Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Complaint
The complainants complained to the Commissioner concerning the treatment provided to the consumer when attending a public hospital accident and emergency department. The complaint is that:
- On a date in early February 1998 the consumer attended a public hospital accident and emergency department experiencing an angina attack and was discharged with the advice that maybe there was a problem and maybe it would be good to have a treadmill exercise test carried out. The consumer was later diagnosed with a 99% blockage in his coronary artery.
Investigation
The complaint was received by the Commissioner on 21 September 1998. An investigation was undertaken and information obtained from:
- The Consumer/Complainant
- The Consumer's Wife/Complainant
- The Senior Medical Officer, at the Crown Health Enterprise ("CHE")
- A Medical Registrar, at the CHE
- The Manager, Accident and Emergency, at the CHE
Medical records relating to the treatment of the consumer were obtained and reviewed. The Commissioner sought advice from an independent emergency medicine specialist.
Outcome of Investigation
The consumer presented to his general practitioner in early February 1998 with a three to four day history of chest pain. The GP referred the consumer to the public hospital's emergency department for acute pain and a possible ischemic episode.
The consumer arrived by ambulance at 9.00pm, by which time he was pain free. The medical registrar saw the consumer, following assessment by nursing staff at 10.30pm.
The medical registrar assessed the consumer. The consumer reported that he had experienced central chest pain, which was cramping in nature and without radiation for ten minutes, while he had been walking at 7.00pm the same evening. Prior to this episode the consumer had a three to four day history of similar pains precipitated by bending forward and lifting. The consumer advised that he thought that he might have strained his shoulder ten days prior. He also advised he had a history of hypertension, is a non-smoker and had a family history of coronary heart disease. On physical examination of the consumer the medical notes made by the registrar stated that the consumer appeared pain free and looked well. Apart from mildly elevated blood pressure at 165/101, the cardiovascular and respiratory system examinations were normal. Electrocardiogram showed non-specific ST-T change in lead III and AVF, but this was not specific of ischemic change. Chest x-ray was normal. Cardiac enzyme tests showed mildly elevated creatine kinase at 254, but troponin T was within normal range.The consumer was not admitted to hospital.
The medical registrar stated that she recommended a treadmill test and explained that a consultation with a cardiologist would be necessary if the test was positive. She wrote a note with this recommendation to the consumer's GP. This note was retained on the consumer's file and was not forwarded to the GP. A GTN spray was prescribed for the consumer, in case he had a further attack, and he was advised to continue taking betaloc for hypertension. A repeat cardiac enzyme was requested for the following morning. The medical registrar reported that the cardiac enzyme test showed that the cardiac enzymes were not increasing.
The consumer visited his GP who organised a treadmill test privately through a private medical provider. This test indicated that the consumer required an angiogram. The angiogram indicated that the consumer had a 99% blockage of his coronary artery, requiring angioplasty. This blockage was treated successfully.
Advice to Commissioner
The Commissioner sought advice from an independent emergency medicine specialist who stated:
"Appropriateness in medical treatment refers to the doctor 'using the available evidence towards making the right decisions'. [The medical registrar] carefully documented [the consumer's] history and physical examination noting those points which the evidence indicates probability of cardiac involvemen [sic]. She then looked at the ECG and noted there were some changes and then performed a CK and troponin assay. Even though she felt the chest pain atypical, she proposed to investigate further with an exercise ECG and indicated that if this were positive, a cardiology referral should follow. She developed a plan which addressed these issues and which also dealt with the possibility of recurrence of the chest pain (prescribed GTN spray) and also indicated the continuation of preventatives (betaloc and aspirin). Given the fact that [the consumer's] pain was not present at the time of his visit to the ED, that the pain was relieved completely with rest, and that his studies were non-corroboratory - her management was appropriate. She also required him to return to the ED for a repeat CK within 9 hours. This test was negative. ?If there was ongoing ischaemia or myonecrosis, this test would have been positive.
Short of keeping [the consumer] in hospital for a cardiologist assessment the following day and, most probably, an exercise ECG test, [the medical registrar] did as much as was reasonable for diagnosing his problem. She undertook an accurate assessment, performed evidence-based tests and assays and provided an evidence-based investigation and treatment plan."
The advisor believed that had the consumer undergone a treadmill test within the timeframe proposed by the medical registrar it was unlikely his clinical outcome would have been any different.
While the care provided by the CHE was reasonable the advisor suggested that an observation facility within the hospital emergency department would be useful for the purpose of ruling out heart problems:
"Inpatients such as [the consumer], where the initial ECG and CKs and troponins are non-diagnostic but the suspicion of myocardial ischaemia is high, such a facility has been shown to improve diagnostic accuracy [sic]. In these units, which are usually operated by the emergency department, the patient is placed on physiologic monitoring which can detect changes in the height or depth of their S-T segments (part of the cardiogram that changes with ischaemia). In addition, repeat 12-lead ECGs can be performed along with repeat CK and troponin assays over a period of 9 hours. After 9 hours, if the event is significant this will be demonstrated to a high degree of sensitivity and specificity. Some units even allow for acute access to treadmill testing as exercise induction will generally be the definitive test to indicate angiography is or is not required."
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
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.?/FONT>
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
Opinion: No Breach - Medical Registrar
In my opinion the medical registrar did not breach Right 4(1) of the Code of Health and Disability Services Consumers' Rights as she took reasonable actions to diagnose and treat the consumer.
Opinion: Breach - Medical Registrar
In my opinion the medical registrar breached Right 4(2) of the Code through the failure to remove the consumer's referral letter from the consumer's notes. The CHE has a protocol for referrals which is standard throughout New Zealand. In failing to comply with this protocol the medical registrar breached Right 4(2) of the Code.
Actions: The Medical Registrar
I recommend the medical registrar take the following action:?Apologises in writing to the consumer for breaching the Code. This apology is to be sent to the Commissioner who will forward it to the consumer.
Other Actions
A copy of this opinion will be sent to the Medical Council of New Zealand.
For further information, contact: HDC Communications Section (09) 373 1060.
Or by email: your.rights@xtra.co.nz