Failure to diagnose heart disease

A female patient in her mid-50s visited her GP complaining of spasms in her arms and pain radiating from chest to upper abdomen. The pain was worse on moving and seemed to be related to eating. The GP did not consider a cardiac cause was likely. However, noting the patient's blood pressure was high, the GP asked the patient to return for a blood pressure review in two weeks. The patient did not return.

The patient was a smoker with a history of hypertension and problems with reflux oesophagitis. The notes recorded that the patient had not complied with advice from several GPs concerning hypertension medication and smoking cessation. She also had a family history of heart problems.

Eight months later, the patient saw another GP at the local community hospital, complaining of chest pain and nausea. She was diagnosed with indigestion and prescribed medication. However, on returning home her condition worsened and an ambulance was called. At that stage, it was established that the patient had had a myocardial infarction.

The following year, the first GP, an MDU member, received a letter of claim from the patient's solicitor alleging that at a consultation several years earlier the GP had failed to prescribe a statin to lower the patient's cholesterol or to provide appropriate follow-up. Had this been done, it was claimed, the patient would have been unlikely to have developed angina or suffered a heart attack.
 
The solicitors also claimed that the GP had been negligent in failing to consider a cardiac cause for the patient's symptoms during the original consultation, particularly given her family history, and that she should have been referred to a rapid access chest pain clinic.

The MDU's response

The MDU asked a GP expert to report on the standard of the GP's care. The expert's view was that the patient's cholesterol level had not been high enough to prescribe statins. Any criticism by the patient of her treatment over the previous few years would have to be considered in the context of the entries in her records about her continued cigarette smoking and poor compliance with medical treatment.

He concluded that the GP had provided appropriate GP care at the original consultation and had considered, but reasonably discounted, a cardiac cause for the patient's pain.

The MDU also obtained an expert report from a consultant cardiologist on causation; that is, whether the alleged negligence caused the alleged injuries to the patient. The expert advised that it was impossible to say, on the balance of probabilities, if the patient had been prescribed a statin several years before and received appropriate follow-up she would not have developed angina or suffered a heart attack.

Even if the patient had been referred to a rapid access chest clinic and seen by a cardiac registrar, the expert considered that no intervention would have prevented her heart attack eight months later.
 
On the basis of this evidence the MDU sent a letter of response denying liability, saying that the MDU GP member's care of the claimant was entirely appropriate throughout. After some months, the claimant decided to drop her case.

Learning points

  • Delay in diagnosis is not necessarily negligent – it is possible to refute claims if the clinical management is shown to be appropriate and reasonable.
  • Keep a record of any advice you offer patients in relation to lifestyle changes and of their compliance with this advice.
  • Have a practice system in place for following up patients who do not attend for review appointments.
  • As in this case, ensure you keep a contemporaneous record of any examination, including negative findings.

This page was correct at publication on 16/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.