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Don’t drop the baton

01 September 2009

Forty-five-year-old bus driver Mr B attended A&E following an episode of central chest pain that resolved spontaneously while he was at work. The pain was severe and radiating to his left arm and it lasted about 15 minutes. Mr B had no previous cardiac history, but had several risk factors: he was a heavy smoker and somewhat overweight. By the time he arrived in the emergency department, brought in by a colleague from work, the pain had subsided.

Junior doctor Dr O was working a day shift at the department on that day. He took a comprehensive history and performed a thorough examination, which was normal. Dr O looked carefully at the ECG carried out on arrival and documented that the ECG appeared within normal limits. Dr O arranged for Mr B to have his troponin levels first tested one and a half hours later. He explained to Mr B the importance of the blood tests and suggested admission to the A&E observation ward, for repeated blood tests and ECGs, but Mr B declined. Dr O documented this.

Dr O’s shift finished before the troponin test results were ready, so he handed over the case to another junior doctor, Dr W, and asked her to make sure the patient didn’t leave before the test was proved to be normal. However, Dr O did not document his plan of action or the name of the doctor he had handed over to.

Two hours later, Dr W discharged Mr B, and noted “Non-specific chest pain. Home”. She didn’t sign her notes. Unfortunately, the troponin levels were raised but Dr W failed to check the test results. Mr B suffered a further episode of severe central chest pain 24 hours later followed closely by a fatal cardiac arrest. The autopsy confirmed the presence of an acute myocardial infarction.

A claim was made alleging substandard care by both Dr O and Dr W. During the course of the investigation, Dr O insisted that he had handed over to Dr W and specifically suggested that the troponin tests had to be checked, but Dr W denied any knowledge of the patient or the handover. The documentation was very limited, but some nursing notes supported Dr O’s account of the events.

At the subsequent inquest, both doctors were called to give evidence. Dr O’s version of events was accepted on the basis of the nursing notes and some of his documentation; his management was considered to be acceptable. However, Dr W’s was considered inappropriate. The hospital settled the claim for a substantial amount.

Further information

Learning points

  • Working shift patterns means that careful handovers are vital for patient safety. When referring a patient or making a handover, it is always useful to document the time, the name and the specialty of the recipient doctor.
  • Documenting a clear plan of action, with specific instructions, makes handing over safer. It is important to emphasise the need for good communications within teams, particularly with the increasing use of flexible working patterns.
  • Leaving written records of what has been said to the patient and relatives is also good practice.
  • The discharging doctor is ultimately responsible for the actual discharge of a patient and its consequences. It is important that care is taken to ensure that discharge of a patient is managed appropriately and that the patient is aware of the risks and when to seek further advice. If in doubt, deal with the patient as if no other doctor has seen him/her before.
  • Readable and clear notes will lower the multiple dangers of handing over and will save time and effort to the receiving doctor, particularly in an environment such as an emergency department where time is precious. Avoid using unusual abbreviations. 
  • Employers indemnity is generally limited to claims but does not usually extend to representation for a doctor for the consequences of an adverse outcome at an inquest. Dr O was represented by MPS and avoided criticism. Dr W was not a member of a defence organisation and was not independently represented.
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