Complaint
The Commissioner received a complaint from the complainant about the care provided to her late husband, the consumer, by the General Practitioner. The complaint was that:
- When, in mid-August 1997, the consumer reported to the GP complaining of chest pains, the GP did not examine the consumer and prescribed medication for indigestion. The consumer suffered a heart attack in late August 1997 and did not recover.
Investigation
The complaint was received by the Commissioner on 9 December 1997, and an investigation was undertaken. Information was obtained from the following:
- The Complainant
- The General Practitioner, Provider
- The Second General Practitioner
The complainant's medical notes and the Coroner's report into the circumstances of his death were obtained and considered.
The Commissioner obtained advice from a general practitioner.
Information Gathered During Investigation
The complainant advised the Commissioner that her husband had been unwell since mid-August 1997:
"He had been complaining of feeling as though 'something was stuck in his chest', nausea and very tired. He was continually burping and rubbing his chest as he attempted to dislodge what he thought was causing his discomfort. He was very stressed and his colour was taking on a greyish tinge."
On the morning of a day in mid-August 1997 the complainant saw the GP. The GP's notes read:
"'[I]ndigestion' for 3 days now worse with sensation of something stuck in his throat and always burping; worse after a meal last night; no nausea o/e \ bp 135/80 chest clear and heart sounds normal; very active bowel sounds; no diarrhoea."
The GP diagnosed gastritis, duodenitis and prescribed pepcidine and mylanta.
The Coroner found that the complainant died in late August 1997 of a rupture of a myocardial infarction. The pathologist reported there were scars in the heart muscle.
The complainant related to the Commissioner that her husband's associates had told her that on occasions he went quiet and seemed to be in pain.
The GP in his response to the Commissioner, dated 24 March 1998, wrote:
"The burping, discomfort on swallowing, aggravation by a meal and very active bowel sounds led me to suspect a gastrointestinal condition. This was reinforced by the findings of a normal blood pressure, normal heart sounds and rhythm and clear lungs.
I must emphasise that chest pain was never an issue at consultation?
The GP advising the Commissioner commented that in the GP's notes there is very little recorded which indicates cardiovascular causes for the pain were considered. Heart related pain is frequently reported by patients as indigestion and not infrequently diagnosed by doctors as arising from the gastrointestinal tract. In the advisor's opinion it is impossible to distinguish between the two on physical examination. If there is any suspicion then the minimum of tests should include a resting ECG and probably myocardial enzymes.
The advisor also commented that the diagnosis reached, "gastritis and duodenitis", was not likely given the symptoms and their pattern of development. He felt the more likely diagnosis would be gastro-oesophageal reflux, but that with either of these a patient would normally have intermittent symptoms for significant periods in their past history. He emphasised it is important to exclude other causes before making a definite diagnosis of gastritis.
The advisor wrote:
"In his [the GP's] letter dated 24 March 1998 he states that "chest pain was never an issue at this consultation". I would suggest it should have been an issue that was raised by the doctor if not the patient and the result of the relevant inquiry recorded along with relevant family history and other risk factors including smoking etc. I also feel some comment on follow up arrangements should be recorded.
I do not agree with [the GP] that a normal blood pressure, normal heart sounds and rhythm, and clear lungs excludes a heart related cause for the pain and these findings should not reinforce the suspicion of a gastrointestinal condition."
The advisor felt there were sufficient pointers in the complainant's story that should have led the GP to a greater level of suspicion with regards to a cardiovascular cause for his symptoms. He listed these as being:
"1 The first consultation of a new patient to the practice.
2 The age of the patient i.e. 55 years.
3 The relatively sudden onset of the symptoms that were getting worse over three days in a man who apparently had no past history of gastrointestinal disorders."
The Code of Health and Disability Services Consumers' Rights
RIGHT 4
Right to Services of an Appropriate Standard
1) Every consumer has the right to have services provided with reasonable care and skill.
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Opinion:Breach
In my opinion the GP breached Rights 4(1) and 4(2) of the Code of Health and Disability Services Consumers' Rights.
Right 4(1)
The complainant was a new patient, he was fifty-five years old, his symptoms had a sudden onset, were getting worse and he had no previous history of gastrointestinal disorders. The complainant had suffered heart attacks previously and had also experienced bouts of significant pain. In my opinion, given the way the consumer presented, the GP should have obtained this history. Although the consumer may not have been forthcoming, and only too happy to accept a diagnosis of indigestion, the GP's notes and response indicate that the consumer was not questioned about his history, nor was his history considered.
In response to a provisional opinion the GP advised he considered and rejected a cardiac cause, due to presenting symptoms, but this was not recorded in the notes. My advisor informed me that normal colour and cheerfulness do not necessarily exclude a cardiac related diagnosis and that indigestion and a feeling of something stuck in the throat are both sensations that patients use to describe cardiac related pain.
In my opinion the GP did not adequately consider that the consumer's symptoms could be cardiac, and as such the GP did not meet the level of care and skill expected of a general practitioner and was in breach of Right 4(1).
Right 4(2)
The GP's notes contain no information about this man's cardiovascular risk factors: family history, weight, diet, smoking history, alcohol intake, exercise, all of which are also important in treating gastritis. No formal follow up arrangements were made or recorded. While the clinical notes indicate that an examination was performed, there was no record of the rate and quality of the pulse, nor is there a record of abdominal palpation taking place.
In my opinion, by failing to both undertake appropriate examination and record details in the notes, the GP did not meet professional standards and breached Right 4(2).
Actions:
In response to my provisional opinion the GP has;
- Written and forwarded to me an apology to the complainant for his failure to take and record an adequate history, and his failure to examine the consumer appropriately. I will forward it to the complainant.
- Undertaken to record adequate notes in future.
- Undertaken to carry out appropriate investigations of patients including obtaining information or medical history.
This matter will be referred to the Director of Proceedings in terms of Section 45(f) of the Health and Disability Commissioner Act 1994.
A copy of this opinion will be sent to the President of the Medical Council of New Zealand and to the Chairperson of the Royal New Zealand College of General Practitioners.
For further information, contact: HDC Communications Section (09) 373 1060.