Woman dies after being sent home by doctor

A New Zealand doctor who blamed a woman’s symptoms on alcohol abuse and anxiety was wrong – and she died the next day.

The incident occurred in 2016. A report by the deputy health and disability commissioner says the doctor’s notes said the woman, age 42, arrived at the medical centre saying she was short of breath and coughing for three days, but did not have any pain or fever.

The report says she had a past history of alcohol dependency, anxiety with depression and was a smoker.

She had a rapid heartbeat and her hands were cold, the doctor’s notes said.

The doctor did not take her temperature.

The doctor, after a electrocardiogram on the woman, concluded that the woman’s shortness of breath and low blood pressure were probably a result of sinus tachycardia.

‘‘In Dr C’s opinion, the most likely cause of the sinus tachycardia was alcohol abuse and anxiety,’’ the report says.

The doctor sent her home, asking her to contact the medical centre or the GP on call if she experienced symptoms worsening, or didn’t feel better in two days.

On the same day, a registered nurse saw the doctor’s notes.

The commissioner’s report says she was surprised by the doctor’s course of action.

‘‘I was surprised no bloods had been [taken] or antibiotics or even that the patient hadn’t gone to hospital as I felt that she was so unwell.

‘‘I was surprised that the GP note said ‘breathing ok’ as I didn’t agree with that observation and also noted there was no temperature.

‘‘I contemplated phoning the patient then but I didn’t.’’

When the nurse arrived at work the next day she discussed her concerns with the clinical nurse leader,

‘‘I was surprised no bloods had been [taken] or antibiotics . . .’’ Registered nurse

who recommended she call the woman and ask how she was feeling.

That afternoon, the woman died. The medical centre received a call from paramedics, who were at the woman’s house.

In the report, clinical advisor Dr David Maplesden was ‘‘critical that the doctor did not take the woman’s temperature.

‘‘[She] had a very cool periphery which, in the context of the other clinical findings, might have represented a degree of peripheral shutdown secondary to shock.

‘‘Given the possibility of sepsis as a cause of shock, [her] temperature should have been taken.’’

Dr Maplesden concluded that the doctor’s management of the patient would be met with ‘‘severe disapproval’’.

The doctor was found to have breached the Right 4(1) of the Code of Health and Disability Services Consumers’ Rights by failing to take the woman’s temperature and to recognise the seriousness of her symptoms, and to take appropriate action in response.

The medical centre was not found in breach of the Code.

It was recommended that the doctor provide a formal written apology to the woman’s family.

The report says the doctor felt very sorry.

‘‘She still feels terrible about Ms A’s death and has reflected on the events leading to it on numerous occasions.’’

The doctor is now retired, and the status of her practising certificate is recorded as ‘‘non-practising’’.

The report said she does not intend to return to practise medicine.