A senior doctor has been found in breach of the Code of Health and Disability Services Consumers’ Rights after a woman with chest pain and shortness of breath was discharged from hospital with a prescription for indigestion medication.
She was readmitted the following day and died the next morning from an aortic dissection – a torn main artery.
The case was outlined in a report published by Deputy Commissioner Carolyn Cooper today.
The report states the incident happened in 2018 when the woman collapsed at her daughter’s home from chest pain and shortness of breath. She was then taken to hospital after her daughter called an ambulance.
Once at the hospital, the woman, known as Mrs A in the report, was put to the front of the queue to be examined by a doctor, known as Dr C in the report, in the emergency department.
Dr C performed numerous tests on Mrs A, including blood tests.
“Dr C advised in his 2018 response to the complaint that diagnoses of pericarditis, pulmonary embolism, and aortic dissection were considered,” the report read.
“However, these were ruled out due to the absence of indicative ECG, decreased intensity of pain, lack of risk factors, and lack of typical features such as sharp, tearing or ripping chest pain and unstable vital signs.”
After showing some relief from the administration of “Pink Lady” reflux medication and paracetamol, Mrs A was discharged five hours after arriving. She was given a prescription for anti-reflux medication and “advice that what she was experiencing was not cardiac related”.
The report said the doctor did not seek cardiology advice before she was discharged.
The report went on to outline Mrs A’s daughter believed it was “nonsensical” her mother was discharged with this advice after having been admitted for acute chest pain.
Mrs A’s pain continued that evening and the next night, after receiving care at home with her husband, she was readmitted to hospital after her condition worsened.
Upon readmission, gastrointestinal issues were again at the forefront of the investigations of a second doctor, known as Dr E in the reports.
Mrs A’s family were told she would be fine overnight and that they could go home. However, before 7am Mrs A suffered a cardiac arrest and died.
“Mrs A’s family feel robbed of the option of surgery for her, and the biggest component of their complaint concerns the first admission, and a diagnosis of aortic dissection not having been considered or made,” the report on the case stated.
In 2023, Dr C told the Health and Disability Commission at the time of the incident he was, “very early on in my emergency medicine training but was given a senior position”.
“In retrospect, I should have declined that position.”
Deputy Commissioner Cooper made the following statement after reviewing the case.
“Although this is a rare diagnosis, it is one with severe consequences and I’m not satisfied that appropriate steps were taken to allow the senior doctor to exclude this confidently.
“I consider that had the appropriate review of the woman’s history been undertaken, along with the advice from her family about the significant family history, it would have been appropriate for the senior doctor to have obtained cardiology advice prior to the woman’s discharge.”
Cooper expressed her condolences to the family for their loss in such traumatic circumstances.
The report states that changes have been made since this event, by both the senior doctor and Health NZ, along with further recommendations from Cooper.
