A woman who was rushed to hospital after she collapsed with chest pain and shortness of breath was sent home with a prescription for indigestion after a senior doctor said it was not cardiac-related.

Two days later, she died from a tear in her aorta.

Now, following a complaint by her family to the Health and Disability Commissioner (HDC), it has been found the doctor, employed by Health New Zealand - Te Whatu Ora at the time, failed to provide the woman with services of an appropriate standard.

Deputy commissioner Carolyn Cooper said in a report released today that the woman, who is not named, was admitted to hospital in 2018 after an ambulance was called when she collapsed at her daughter’s home.

She was experiencing pain, shortness of breath, and nausea.

At the time, the woman, in her 70s, was under the care of her GP, who was treating her for high blood pressure. She was otherwise in good health, fit and active, and led a healthy lifestyle.

In the Emergency Department (ED), she underwent a range of tests, including an ECG and bloods.

She was given medicine for pain and inflammation as well as a “Pink Lady”, a mixture of a liquid antacid and a local anaesthetic given to ED patients to help determine whether chest pains are related to the heart or the digestive tract.

Following this, the woman showed signs of improvement, and it was recorded in her clinical records that she was having cups of tea and eating sandwiches.

But her daughter told the HDC that while the medicines did provide some relief, her mother continued to experience pain.

The daughter also provided staff with further details about the family’s medical history, including the sudden death of a close family member due to an aortic aneurysm.

They were assured that medical staff were aware of this history.

The doctor who treated the woman told the HDC that diagnoses of pericarditis, pulmonary embolism, and aortic dissection were considered but then ruled out.

He believed she might have been suffering from gastrointestinal reflux rather than a primary cardiovascular event.

She was discharged later the same day with a prescription for indigestion medication and advice that what she was experiencing was not cardiac-related.

But the following day, she returned to hospital after she continued to experience pain in her chest, left shoulder, and neck, and shortness of breath.

She was readmitted and began to deteriorate.

Eventually, the woman was moved to the Intensive Care Unit where she died the next day.

A coroner later determined her cause of death was an acute aortic dissection, a serious condition in which a tear occurs in the inner layer of the body’s main artery (the aorta).

Following an investigation into the woman’s care, Cooper found the doctor breached the Code of Health and Disability Services Consumers’ Rights. The breach covered several issues with the care provided.

Cooper said in her report that the doctor ruled out the diagnosis of aortic dissection, despite the woman’s presentation and concerning symptoms.

“Although this is a rare diagnosis, it is one with severe consequences and I’m not satisfied that appropriate steps were taken to allow the senior doctor to exclude this confidently.”

In addition, he did not utilise appropriate tools for discounting other relevant diagnoses, the supervision available to him, or seek cardiology advice before discharging the woman following her first visit to ED.

“I consider that had the appropriate review of the woman’s history been undertaken, along with the advice from her family about the significant family history, it would have been appropriate for the senior doctor to have obtained cardiology advice prior to the woman’s discharge,” Cooper said.

She also found the doctor breached the code for failing to document the woman’s presentation in a way that included vital observations, discounted diagnoses, interpretation of the chest X-ray and clear instructions regarding the circumstances under which to re-present to ED.

Cooper found the care breaches related to the doctor’s individual actions, whose responsibility was to ensure the woman was assessed appropriately and not discharged until presenting symptoms were adequately reviewed.

However, Cooper made an adverse comment about Health New Zealand in relation to pain relief and vital sign monitoring and the serious adverse event review.

She made several recommendations around education, documentation, and audits relating to aortic dissection, and recommended that the doctor write a letter of apology to the woman’s family.

He should also undertake refresher training on clinical documentation requirements and provide an anonymised version of the case to his employer for wider education purposes, Cooper recommended.

The doctor and Health New Zealand have made several related changes since the woman’s death.

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.