Ethics · Advanced · Medical Error

Discussion of Missed Heart Attack

Practise this PLAB 2 ethics station on Missed Myocardial Infarction. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a hospital clinic. You are seeing Mr Nitin Narayan, a 61-year-old man, six months after he suffered a myocardial infarction. He attended A&E three months before his MI with chest pain and was discharged without diagnosis. The MI occurred three months later. You have been asked to discuss what happened, explain the missed diagnosis, apply duty of candour, apologise appropriately, and discuss next steps including correction of his medical management.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Type 2 diabetes, Osteoarthritis bilateral knees (age-related)

What this station tests

  • Duty of candour for a missed diagnosis: honest explanation of what happened and what should have been different
  • Early normal troponin does not exclude MI: serial troponins or clear safety netting should have been provided
  • Proportionate outcome assessment: the delay may have caused additional damage but most occurs early
  • Supporting the complaint process while continuing care
  • Not blaming individuals: system learning, not blame culture

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Explaining a missed diagnosis to the patient requires duty of candour, honesty about what happened, and reassurance about ongoing care. Mr Narayan is 61, attending 6 months after an MI that was initially missed in A&E. He wants answers. Open with: 'Mr Narayan, I understand you have questions about what happened when you came to A&E. I want to be completely honest with you.'

Core approach

Explain what happened. He attended A&E with chest pain. The initial ECG and troponin were normal (can happen early in MI). He was discharged. He returned 12 hours later with worsening pain, and MI was confirmed. The initial assessment was not necessarily wrong (early normal troponin is common), but the safety netting may have been inadequate.

Duty of candour: 'I want to be open with you. The initial tests were normal, which is why you were discharged. However, we should have either kept you for serial troponins or given you clearer instructions about when to return.' Acknowledge the gap without blaming individuals.

Did it affect his outcome? Honestly assess: the 12-hour delay may have resulted in more myocardial damage. His current cardiac function reflects this. Be proportionate: most of the damage occurs in the first hours regardless.

Closing and safety netting

Ongoing care: cardiac rehabilitation, medication optimisation (dual antiplatelet, statin, ACEi, beta-blocker), lifestyle modification. If he wants to complain: PALS, formal investigation. 'You have every right to pursue this, and I support you in doing so.' The learning from this case should improve future care.

Reassure about ongoing care: 'Whatever happened before, my job is to make sure you get the best care going forward.' Follow-up: cardiology, cardiac rehab, GP review.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Supporting)

Scores well: Timeline reconstructed. Early troponin limitation explained. Current cardiac function assessed.

Costs marks: Not explaining what happened.

Domain 2 (Primary focus)

Scores well: Duty of candour applied. Ongoing cardiac care optimised. Complaint supported. System learning discussed.

Costs marks: Defensive. Not applying duty of candour.

Domain 3 (Primary focus)

Scores well: Honest without defensive. Acknowledging the gap. Supporting complaint. Committing to future care.

Costs marks: Defensive. Blaming others. Not supporting complaint.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Being defensive: he deserves honesty about the gap in his care
  2. Blaming the A&E doctor: duty of candour is about transparency, not blame
  3. Speculating about outcome: only state what is known about the impact of the delay

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

What is the right way to handle the missed myocardial infarction scenario in this station?

Explaining a missed diagnosis to the patient requires duty of candour, honesty about what happened, and reassurance about ongoing care. Mr Narayan is 61, attending 6 months after an MI that was initially missed in A&E. He wants answers. Open with: 'Mr Narayan, I understand you have questions about what happened when you came to A&E. I want to be completely honest with you.'

Where are marks won and lost in this missed myocardial infarction station?

Examiners reward: Timeline reconstructed. Early troponin limitation explained. Current cardiac function assessed. Candidates are penalised for: Not explaining what happened.

Where do candidates most often go wrong in this station?

Being defensive: he deserves honesty about the gap in his care. Another frequent error: Blaming the A&E doctor: duty of candour is about transparency, not blame.

Can I do well in this station without real-world experience of missed myocardial infarction?

Structure beats experience here. Focus on early normal troponin does not exclude MI: serial troponins or clear safety netting should have been provided. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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