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Filed and forgotten

01 September 2010

A 49-year-old patient, Mrs A, underwent an uneventful laparoscopic colectomy under the care of consultant surgeon Mr B. The patient was reviewed, prior to her discharge, on a ward round by Mr B and his team the following morning. Mrs A reported that a few minutes before the doctors had arrived, she had experienced some chest discomfort, shortness of breath and a sensation that she might pass out.

The symptoms had subsequently resolved but she mentioned an ongoing feeling of claustrophobia and some anxiety about being in hospital. Clinical examination at this stage was unremarkable and there appeared to be no direct complications from her laparoscopic surgery. As a precaution, Mr B asked the nursing staff to obtain an ECG at the end of the ward round, although he remarked to his junior doctors (Dr C and Dr D) that this had all the appearances of a panic attack.

Two hours later, Mrs A had an ECG and the tracing was placed in her medical notes, but was not seen. Subsequently, Dr C and Dr D reported that they both thought it was the other’s responsibility for checking it. Mr B admitted that he had completely forgotten about the request for an ECG himself.

Later that evening, the nursing staff found Mrs A collapsed in her bed, completely unresponsive and with no palpable pulse. She was immediately attended by the duty resident doctor on call, who found her to be in a state of cardiac arrest with VF on a cardiac monitor. Cardio-respiratory resuscitation was commenced but, despite prolonged efforts, this was unsuccessful.

The ECG that had been filed in the patient’s notes earlier in the day showed very clear ischaemic changes and a run of five extra-systoles. The relatives made a claim against Mr B and the members of his team. Expert opinions were sought and there was common ground amongst all of them that had the ECG been reviewed and cardiological input been requested, the subsequent collapse could have been prevented.

The claim was eventually settled for a substantial sum.

Learning points

  • It is important not to dismiss potentially serious symptoms – postoperative chest pain requires thorough and prompt investigation. A diagnosis of a panic attack should be a diagnosis of exclusion.
  • A complication that was not directly related to the initial laparoscopic surgery occurred in this patient. If the problem was beyond the expertise of the consultant surgeon concerned, he should have requested a review by an appropriate colleague.
  • The ECG that was requested should have been looked at and not simply filed in the patient’s notes. Although it was the nursing staff who arranged the ECG, it was the responsibility of the medical team to review the tracing. When requesting investigations, the clinician responsible for overall care must have in place a robust system amongst all members of the team, to ensure the results of tests are always reviewed and acted upon. 
  • Teamwork is important and the roles and responsibilities of each team member need to be clarified. 
  • As ever, good communication and documentation within the notes are extremely important. At the very least, Mr B should have specifically told either Dr C or Dr D that it was their responsibility to look at the ECG, report any abnormality on it and act accordingly. This should also have been written in the medical notes.