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Misdiagnosis and premature discharge of elderly woman with shortness of breath (09HDC00865)
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(09HDC00865, 26 March
Locum medical registrar ~ Accident and medical clinic ~
Public hospital ~ District health board ~ Shortness of breath ~
Abnormal test results ~ System for reporting abnormal results ~
Premature discharge ~ Junior doctor ~ Orientation, training,
support, and supervision ~ Consultation with senior doctor ~ Open
disclosure ~ Right 4(1)
A 75-year-old woman was transferred to hospital after presenting
at an accident and medical clinic with shortness of breath and
chest pain. On arrival at the Emergency Department, a nurse ordered
blood tests, an X-ray and an electrocardiogram (ECG). The woman was
also placed on a monitor to take automatic readings of her pulse,
oxygen saturation levels and blood pressure. A medical registrar
examined the woman, reviewed her clinical notes, chest X-ray, ECG,
and partial blood test results, and reached a diagnosis of panic
attack. The registrar then discharged the woman, less than two
hours after her admission.
Shortly after returning home the woman stopped breathing.
Attempts to resuscitate her were unsuccessful and she died. A
post-mortem was inconclusive, but the most likely cause of the
woman's death was coronary heart disease.
Unknown to the doctor at the time of discharge, the woman's full
blood test results were available and showed an abnormal Troponin
level (indicating that a heart attack may have occurred). Also
unknown to the doctor, just prior to the woman leaving the hospital
the automated monitor had recorded a significantly low oxygen
saturation level. The DHB openly disclosed to the family the
misdiagnosis and premature discharge.
It was held that the doctor's diagnosis of "panic attack", and
his decision to discharge the woman when he did, without waiting
for the full test results, was inappropriate and he breached Right
4(1) of the Code.
The DHB was found to have inadequately orientated, trained,
supported and supervised the doctor. It was also found to have had
inadequate systems for alerting doctors to abnormal test results in
a timely manner. Accordingly, the DHB breached Right 4(1).