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Farmer treated for muscular pain and cholesterol died of heart attack (00HDC05372)

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(00HDC05372, 14 November 2002)

General practitioner ~ Standard of care ~ Ischaemic heart disease ~ Missed diagnosis ~ Rights 4(1), 4(4)

A 51-year-old man with heart disease died of a heart attack while working on his farm. During the previous year he had seen a GP in relation to a number of problems including elevated cholesterol. The man's wife complained that the GP had sufficient information over the course of the year to identify that her husband was at risk of having a major heart attack, and should have taken action to lessen the risk.

The man consulted the GP in relation to a back strain. An electrocardiogram (ECG) and cholesterol blood tests were arranged with a plan to see him again in five days' time. The GP's management at this consultation was considered appropriate although the differential diagnosis should have included ischaemic heart disease, as well as the working diagnosis of a muscular problem.

The patient did not present for his blood tests until about five weeks after the consultation. The tests revealed a very elevated cholesterol level, and the GP prescribed cholesterol-lowering medication and performed a resting ECG, which was normal.  Independent GP advice noted that angina can be diagnosed only with an exercise ECG.

A cardiologist noted that if GPs referred patients with multiple risk factors, this would result in an overwhelming amount of work for the health system. He considered that specialist referral would have been justified only if the GP had suspected the chest pain was angina. Despite the cardiologist's view, the Commissioner held that the GP was aware of sufficient factors to have taken a more risk-averse approach and, in failing to do so and refer the patient to a specialist, breached Right 4(4).

About six months later the patient made an appointment because he had suffered chest pains while on holiday. In describing pain going down his arm, he went to the level of his left bicep and occasionally touched his hand. By this stage, the GP was aware that the patient had a family history of heart disease. In the Commissioner's opinion, at this consultation the GP should have taken immediate steps to rule out a serious underlying heart condition by measuring the patient's cardiac enzymes, performing an ECG and/or prescribed a trial of nitrolingual spray, and arranging a specialist assessment. (The GP did decide that a specialist consultation was wise as a precautionary measure, but did not act with urgency.) By failing to take more appropriate diagnostic steps the GP failed to exercise reasonable care and skill and breached Right 4(1).