The Commissioner received a complaint that when the consumer presented to the provider, a General Practitioner, in mid-February 1997 complaining of chest pains and sweating profusely, the provider failed to take appropriate action to correctly diagnose the consumer's condition.
The complaint was received by the Commissioner on 9 April 1997 and an investigation undertaken. Information was obtained from:
- The Consumer
- The Provider / GP
Advice was provided to the Commissioner by a General Practitioner.
Outcome of Investigation
In 1997 the consumer was a patient at the Medical Centre where the provider works. The consultation system at the Medical Centre is that patients are not allocated individual doctors but are seen by whoever is on duty at the time. One set of notes is kept for each patient and added to by the duty doctor at the time of consultation.
For two days in early February 1997 the consumer had been an in-patient at Hospital for the treatment of unstable angina. On that occasion the consumer had referred himself to hospital when he felt unwell at home on a Sunday evening. That period of hospitalisation does not appear in the provider's notes.
The consumer began to experience chest pains and profuse sweating while playing golf in mid-February 1997. He used his prescribed anti-angina medication (Trinitram spray) twice without any relief so went directly to the Medical Centre where he was seen by the provider. The consumer told the provider that he had chest pains and that he had used his Trinitram on two occasions. The consumer does not recall whether he advised the provider of his discharge from hospital three days earlier from a heart related matter. The provider advises he was not aware that the consumer had been in hospital as the consumer did not mention it nor are there any hospital notes to that effect.
The provider examined the consumer, sent him to a laboratory in town for blood tests, and advised him that if the pain got worse he should go to hospital. The provider also adjusted the consumer's medication. On returning home the consumer felt worse and a friend drove him to Hospital where he was admitted to the Intensive Care Unit and diagnosed as having had a heart attack. The consumer was discharged from hospital a week later.
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to Services of an Appropriate Standard
2)Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
In my opinion, the provider breached Right 4(2) of the Code of Health and Disability Services Consumers' Rights.
The consumer was in pain, sweating and reporting no relief from the Trinitram when he consulted the provider. This combination of symptoms, irrespective of whether the provider was aware of the consumer's previous admission to hospital for a similar matter, obliged the provider to arrange an immediate investigation, by way of an ECG or referral to hospital, in order to accurately determine a diagnosis. The provider's actions in sending the consumer for blood tests, prescribing rest and telling him to go to hospital if the pain got worse was not a vigorous enough approach to diagnose what was likely to be an evolving ischaemic episode. In response to my provisional opinion, the provider advised "however in the back of my mind there was the possibility of an infarction, and that was why I referred him for a blood test to estimate a cardiac enzyme level; if this was abnormally high the laboratory will always ring or fax me immediately. I would have taken immediate action to admit [the consumer], as this is the normal procedure I adopt in case of unstable angina and it has worked well. An ECG is reliable only in about 50% of cases."
In the circumstances I acknowledge that it would have been an advantage if the provider had been advised of the hospital admission. However, regardless of the lack of information, in my opinion the provider's failure to arrange for immediate diagnostic studies or a referral to hospital for those studies did not comply with the professional standard required in the treatment of the consumer.
I recommend that the provider apologise in writing to the consumer for his breach of the Code. This apology is to be sent to my office and I will forward it to the consumer. A copy of the apology letter is to remain on the investigation file.
A case note of this investigation will be sent to all Crown Health Enterprises to reinforce the need to send records to general practitioners as soon as possible.
A copy of this opinion will be sent to the Medical Council of New Zealand.