CASE FILES CLAIM TELEPHONE TRIAGE


BACKGROUND Mrs T – a 54-year-old smoker – phones NHS 111 in the morning complaining of left-sided chest pain and discomfort in both arms over the last 24 hours. She speaks to a nurse adviser who also records that the patient has been generally unwell over the last few days with a fever and cough. The call is passed to a locum GP – Dr D –


for triage and Mrs T relates that whenever she exerts herself she gets sharp chest pains and that lately at night she has awoken breathless and panicked. The GP asks if there is any history of heart disease in the family and Mrs T reports that her mother had angina and that her father died of a heart attack at age 60. Dr D records symptoms of cough with chest and arm pain but that, apart from being a smoker, the patient seems otherwise fit and healthy and is taking no medication – though he does note the family history of heart disease. The doctor refers the patient to an


out-of-hours clinic for review and that afternoon she is seen by another GP – Dr G – who records symptoms of cough, chest pain and fever. On examination the patient’s chest is found to be clear apart from a slight non-focal respiratory wheeze. A diagnosis of upper respiratory tract infection is recorded and the GP prescribes amoxycillin. Five days later Mrs T collapses at work and is found by ambulance crew to have


16 / MDDUS INSIGHT / Q2 2017


suffered a cardiac arrest. Attempts at resuscitation fail and she is pronounced dead on arrival at the local A&E. The diagnosis is myocardial infarction. Dr D later receives a letter of claim from


solicitors acting on behalf of the family of Mrs T, alleging negligence in not making an immediate referral to hospital in the telephone triage, given the “obvious” symptoms of acute ischaemic heart disease. It is also alleged that the history documented by Dr D and passed to the OOH centre omitted significant details from the call. The second GP – Dr G – is also claimed against separately.


ANALYSIS/OUTCOME MDDUS instructs a primary care expert and consultant cardiologist to review the case on behalf of Dr D. In considering both a transcript of the call and the recorded


notes, the primary care expert forms the opinion that the GP failed to respond appropriately to the history provided by the patient. The symptoms reported in the call transcript should have prompted Dr D to undertake a more detailed enquiry into the nature and severity of the chest pain and breathlessness reported by Mrs T, including any significant accompanying symptoms. A more detailed history would have likely indicated the need for immediate emergency referral to hospital. The patient was referred for a face-to-


face consultation at the OOH centre but the primary care expert considers that the history documented by Dr D and passed to Dr G was not an accurate reflection of the telephone consultation and omitted significant details – including the breathlessness and panic – reported by the patient that might have led to more thorough investigations. A consultant cardiologist also reviews the


KEY POINTS ●Ensure that in any history of chest pain you enquire into the specific nature and severity of the pain and other related symptoms. ●Ensure that all details relevant to clinical decisions made in telephone triage are clearly recorded.


case in regard to causation and agrees that had Mrs T been referred to A&E by Dr D this, on the balance of probabilities, would have led to an ECG and blood tests revealing an ST elevation and raised serum troponin level. Immediate treatment could then have possibly prevented the fatal outcome. A settlement is agreed by MDDUS acting


on behalf of Dr D with a share paid by another medical defence organisation representing Dr G.


These studies are summarised versions of actual cases from MDDUS files and are published in Insight to highlight common pitfalls and encourage proactive risk management and best practice. Details have been changed to maintain confidentiality


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