Medicolegal challenges in cardiovascular-related claims
Cardiovascular medicine is concerned with all conditions of the circulatory system, while cardiologists specialise in diseases and abnormalities of the heart. Compared to other specialties, negligence claims in cardiovascular medicine are relatively rare and make up only around 2% of all claims, and claims against cardiovascular and thoracic surgeons outnumber those against cardiologists. Despite its infrequency, the consequences of alleged negligence in this field can be severe for the patient. Furthermore, the amount of damages awarded in a successful claim is potentially considerable, due to the costs involved in the patient’s ongoing care, the risk of permanent disability or reduced function, and the possible loss of earnings.
The majority of claims arise due to allegations of failure to assess, diagnose or treat appropriately. Some patients who have undergone procedures such as angiography and coronary bypass may later claim that their suitability for these treatments was not properly assessed, particularly if they suffer an adverse event or the outcome of the procedure is not as they expected. This highlights the importance of assessing whether a patient is likely to be at particular risk of complications following a procedure.
A common reason for a patient to make a claim is a failure, or delay, in making a diagnosis. A recurring theme in claims of misdiagnosis is the failure to identify an underlying cardiac condition, such as a dissecting aneurysm, in a patient complaining of chest pain, but endocarditis and atherosclerosis are also commonly missed. One especially problematic area of diagnosis involves exercise-induced sudden death, particularly in professional athletes. In a typically young and healthy population, it is difficult to identify many of the causes of sudden death, such as cardiomyopathy, valvular heart disease and coronary artery disease, in the usual screening tests. Therefore, other screening procedures may be necessary.
Claims of inappropriate or inadequate treatment are usually associated with conditions such as hypertension, angina and valve disease. Further problems can arise with the incorrect interpretation of test results such as ECGs and angiograms, or the performing of improper or unnecessary tests. There may also be issues around the failure to diagnose and treat myocardial infarction. A particular concern is a delay in performing emergency heart catheterisation in patients with acute chest pain. Other treatment complications include surgical or postprocedural adverse events, such as perforation following angioplasty, a kinked catheter, postoperative strokes, haemorrhage, infection and paralysis. Implanted pacemakers can cause injuries or develop faults.
Importantly, if a doctor does not treat risk factors for cardiovascular disease, this may also constitute negligence. This is particularly true where there are national guidelines available for conditions such as diabetes, high blood pressure and raised cholesterol levels. It has been successfully argued that this type of preventative treatment forms part of the standard of care to be expected from a doctor, and omitting to offer treatment represents a failure to prevent injury.
Issues of consent rarely arise alone, but more usually form part of an allegation of a more serious nature. Commonly, patients allege that they were not warned about a recognised complication of the procedure. This underlines the importance of comprehensively documenting any discussions between the physician and patient before the procedure. However, it is not always clear as to precisely what constitutes a material risk. Thus, it is good practice to inform a patient about all serious risks, even if they are rare. As well as the risks and benefits of a procedure, patients should be made fully aware of possible alternative treatments, including the option of no treatment, along with the complication rate for the suggested procedure. The provision of information leaflets, which should also be noted in medical records, may provide a useful defence against allegations of lack of consent. For more complex procedures, it may be necessary to have more than one consultation before the procedure, to allow the patient sufficient time to consider all the risks involved.
Drug errors are much less common in cardiovascular medicine than in other specialties, but claims can arise from the inappropriate delivery of a drug (for example, an intravenous drug being delivered as a bolus rather than an infusion, leading to tissue damage), or adverse reactions, which may even prove to be fatal. Furthermore, the administration of amoxicillin to patients with a penicillin allergy does still sometimes occur.
While errors in cardiovascular medicine do not occur frequently, the consequences of them can be severe. In an analysis of claims defended by the MDU, it was alleged in just over 20% of claims that the negligence suffered directly lead to the patient’s death. In a further 15% of claims, an outcome of stroke or myocardial infarction, as a consequence of mismanagement of the patient’s condition, was reported. However, not all of these deaths were necessarily the result of a procedure: some were due instead to a failure to recognise another condition, particularly malignancy, which later proved to be fatal.
In order to prevent claims, those working in the field of cardiovascular medicine must develop an excellent knowledge of recent advances of cardiology, cardiac and vascular surgery. Patients must be thoroughly assessed before undergoing a procedure, and the risks and benefits fully explained to them. Comprehensive documentation of this in the patient’s medical records can be vital in defending any possible claims that may later arise.
About Dr Hayes
Dr Hayes is a Consultant Cardiologist based at York Hospital NHS Trust. He is also an Honorary Consultant Electrophysiologist at Castle Hill Hospital, Hull.
Dr Hayes specialises in electrophysiology and complex device implantation and he is skilled in all aspects of arrhythmia management including the diagnosis and treatment of palpitations and dysrhythmias. He has a particular interest in pacing and in complex pacing for heart failure.
He is also trained in echocardiography including transoesophageal echocardiography and diagnostic angiography.
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Tan, S. Y. (2012). Medical malpractice: a cardiovascular perspective. Cardiovascular Therapeutics, 30(3), e140-5. https://doi.org/10.1111/j.1755-5922.2010.00254.x