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Crying wolf

01 May 2012

Mrs Z was a 34-year-old mother of four who smoked 20 cigarettes a day. She had recently been under investigation for central chest pain related to minimal  exertion. Her GP, Dr B, had arranged an ECG, which had been normal, and done some blood tests, which showed raised cholesterol. He had also found her to be hypertensive. He had made no firm diagnosis regarding her central chest pain but was considering a referral to cardiology.

Mrs Z developed what she thought was indigestion, which was also causing aching in both her arms. When she started feeling unwell with it she rang the out-of-hours (OOHs) service complaining that in addition to the indigestion she also felt hot and sweaty. Mrs Z was very well-known to the OOHs staff because she used the service very regularly for herself and her children. The triage nurses advised her to take some antacid or milk for the indigestion. The nurse had failed to get a past history for Mrs Z’s cardiac symptoms.

Mrs Z waited for an hour after drinking some milk but felt worse. She was still feeling sweaty and hot with the chest pain and rang the OOHs service again to explain this. She asked to speak to the doctor but the triage nurses remarked that “the doctor would not be able to do much more for that kind of problem”.

That evening she became really concerned after several hours of pain were showing no signs of remitting. She had managed to get all her children to bed but was feeling like something awful was going to happen. She rang the OOHs services again but was given the same advice by the triage nurses.

Unfortunately during the late hours of the evening, Mrs Z collapsed at home. One of her children called an ambulance but attempts by the paramedics to resuscitate her were unsuccessful. She was pronounced dead. The postmortem confirmed that the cause of death was an acute MI.

Mrs Z’s relatives made a claim against the triage nurses and the on-call doctors that night. The doctors denied having any knowledge about her. There were long discussions about the standards of training and support for the triage nurses and the levels of GP cover. The case was settled for a high amount.

Learning points

  • It is important to listen to patients who make recurrent calls regarding the same problem. Mrs Z had contacted the OOHs team and the GP surgery on multiple occasions. Doctors must not let an element of “crying wolf” blind their judgment.
  • There are risks associated with telephone triage and information not being appropriately passed on to the medical team. It is harder to make a diagnosis without the visual information from a patient’s appearance, behaviour and non-verbal cues so great care must be taken.
  • Written protocols should exist for the management of chest pain with clear guidance about when to pass on information to doctors. Although protocols often lack the “intuition” of experience, it would have been helpful if one had been adhered to in Mrs Z’s case.
  • Ischaemic heart disease is rare in younger women, but not impossible, particularly when associated with risk factors. It is important to consider this diagnosis in the differential even if it is uncommon.