous records provided essential evidence during the inquest.

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