What was the cause of death?
The patient had a whole host of pathologies but what was the cause of death? Dr Alison Cluroe explained her decision to Chris Smith...
Alison - I think at the end of the day the cause of this man's death is a combination of different pathologies, and then teasing out how we prioritise those to get a proper and accurate cause of death on the death certificate is the issue that we're now faced with. And in my view, looking a the degree of fluid in this gentleman's lungs and the presence of the superimposed infection in his lungs, those are going to be his primary cause of death. I think, in fact, he has died as a consequence of bronchopneumonia secondary to heart failure as a consequence of ischaemic and hypertensive heart disease. However, he is also a very unwell gentleman because we know in the background of all of that he's got lung cancer which appears to have spread to his liver.
So, I will give the cause of death as bronchopneumonia, arising on a background of ischemic and hypertensive heart disease. And under number 2 on the death certificate, we will put down disseminated lung cancer and also diabetes.
Chris - So James - now you know the verdict, what do you think.
James - Well, I think I'm not surprised by the verdict. We've been building up, I think, to this sequence of events, the diagnosis, for some time. So this would explain the patient's dying had a number of serious illnesses, some of which had relatively recent onset like pneumonia, but some of which, I think, have been present form a long time such as the heart disease.
Chris - Hugo.
Hugo - Well, I would agree with that. What I think is interesting about this gentleman is actually how many different things he had wrong with him which, apparently, nobody knew about. And I think that does ask the question about how often we actually do ask our doctors about the symptoms that we have.
Chris - When I was at medical school, on the front of one of the handouts, very memorably it said "a healthy patient is one who has been inadequately screened." It's absolutely true here I think, isn't it James?
James - No it is, you're right. I don't know if this patient lived alone. That might have been an important factor whether he had nobody to complain of any symptoms to. But yes, he seemed to have multiple things wrong with him which, unfortunately, culminated in his dying.
Chris - Now everyone sitting here has the benefit of all of the technologies that hospitals can bring to bear to solve a problem - blood tests, scans - we've talked about many of them. If you're a general practitioner though, which is the individual to whom most cases will present in the first instance because that's who they have a relationship with. They can't get to see one of you guys until they've actually been to see a GP. They don't have access to these sorts of things Helen.
Helen - No, I think it must be incredibly difficult. GPs are great, they have to deal with everybody who walks in through the door and some of these symptoms, as Prina said, can be non-specific. If someone's breathlessness with known lung disease, you may not think it can be anything else if that's the only symptom, so I think they have a very difficult job unpicking everything. We can call a colleague up very easily on the telephone within the hospital and, as you say, we have access to blood tests and scans. GPs have to refer, there may be delays, so I think primary care has a very difficult job in teasing out all the different things that patients can present with.
Chris - Prina - you're the respiratory person and it did turn out to have a very important bearing on what happened here because, ultimately, we think that's why this person died, but there was a lot more to it than just having a chest infection in this instance.
Prina - I think he clearly had many different medical problems and going through the post-mortem, much of what we saw in the first external examination is explained. The clubbing is certainly explained by his lung cancer.
Chris - Well it was you at the beginning who said "well I think something else is going on because we can explain, on the basis of the history, why he got that."
Prina - Yes, so that certainly had a bearing but I think also you could see from his heart failure and his COPD that he had many reasons to be breathless. So that might explain why he didn't perhaps present with his lung cancer as well because many of the symptoms he had may have overlapped with his other conditions.