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Alleged failure to investigate chest pain

13 November 2020

By Dr Sophie Haroon, Medicolegal Consultant, Medical Protection

Mr O was a 55-year-old, self-employed man who smoked ten cigarettes a day. He saw his GP Dr H complaining of “not feeling right” for one year. He had headaches, tingling in his throat, nausea, brief losses of vision and tiredness. On examination his eyes appeared normal, his BP was 142/95, his pulse was regular at 56, and there was no anaemia or jaundice. Blood tests were planned – which came back as normal – and Mr O was advised to see an optician.

Two weeks later Mr O saw another GP, Dr J. He was still getting intermittent headaches but there was no pattern to them. Cranial nerve examination was normal, as was his BP. He was encouraged to still see an optician as he had not yet done so, and “watchful waiting” was advised.

An optometrist reviewed Mr O the next day and found slightly raised intraocular pressures but not enough to cause symptoms, and short sightedness.

Two weeks after seeing Dr J, Mr O returned to see him again. This time he complained that his original symptoms, as reported to Dr H, were becoming more frequent, lasting longer and that he was very fatigued by them. He thought he might have some possible indigestion. There were no exertional symptoms and he was well in between. Blood tests, ECG and COR were arranged and omeprazole was started, with a planned review in one month.

The practice managed to perform Mr O’s ECG the very next day. This showed a sinus bradycardia and an established inferior myocardial infarction (MI). An ambulance was called and he was admitted to hospital. Cardiac intervention was attempted but it was not possible to open the thrombotically occluded right coronary artery so this had to be abandoned.

After the operation Mr O ended up back in hospital due to a post-MI inflammatory reaction. A cardiac multidisciplinary team meeting decided that percutaneous coronary intervention would be attempted if symptoms were significant. This was done five months after the first attempt – again with limited success.

By the end of the year, Mr O could not work due to his health, and was getting throat pain and sweating on minimal exertion. Further attempts at stent insertion also failed. Two years after the MI Mr O claimed he had not made a full recovery, was unable to work and was still symptomatic.

The patient makes a claim

Mr O brought a claim against Dr H and Dr J. He alleged that there was a failure to undertake cardiac-related investigations when he first presented, review him again when the optometrist found no cause for his symptoms, consider a cardiac diagnosis, administer GTN and aspirin, and refer him to the local cardiology service or, particularly at the last consultation, refer him to hospital as an emergency.

It followed that because of these breaches in duty, his diagnosis of coronary artery disease was delayed, as was its management; if diagnosed earlier, intervention would have been successful and circumvented the eventual MI he had, and all the subsequent long-term symptoms and failed procedures he ended up with.

As the claim progressed, it came to light that Mr O alleged he had told Dr H that he had had chest pain and that he had told Dr J at his first consult that he was having “funny turns”. Neither of these reports were noted in the records.

How Medical Protection assisted

Medical Protection was contacted for assistance. We obtained expert GP evidence and this deemed that Dr H’s actions were reasonable if it was accepted that Mr O had not mentioned chest pain at this consult and only the headaches and visual issues. The expert was more critical of Dr J in failing to act on the report of “funny turns” as although not recorded and possibly a factual dispute, on balance it was deemed more likely that Mr O had reported these symptoms, as the optometrist who subsequently saw Mr O recorded the same.

Expert cardiology evidence was also obtained. This concluded that Mr O’s presenting symptoms were complex, unusual and certainly not typical of angina or any other manifestation of coronary artery disease. It was thought that Mr O had an unrecognised and incomplete inferior infarction caused by occlusion of the right coronary artery, most probably when he began to experience chest pains three or four months before he ever presented.

Furthermore, given that this was thought to be a chronic total occlusion, any treatment, even if before Mr O was admitted to hospital, would not have been successful and would not have made a difference to his outcome in terms of persistent angina and his other impairments. However, it was thought that Mr O had, on balance, had a second MI when he presented for the final time to his GP. This in itself could have been avoided with earlier referral and because of it, life expectancy was reduced by one to four years.

Outcome

Initially it appeared this was a claim capable of being partially defended. However, there were some difficulties. Firstly, Mr O claimed he had reported chest pain to his GPs on two occasions. This was his recollection but for the GPs they were having to rely on their memory of their consultations from many years ago. Unfortunately the contemporaneous records had been summarised when Mr O had changed practices and did not reflect what was documented at the material time so were not useful in substantiating what did or did not happen.

Secondly, GP experts for Dr H and Dr J both concluded no breach of duty for Dr H but only if chest pain was not complained of. If it was, then there was a breach. Causation could be defended to a certain extent, albeit there was the issue of reduced life expectancy and some minor pain, suffering and loss of amenity.

It was considered that if this proceeded to trial, there were risks for the GPs. On balance, Mr O’s version of events would be more likely to be believed and could not be refuted comfortably for lack of clear recollection and records. There was then the issue of causation; most but not all could be refuted. In light of this, an offer to settle early was put to the solicitors. Unfortunately they refused.

There then followed a protracted course of events over a couple of years. Medical Protection collaborated with the other medical defence organisation involved, pooling resources and expertise in terms of the experts and panel solicitors used. This was a cost effective strategy. Various complications arose from Mr O’s side, including problems with attending for a medical examination to assess Mr O’s current condition and prognosis, disclosure of various other records, expert opinion changing, and questions arising over the fitness of Mr O to return to work.

The original claim for damages was a fairly low sum but rose through the life of the claim to something substantial. Given the weaknesses in the defence, success at a trial was not deemed likely. However, given the developments from Mr O’s side, there was certainly room for manoeuvre on the damages claimed. Mediation was sought. This successfully brought the case to a conclusion with damages paid out being reduced by 80%, shared equally between the two defence organisations involved.

Learning points

From a strategic, cost effective, and time management perspective, pooling of experts and panel solicitor firms can be an efficient and effective use of resources when managing a claim.

Mediation is a form of alternative dispute resolution. It is much less formal (though it follows a structured process) and much less costly than going to court. The primary goal is for all parties to work out a solution they can live with and trust. In addition to being more cost beneficial, mediation is strictly confidential, increases the control parties have over resolution, and usually has high compliance with the agreement reached. Medical Protection uses mediation where possible when it is in the best interests of the member and the wider membership fund.

Care should be taken when summarising patient records if a patient decides to change practice. With paper records in particular, it is easy to lose granular details. For more advice on good record-keeping, read our factsheets on the Medical Protection website, or alternatively log in to the e-learning platform PRISM.