This is an actual TMLT medical malpractice case. It involves a family physician treating a patient with chest pain. This presentation illustrates how action or inaction on the part of the physician led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician's defensibility. The case has been modified to protect the privacy of the physician and the patient.

1. failure to insist on
ems transport
Case Closed
A case study to help
you manage risk.

2. presentation
At 8:30 a.m., a patient’s wife called her husband’s
family physician and requested an appointment
because her husband was experiencing chest pain
that began the previous evening. The wife reported
that her husband refused to go to the emergency
department (ED).
The patient was a 61-year-old man and his medical
history included low back pain, hypercholesterolemia,
and hypertension. He had been a smoker for 40
years.

3. presentation
The patient’s wife was instructed by the physician’s
staff to take her husband directly to the ED, yet the
patient insisted on being seen by the physician. The
wife was told to bring him to the office.

4. presentation
Upon arrival, the patient’s blood pressure was 95/65
mm Hg and his pulse was 57 bpm. The family
physician noted bilateral wheezing in the patient’s
lungs. EKG results indicated ST elevation and some
disturbance in the inferior leads. The physician
interpreted the EKG results as abnormal and noted
“probably acute inferior infarction” on the EKG
printout.

5. presentation
The physician called the ED and spoke to the on-call
cardiologist advising him of the patient’s symptoms
and EKG results. He asked the cardiologist to meet
the patient in the ED.

6. presentation
The physician spoke to the patient’s wife advising her
that the patient needed to go to the ED to determine
if the patient was having a myocardial infarction. The
physician handed them a copy of the EKG printout
and offered them the option of traveling to the ED by
ambulance or private car.

7. presentation
They declined the ambulance and chose to travel
by private car, believing that it would be faster. This
discussion was not documented in the patient’s chart.
On the way to the hospital, the patient experienced
cardiac arrest and died.

8. Allegations
A lawsuit was filed against the family physician. The
allegations included failure to call EMS to take the
patient to the hospital and failure to take measures
to prevent the cardiac arrest.
The plaintiffs alleged that the patient might have
survived if he had been transported to the hospital by
ambulance.

9. legalimplications
TMLT consultants who reviewed this case did not
support the family physician’s decision to allow the
patient to go by car to the hospital. He should have
insisted on EMS transportation, which would have
been safer for the patient.

10. Consultants also had concerns about the phone
call documentation in the patient’s chart. The notes
documenting the wife’s initial call to the office
appeared to have been written after the office
was notified of the patient’s death. The physician
encounter notes and instructions to the patient
appeared to have been added at a later time as well.
legalimplications

11. Also affecting the outcome of this case was the
patient’s noncompliance and poor judgment.
His refusal to go to the ED as initially instructed
contributed to the poor outcome.
legalimplications

12. This case was settled on behalf of the family
physician.
disposition

13. Based on the patient’s symptoms and cardiac risk
factors, TMLT consultants who reviewed the case
stated he should have been firmly directed to go to
the ED. They felt the patient should not have been
given a choice in the matter.
Risk management
considerations

14. The wife’s phone call and the physician’s instructions
were recorded as late entries and were not identified
as such. As a result, the entry was perceived as an
alteration to the medical record.
Medical records should never be altered. Late entries
should always be annotated with the time and date
along with the reason for the late entry.
Risk management
considerations

15. Although the patient was appropriately referred to the
ED, it is recommended that well-defined telephone
triage protocols be developed and followed by staff.
Physicians and staff should document actions to
demonstrate that protocols are followed. Emergency
protocols should also be developed.
Risk management
considerations

16. disclaimer
This closed claim is based on an actual malpractice
claim from Texas Medical Liability Trust. This case
illustrates how action or inaction on the part of
the physician(s) led to allegations of professional
liability, and how risk management techniques may
have either prevented the outcome or increased the
physician’s defensibility. This study has been modified
to protect the privacy of the physician and the patient.
© Copyright 2016 TMLT.

17. about tmlt
With more than 19,000 health care professionals
in its care, Texas Medical Liability Trust (TMLT)
provides malpractice insurance and related products
to physicians. Our purpose is to make a positive
impact on the quality of health care for patients by
educating, protecting, and defending physicians.
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