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A coincidental finding

01 September 2007

Mr S was a 51-year-old warehouse worker with no medical problems. He was lifting a very heavy box at work when he felt a severe pain to his lower back with some radiation to his right buttock. He was sent home, and his wife drove him to their local A&E department.

On arrival, Mr S was seen by the assessment nurse. She noticed that Mr S’s pulse was fast and irregular so she decided to get an ECG done. The ECG showed that Mr S was in rapid AF. The ECG read-out was then stapled to the medical notes. The observations were recorded in the notes: HR 120, BP 130/60 and oxygen saturation 99%.

Emergency medicine registrar Dr Q saw Mr S and assessed him fully. He did a full clinical examination and also noticed a fast heart rate. He detached the ECG read-out and had a look at it.

He mentioned to Mr S and his wife that he had “a bit of a funny heartbeat” and asked whether he was on any medication for it. They both told Dr Q that Mr S had not seen his GP for about four years when he fell off a ladder and he was not on any medicines for anything. Dr Q folded the ECG and put it in the pocket of Mr S’s patient’s card.

Dr Q then performed a comprehensive assessment to exclude cauda equina syndrome. His final clinical impression was that Mr S had a muscular spasm and prescribed some analgesia. Immediately after, Dr Q was called to assess another patient so he did not write up his notes. Mr S’s back pain improved soon after this and he was discharged home.

Two months later, Mr S suffered an extensive CVA, resulting in long-term speech and mobility problems. He was found to be in AF at the time of admission and this was thought to be the possible cause for the stroke. Mrs S remembered then that the A&E doctor had mentioned something about an abnormal heartbeat. A formal complaint triggered an investigation.

There was no mention in Dr Q’s notes about the abnormal rhythm, but the nursing observations and ECG confirmed that Mr S was in AF at his first attendance and that no action had been taken.

Expert opinion

A&E and cardiology expert opinion was critical of Dr Q’s lack of action once he noticed that Mr S had an AF. They agreed that this finding had nothing to do with Mr S’s reason for attendance and was only a coincidental finding. However, it was clear that Mr S was at a high risk of suffering a stroke when he saw Dr Q, who missed a good opportunity to arrange treatment.

Expert opinion was also critical of the documentation. Dr Q had only recorded in his notes the examination of back, legs and perineum, with no mention of the findings on Mr S’s chest.

A subsequent claim against the hospital was settled for a moderate amount.

Learning points

  • Emergency medicine is a busy specialty where you are likely to see many different patients in a short period of time. It is good practice to write your notes as soon as possible after seeing each patient.
  • Failing to document or act upon relevant findings just because you “were very busy” does not make you less liable if you make a mistake. You have a duty of care to all your patients.
  • It is not unusual to find, by coincidence, a previously undiagnosed pathology. You have a responsibility to take action even if it is completely unrelated to the presenting complaint. In this case Dr Q should have arranged an urgent cardiology opinion.
  • For a reminder on the management of atrial fibrillation see a recent NICE guideline.