I recently wrote a blog about a High Court decision concerning liability of a trust concerning an A&E receptionist and triaging a head injured patient. In that case, the trust was not found liable for either the receptionist or the nurse triage process.
In another recent A&E decision, John David Crammond v Medway NHS Foundation Trust(extempore on 1 December 2015, reported on Lawtel), Judge Forster QC, sitting as a Judge of the High Court, also had to review A&E management; on this occasion whether the management by an A&E nurse and doctor had been of an appropriate standard regarding a patient presenting with another common problem, chest pain.
In essence, the claimant had attended the defendant hospital's A&E department complaining of chest pain and was seen by a triage nurse who appropriately performed an electrocardiogram (ECG), which was essentially normal. The nurse recorded the claimant's history and reported to an A&E doctor in the department who, based on the nurse's recordings, chose not to review the claimant himself but, instead, decided to “stream” him to a same-day treatment centre to be seen by a GP three hours later. When the GP saw the claimant, he diagnosed him with gastritis. Unfortunately, 4 years later, in 2010, the claimant was diagnosed with cardiac failure and, whilst being assessed, suffered a stroke. An coronary angiogram was carried out which confirmed that he was suffering with “acute coronary syndrome”, which is an umbrella term that encompasses conditions which cause the obstruction of coronary arteries, potentially resulting in chest pain caused by angina or a myocardial infarction (heart attack).
The judge decided this case in favour of the claimant. He considered that the nurse had not been negligent, in that she only had 10 minutes within which to obtain and record the history and carry out an ECG, and it was not her decision to make about what management the claimant required. She had correctly triaged to the doctor.
However, the judge held that the A&E doctor had been negligent, in that he had not had sufficient information upon which to make a diagnosis of non-cardiac chest pain; a normal ECG was simply not enough information, as the medical experts agreed that an ECG was a tool that provided only limited diagnostic information. The judge decided that a competent A&E doctor would have reviewed the claimant himself and taken a proper history, which would have elicited several cardiac risk factors, resulting in further tests which would have established the claimant’s underlying cardiac condition and which would have avoided all of the problems that surfaced in 2010.
Determining the critical question of whether a patient presenting with chest pain has cardiac pain or non-cardiac pain is a well-known difficulty both in medical and legal circles. It can be a notoriously difficult distinction to make; it is easy to think that a patient has oesophagitis or gastritis when they have angina or a myocardial infarction, or vice versa. An abnormal ECG may clinch the diagnosis of a myocardial infarction or unstable angina, for example, but it is well-known that a normal ECG cannot rule either out with any degree of certainty or precision, and it is essential, therefore, to take a full and careful history, perform a proper examination and carry out any necessary baseline investigations in such patients. Accordingly, it is very surprising that the A&E doctor was not prepared to spend even a short period of time taking a history from the patient before concluding that the pain was non-cardiac; and, to the contrary, it is of no surprise whatsoever that he was found to be negligent in not doing so.