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Getting to the heart of the matter

01 January 2007

Mr T, a 49-year-old accountant, visited his GP,Dr F, on several occasions. He had experienced episodes of upper abdominal pain. Dr F documented a history of bouts of epigastric pain, lasting typically for about 30 minutes, that had come on gradually over the preceding six months. They usually occurred at night and were associated with abdominal bloating and belching.

The pain was not brought on by exertion and there had been no syncope, sweating or breathlessness associated with the pain. Mr T had a past history of gastric peptic ulcer, which had been managed with ranitidine.

Dr F considered a diagnosis of ischaemic heart disease and assessed Mr T’s cardiac risk profile.His father had a heart attack at the age of 68.Mr T’s fasting cholesterol had recently been checked in a well-man clinic and was 6.1 mmol/l with a marginally elevated LDL/HDL ratio. Mr T’s BP was normal (122/76 mmHg), he had never been a smoker and had no history of diabetes.Urinalysis at the well-man clinic had shown no evidence of glycosuria.

Dr F calculated Mr T’s 10-year risk of coronary heart disease at 10%, ie low-risk, using a calculator provided with his practice’s software package. Dr F examined Mr T’s cardiovascular and respiratory sytems and found no abnormality.

On this basis, Dr F decided that the most likely cause for Mr T’s symptoms was recurrence of his gastric peptic ulcer. He changed his ranitidine to omeprazole and arranged a routine outpatient gastroscopy. Two weeks after last consulting Dr F, Mr T experienced a sudden onset of severe central chest pain, sweating and dyspnoea after retiring to bed. He phoned an ambulance and was taken urgently to his local emergency department. He was quickly diagnosed as suffering from an acute inferior myocardial infarction and received thrombolysis within 30 minutes of arriving in the department. He made a good recovery and had no clinical or echocardiographic evidence of cardiac failure when he was reviewed six weeks later.

Mr T started a legal claim against Dr F, alleging that he had been negligent in attributing his symptoms to a gastric ulcer, and that he should have arranged investigations such as an exercise ECG or angiography, via a cardiologist.

Expert opinion

We asked two GP experts to examine the notes. They were very supportive of Dr F’s assessment of Mr T’s symptoms and felt that he had reached acceptable conclusions based on sound clinical reasoning. At all times he had kept good records of the consultations, documented his clinical thought processes and used all the practicable tools available to him to consider the likelihood that Mr T’s pain could be myocardial in origin.

We rebutted Mr T’s claim but his legal team persisted and took the case to court.We defended Dr F and won the case. The judge noted that Dr F’s care of Mr T was exemplary. The judgment stated that whilst it was unfortunate that Mr T had suffered a heart attack, Dr F could not be held liable for this, as it was well recognised that atypical presentations of ischaemic heart disease could be very difficult to diagnose, and Dr F had done all in his power to consider and seek evidence of the diagnosis.

Learning points

  • Dr F had performed a thorough clinical assessment, considered the correct possible diagnoses and acted appropriately on the information that he had to hand.
  • Dr F’s excellent clinical notes allowed us to defend him with relative ease, once we had ascertained that his standard of care was what could reasonably be expected of a general practitioner.
  • It is not negligent for a doctor to miss a diagnosis where they have acted appropriately and in line with what is reasonable for their specialty and experience. This is particularly true where an illness presents in an atypical fashion.
  • We were sympathetic to Mr T’s experience but defended Dr F as he should not be held liable for the unfortunate chain of events.
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