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I would like to highlight the following case, Crammond v Medway NHS Foundation Trust.
The full judgment is here. I would strongly urge you to read this.
In this case, a nurse triaging in A&E asked an A&E doctor for an opinion on a patient with chest pain with a normal ECG. The A&E doctor did not assess the patient but, based on the information provided, forwarded the case to a GP in the same day treatment centre. The GP subsequently diagnosed the patient with gastritis.
Four years later the patient developed heart failure and brought a claim against the A&E doctor and was successful.
I find this case disturbing as there is no way of knowing at the time of presentation whether this episode was truly ACS or not, nor whether this particular instance resulted in the patient developing heart failure four years later.
Furthermore, it appears that the patient had been seen multiple times during the four-year period with a similar diagnosis of gastritis, including a two-day admission (although the judgment does not say what the admission was for).
There appears to be no claim brought against any of the other doctors, so the case focuses on a breach of duty by the A&E doctor for not investigating the patient appropriately.
In this case it all came back to the triaging.
Despite there being no way of confirming that this episode was truly ACS and the fact that the patient had subsequently been seen by multiple doctors, including a two-day admission, the claim was still brought against the A&E doctor who initially saw the patient and, worryingly, was successful.
If triaging, when taking a history, ensure you document all cardiac risk factors and keep in mind that, as we all know, a normal ECG does not exclude cardiac chest pain.
It can be inferred from this judgment that forwarding a case does not remove your liability; you cannot ‘pass the buck’. Even though the final doctor who saw the patient diagnosed gastritis, it was the doctor who triaged the patient whom the successful claim was brought against.
My concern is that this is now legal precedent, such that if a triage doctor makes an incorrect decision regarding chest pain, and even if the consulting GP makes an alternative diagnosis, the triage doctor may still be found liable. Furthermore, on that basis, presumably this same principle could, depending on the facts of the case, be applied to other conditions.
There is always a chance this case could be appealed, in which case it is possible that the decision could be overturned by a higher court, but in any event, this case highlights the significance of triage.
Triage safely folks! Krishan Aggarwal is deputy chair of the GPC sessional GPs subcommittee
You can follow him on Twitter @Krishanx
Krishan I disagree with your assessment. The pertinent issue is was the A_E assessment in 2006 appropriate? the answer is no it was not. The nurse did not take an appropirate history, or record of clinical signs, the patient described central chest pain. The Dr in A+E should have seen the patient and then followed the ACS protocol which would have included trops/enzymes as the nurses assessment had not sufficeint proved or excluded ACS as diagnosis. What ever role a dr is working in we must ensure that we have sufficeint information to make a diagnosis, especially if we are being asked about patient by a colleague, and if not to take steps to ensure that we do. Referring patient elsewhere to GP would have been fine had the ACS been sufficeintly excluded, and is likley not be in line with A+E protocols at the time. The subsequent issue about cardiac problems may or may not be relevant depending on whether this would have been worse had the patient had a ACS in 2006, this is not directly relevant to the judgement but will affect quantum, ie the amount of compensation. The fact that the GP was not involved in this may be due to a number of reasons, which is not addressed in the judgement and therefore cannot comment on the GP responsibility, it is likely that the prosecution would unlikely to miss the opportunity to include the GP should it have been relevant, we have no information about this and therefore cannot coment. an interesting case and has implication for all of us who supervise any trainees or nurses. thank you.
Thanks for this. Those of us involved in triage are well aware of the potential for error and while triage is sometimes regarded as the easy part of a pathway, in fact isn't. Unfrotunately I can't get the link to work so cannot see the detail.
I'm interested in the fact that the triage clinician was a doctor (which may explain why it happened as triage in A&E is often done by specifically trained nurses) , and that a diagnosis was suggested at the triage stage. The function of triage is usually to determine the pathway and priority - in this case whether it is appropriate / safe for the patient to be referred to the GP service. Once in the GP service it is expected the clinician there will do what a GP will do; presumably that happened hence no legal case was brought against the GP. I agree with Anonymous. above!
Learning points for sessional GPs might be: 1) If triaging , take an appropriate history & observations; refrain from diagnosis but focus on apporpriateness of the pathway 2) If receiving from a triaging clinician, do not be swayed by their diagnosis or assume they have completed a consultation, especially if they are not a medical CCT holder.
Thank you for this Krishan. It has provided some very interesting discussions and has taught me the lesson which I am reliably informed is taught to all law students, namely ‘read the judgement for yourself and reach your own conclusions. Do not rely on the summary, which is someone else’s interpretation’.
Initially I read only your comments and was rather scared by your opinion on the outcome and its potential implications. However, I have subsequently reviewed the full judgement above with a member of the legal profession and find that this case is not disturbing at all if one considers the following:
1) This case was a civil case and therefore does not carry the same burden of proof required in a criminal case (where it must be proved ‘beyond all reasonable doubt’) but is instead based on the balance of probabilities, i.e. was it likely that this patient had ACS considering risk factors not obtained at the time, which would have become apparent with a proper history and examination:
• He was an ex-smoker with a
• family history of ischaemic heart disease, and
• central chest pain radiating to both arms
• BP on admission of 193/103
And, if it was a missed diagnosis of ACS, is it likely that this could be the cause of the subsequent heart failure four years later?
2) You say that the point is ‘if triaging when taking a history’ – THE WHOLE POINT OF THE CASE IS THAT THIS DOCTOR DID NOT TAKE A HISTORY OR ASSESS THE PATIENT IN LINE WITH HOSPITAL’S OWN PUBLISHED GUIDELINES. THE HISTORY WAS INCOMPLETE AND A FEW FURTHER QUESTIONS WOULD LIKELY HAVE RULED THE POSSIBILITY OF CARDIAC CHEST PAIN IN NOT OUT.
3) This is, as you say, about TRIAGE, not about diagnosis. It was not the point of the triage system to make a formal diagnosis of ACS at that stage but to work out whether the patient required further assessment based on the presence of intermediate risk factors. The decision to stream the patient to urgent care was based on an incomplete history and a normal ECG, which the expert witnesses conclude is not in itself enough to fully exclude ACS and the hospital’s own guidelines caution against discharging a patient with a single normal troponin result, which in this case was not even taken.
4) Your concern also centres around the GP making a diagnosis of gastritis. Here the GP does not have a case to answer in that the patient had already been risk-assessed in A&E in order to exclude cardiac chest pain.
5) The A&E doctor failed in their duty of care to properly risk assess the likelihood of this patient having cardiac chest pain, and the moral of the story is ASSESS THE PATIENT!
I would say the GP in this case is fortunate not to have been included in the action. Surely discharging a full duty of care would involve reviewing the information provided by A&E (see Natalie's post above), recognising its insufficiency and sending the patient back to A&E for a full and proper assessment?
Well perhaps in A+E he should have seen the patient and not just palmed him off to the GP! Also there are many causes of chest pain. Its not good enough just to say 'Troponin negative- Discharge'
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