The death of a man from a missed pulmonary embolism serves as a cautionary tale for junior doctors to “look at the bigger clinical picture” when diagnosing patients with respiratory conditions, a coroner says.
A Victorian coronial inquest heard that James Pickup presented to Angliss Hospital, Melbourne, on 26 October, 2015, with a history of breathlessness on minimal exertion lasting two days.
The 59-year-old had a complex history of obesity, hypertension, OSA, hypercholesterolaemia, bipolar disorder and heavy smoking.
Mr Pickup was seen in the emergency department by registrar Dr Peak Chan Looi, who noted that he had mild ankle swelling, no cough, chest pain, fever or syncope.
An ECG showed subtle abnormalities that were non-diagnostic, while a chest X-ray reported increased lung volumes with a background in keeping with chronic pulmonary obstructive disease (COPD), and there were no signs of pleural effusion or heart failure.
Dr Looi made a working diagnosis of COPD. Mr Pickup was discharged with a recommendation to see his GP and have a lung function test and echocardiogram.
The next morning, Mr Pickup collapsed and died at home. A postmortem revealed his death was due to pulmonary embolus.
The Coroner’s Court of Victoria was told by expert witnesses that COPD was one of a number of reasonable diagnoses. However, the acute presentation of someone who is suddenly short of breath on minimal exertion was not consistent with someone who gradually developed lung disease.
Therefore, pulmonary embolus should have been considered as a possible differential diagnosis, according to two emergency physicians who provided expert commentary on the case.
A more experienced doctor would have suspected pulmonary embolism and ordered a D-dimer test, the clinicians said. But most junior staff would not have considered pulmonary embolism, and even if a D-dimer was ordered they would not be able to interpret the results, they suggested.
In her conclusion, coroner Jacqui Hawkins said pulmonary embolus could be hard diagnose due to its sometimes non-specific presentation, and Dr Looi’s diagnosis of COPD was reasonable.
“However I do consider Dr Looi’s failure to consider pulmonary embolus as a potential differential diagnosis, based on the sudden onset of shortness of breath, which resulted in further investigations not being conducted, as a missed opportunity in this case.”
“The death of Mr Pickup highlights the importance of junior clinicians in an emergency department taking the time to step back from their patient and look at the bigger clinical picture,” the coroner concluded.