On 26 October 2015, James Pickup, a 59 year old man died at his home after complaining of shortness of breath. The day before his death, he was taken to the Angliss Hospital by ambulance where a diagnosis of chronic obstructive pulmonary disease (COPD) was made before he was discharged. The autopsy report showed that the deceased died of pulmonary embolus (PE).

Background Facts

The deceased had a health history of obesity, hypertension, hypercholesterolaemia, bipolar disorder, and obstructive sleep apnoea. He was also a heavy smoker.

On 25 October 2015, the deceased called an ambulance after he experienced shortness of breath for two days and struggled under exertion. He was taken to the Angliss Hospital for further investigation. A physical examination of the deceased conducted Dr Peak Chan Looi revealed no abnormalities.

Dr Looi ordered an electrocardiogram which showed some subtle non-diagnostic abnormalities. A chest x-ray reported increased lung volumes with a background consistent with COPD. There were no signs of pleural effusion or heart failure. The deceased's blood tests were normal. The deceased was discharged home at 4.14pm the same day and recommended to follow up with his GP.

On 26 October 2015 at 9am, the deceased experienced shortness of breath while walking down the hallway and collapsed unexpectedly. An ambulance was called but he could not be resuscitated.

On 28 October 2015, an autopsy was performed on the deceased. It was found that the medical cause of death was PE, a condition which causes death by clots, usually from the deep calf veins breaking off, travelling to the lungs and occluding the major vessels into the lungs.

Dr Looi's evidence

Dr Looi's evidence was that she did not consider PE as a likely diagnosis because the deceased was a smoker and did not have any key symptoms of PE on examination. She submitted that her finding of COPD was reinforced by the chest x-ray that was carried out. She further submitted that if she had considered PE, she would have applied the Wells and PERC scoring criteria which would have necessitated a D-dimer, but would have discussed this first with the on-call consultant.

Expert opinion

Dr David Eddey, a specialist in Emergency Medicine at The Geelong Hospital, found that a diagnosis of COPD was reasonable given the medical examination and history of the deceased. However, his opinion was that PE should have been considered as a differential diagnosis given that the deceased presented with a sudden and acute shortness of breath.

Associate Professor Graeme Thomson, Emergency Physician, generally agreed with Dr Eddey that the diagnosis of COPD was reasonable given the deceased's history of smoking and his chest x-ray result. He further stated that in his 30 years of experience, most Emergency Department doctors would not have actively considered PE because there was no reason to do so.

Findings

The symptoms of the deceased were atypical. The diagnosis of COPD was reasonable. However, the presentation of the deceased with sudden onset of shortness of breath should have triggered a level of suspicion of PE as a differential diagnosis and the failure to consider this was a 'missed opportunity'.

Recommendations

The Coroner stated that this case highlights the need for hospitals to listen to patients, consider patients' medical history in the context of their immediate presenting problems, seek opinion from consultants and determine differential diagnoses with an open mind.