Misdiagnosed Pulmonary Embolism in Georgia: Why Blood Clots Are Still Being Missed in Emergency Rooms
The chart often tells you what went wrong within an hour of reading it. Someone you loved walked into a Georgia emergency room short of breath, or with chest pain, or with a racing heart that would not settle. A few hours later they walked out with a diagnosis of anxiety, a panic attack, pneumonia, costochondritis, or “known CHF.” Within hours or days they were gone, and the autopsy or the second hospital said pulmonary embolism.
A pulmonary embolism is a clot in the arteries of the lung, and it almost always traveled there from a vein in the leg. This article is a reconstruction of what a competent Georgia emergency department should have documented when your loved one presented, in language you can hold against the records you were sent home with. It is not medical advice. It is a description of chart artifacts.
Our honest position at the outset: not every missed pulmonary embolism is malpractice. Some presentations genuinely mimic anxiety or a pulled muscle, and Georgia law raises the bar for ER cases specifically. What decides these cases is what the record shows, and what it does not.
What a competent Georgia ER should have done when someone couldn’t breathe
The six moments below are what should already be timestamped in the record. The phrase “standard of care” gets used a lot in these cases, and it means something specific but ordinary: what a reasonably careful ER would have done in the same situation. When a patient arrives with breathing difficulty, chest pain, or a suspiciously fast heart rate, the standard workup for pulmonary embolism follows a sequence that should appear in the chart. Silence in the record where that sequence should be is itself the artifact worth looking for.
Triage vitals and the first ten minutes
Everything begins at the intake desk. The triage nurse records heart rate, oxygen saturation, respiratory rate, blood pressure, and temperature, and those numbers set the tone for everything that follows. A heart rate over 100, an oxygen saturation below 95 percent, or a respiratory rate above the normal range are the kind of values that should have pulled pulmonary embolism onto the differential and kept it there.
The triage sheet should also reflect what the patient actually reported: sudden shortness of breath, chest pain that worsens with a deep breath, coughing up blood, fainting, or unilateral leg swelling. When any of those complaints appear next to abnormal vitals and no one documented why pulmonary embolism was ruled out, the workup gap starts here. These cases often begin with a triage sheet that already contained the answer.
The Wells score, and what its absence from the chart means
A Wells score is a seven-question calculation the ER physician should have run and documented when pulmonary embolism was in the picture. It is not obscure and generally should not be optional in a plausible presentation. It exists precisely to force a structured pretest probability instead of a gut call.
The seven components are:
- Clinical signs or symptoms of a deep vein thrombosis
- Pulmonary embolism is the most likely diagnosis, or as likely as any alternative
- Heart rate greater than 100 beats per minute
- Immobilization for at least three days or surgery in the prior four weeks
- Prior objectively diagnosed pulmonary embolism or deep vein thrombosis
- Hemoptysis (coughing up blood)
- Active malignancy
A score above 4 places the patient in the “PE likely” category and calls for imaging. When no Wells score appears anywhere in the chart of a patient who died of a pulmonary embolism hours after discharge, the question is not whether the score would have been positive. The question is why the calculation that would have answered it was never done.
PERC, and the misuse that ends workups too early
The Pulmonary Embolism Rule-out Criteria, or PERC, is an eight-item screen designed to close the door on pulmonary embolism in patients whose pretest probability is already low, generally below about 15 percent. Applied correctly, it prevents unnecessary D-dimer testing and imaging. Applied incorrectly, it becomes a shortcut that ends the workup before it began.
The criteria touch age, heart rate, oxygen saturation, unilateral leg swelling, hemoptysis, recent surgery or trauma, prior clot history, and exogenous estrogen use. All eight must be negative for PERC to rule out. And PERC is only appropriate after the physician has actually determined that pretest probability is low, and documented that determination. When a chart reflects PERC applied to a patient whose Wells score would have been moderate or high (had it been calculated), that is the kind of workup failure we see repeatedly. “PERC closed the door” is a defense that only holds if the door was low-probability to start with.
D-dimer, and why age changes the answer
The standard D-dimer cutoff is 500 nanograms per milliliter, and above that number pulmonary embolism cannot be ruled out by blood test alone. But for patients over 50, the age-adjusted cutoff is the patient’s age multiplied by 10. A 75-year-old with a D-dimer of 700 is not “normal” under the standard cutoff, but they are below the age-adjusted cutoff of 750. A 35-year-old with the same 700 is well above the 500 threshold and needs imaging.
The age-adjusted cutoff is one of the cheapest interpretive corrections in emergency medicine and one of the more common places we see it interpreted lazily. The “negative D-dimer, discharged home” defense requires the chart to show that the pretest probability was genuinely low and that the correct cutoff was applied. Both must be documented. Neither being documented is not a technicality.
CT pulmonary angiography, the imaging that should have followed
CT pulmonary angiography, or CTPA, is the imaging test pulmonary embolism cases are decided on. The American College of Radiology recognizes it as the standard for suspected pulmonary embolism, and a ventilation-perfusion (V/Q) scan is the recognized alternative when contrast is contraindicated by renal impairment, contrast allergy, or in select pregnancies.
What CTPA is not is a chest x-ray. A normal chest x-ray does not rule out a pulmonary embolism, and it never has. “The chest x-ray was clear” is the single most common wrong-turn documentation we encounter in a suspected-PE record. It answers a different question than the one the presentation asked. When the clinical picture called for CTPA and the record shows only a chest x-ray, that is what “failure to order CT angiography for suspected PE” looks like on the page.
The treatment call, once PE is on the table
Once pulmonary embolism is diagnosed, the treatment call runs through risk stratification (often using the simplified Pulmonary Embolism Severity Index, or sPESI), initiation of anticoagulation for stable patients, escalation to thrombolysis for hemodynamic instability, and catheter-directed therapy or surgical embolectomy for massive presentations. An inferior vena cava filter enters the discussion when anticoagulation is contraindicated. These are decisions the chart should reflect, in order, with timestamps. The treatment call is rarely where these cases turn. The workup that came before it usually is.
How the wrong label sticks: anchoring bias and the workup that never happened
Anchoring bias is the diagnostic error that names most missed pulmonary embolisms. In plain English, it means the diagnostic label the patient walks in with pulls the workup toward confirming it. The primary care note said musculoskeletal pain. The EMS handoff said “known CHF exacerbation.” The chief complaint at intake said “anxiety, worse at night.” Whatever came first tends to survive, and the tests that would have contradicted it tend not to be ordered.
Researchers describe this pattern as premature diagnostic closure: the label closes the workup before the workup can contradict it. Emergency department visits arriving with a pre-existing diagnostic label often receive a narrower workup than visits arriving with the same symptoms but no label attached, even when the underlying risk of pulmonary embolism is the same.
This matters legally because it explains, mechanically, why a workup that should have happened did not. In our experience, “the workup wasn’t done” is almost always a more honest description of what went wrong than “the diagnosis was wrong.” The diagnosis was never really made. A label was inherited, and the tests that would have questioned it were never ordered.
Why pneumonia, panic, and pulled muscles keep winning the coin flip
Four wrong labels dominate the missed-PE fact patterns we see. Each one wins for a reason, and each one should have been beaten by features already on the chart.
Pneumonia wins when the patient has a fever, a cough, and pleuritic chest pain. The overlap is real. What should have kept pulmonary embolism on the differential is a recent surgery, recent immobility, hemoptysis, or a unilateral swollen leg that never got examined. A pulmonary embolism can produce a low-grade fever, and pneumonia does not usually produce a swollen calf.
Panic attack is the label most often stuck on young women. Tachycardia, air hunger, a sense of dread, and a prior history of anxiety line up cleanly with a panic diagnosis, and the workup ends at the psychiatric intake. What should have kept pulmonary embolism in the picture is hormonal contraceptive use, pregnancy or the postpartum period, a recent long flight, or family history of clotting disorders. A young woman on combined oral contraceptives with sudden dyspnea and a normal chest x-ray discharged with a panic-attack label is the single fact pattern we see most often in these records.
Myocardial infarction and congestive heart failure win when the patient is older, has cardiac history, and presents with chest pain and dyspnea. Troponin and ECG do their work, and when they come back reassuring, the workup often closes there. What should have kept pulmonary embolism alive is that a normal troponin does not rule out a clot in the lung, and CHF and PE can present together in the same patient on the same visit.
Musculoskeletal pain and costochondritis win when the physician can reproduce chest wall tenderness on palpation. It feels definitive, and it is not. Reproducible chest wall tenderness has been documented in patients later found to have pulmonary embolism. Recent surgery, active cancer, or a prior clot should have kept the differential open regardless of what the exam elicited.
Georgia’s ER statute raises the bar, and it matters that families understand exactly how
O.C.G.A. § 51-1-29.5 is the Georgia statute that governs medical care rendered in emergency departments, and it changes the plaintiff’s burden in ways every family considering a case should understand before they invest months of hope in it. The statute exists because the legislature decided emergency care is different from planned care, and it should not be judged by the same yardstick.
Two terms carry the weight. “Gross negligence” is more than a slip below the ordinary standard. It is a substantial deviation from what a reasonably careful emergency physician would have done: a workup so thin, or a discharge so unsupported by the chart, that a jury can call it a real departure from care rather than a defensible judgment call. “Clear and convincing evidence” is the burden the plaintiff carries to prove it. That burden sits above the ordinary civil standard of “more likely than not,” and below the criminal standard of “beyond a reasonable doubt.” The statute itself spells out both requirements in the same sentence.
What that means practically is not that Georgia ER cases cannot be won. The winning cases are the ones where the workup gap is plainly documented (or plainly absent) and hindsight-only explanations do not save the discharge. A Wells score that was never calculated in a patient with tachycardia, a unilateral swollen leg, and recent surgery is the kind of gap a jury can call gross. A judgment call between two reasonable differentials, with a workup that actually happened and vitals that actually reassured, is usually not.
We do not walk families away from § 51-1-29.5 cases as a rule. We walk families toward the ones where the chart shows the workup did not happen, because those are the cases the statute lets us prove.
The Gwinnett verdict that shows what a losing case looks like
Connie Arnold was 61 years old when she went to a Gwinnett County emergency room. Her primary care physician had already diagnosed her chest complaints as musculoskeletal pain, and the ER, after evaluating her, agreed and discharged her. Less than three hours later, she was dead of a pulmonary embolism.
Her family filed suit against the nurse practitioner and the ED physician who saw her. The case, Arnold v. Lee (Gwinnett County State Court, No. 17-C07323-S2), went to trial in 2023. Plaintiffs asked the jury for $25 million, including $10 million for pain and suffering. The trial ran six days. The jury deliberated approximately four hours. It came back for the defense, finding neither the nurse practitioner nor the ED physician grossly negligent under § 51-1-29.5. The reporting on the trial by Courtroom View Network laid out both sides’ positions in detail.
The lesson is not that Georgia PE cases cannot be won. Sympathetic fact patterns, dead patients, and grieving families do not decide these cases. The chart does, and § 51-1-29.5 is the reason. Where the record shows a workup that a reasonably careful physician could have thought was adequate at the time (whatever the outcome), the gross-negligence standard is very hard to meet.
In 2018, a Gwinnett County jury returned a $15.5 million verdict against Quality Nighthawk Teleradiology Group in a case where a radiologist misread a spine scan, and the patient was left quadriplegic. Law.com covered the verdict. The case turned on what the imaging showed and what the report said it showed, which are the two documents that make a radiology misread case.
The pattern (a diagnostic tool ordered, misread, and consequential harm) is a pattern our firm has proven. In February 2023 we resolved a radiology malpractice case for $9.9 million on behalf of a high school senior whose head CT following an unexplained seizure contained a clearly visible arteriovenous malformation the radiologist failed to identify. A year later he suffered a massive stroke from that AVM, with permanent neurological impairment. The case was built on a meticulous review of the initial scan alongside opinions from leading neuroradiologists and neurologists, who confirmed the finding should have been called on the first read. Past results do not guarantee future outcomes.
A structurally similar investigation drove the resolution of an infective endocarditis misdiagnosis in May 2021 for $10 million. Our client, a woman in her mid-fifties, had presented to the defendant healthcare system with intermittent fevers over several weeks. Blood cultures and an echocardiogram (the standard diagnostic tools for suspected endocarditis) were never ordered. The infection went undetected. She suffered a massive stroke, leaving her with permanent neurological deficits.
What these cases share is not the diagnosis. It is the shape of the record. Symptoms present. Standard workup absent. A catastrophic outcome that the standard workup would very likely have prevented. That is the shape a missed pulmonary embolism case usually takes, and it is why the investigation runs the way it does.
What a records review of a missed pulmonary embolism actually looks like
An initial records review is a specific piece of work with a specific sequence, and it is worth understanding what we actually do before deciding whether to request one.
First, we obtain the full emergency department chart. That means the triage nursing note with vitals and chief complaint, all physician and provider notes, every order placed (and the timing of each), test results in the order they returned, any imaging that was ordered along with the reports, and the discharge instructions with their timestamp. It also means the orders that were not placed. What is missing from the chart is often as important as what is in it.
Second, we request EMS transport records where an ambulance was involved, and any admission or transfer records if the patient was later admitted to another hospital or died en route. Handoff documentation matters because anchoring bias often lives in the language used at handoff.
Third, we review the records with an emergency medicine expert. When imaging is central (a chest x-ray read as normal, a CT that should have been ordered, an incidental finding that was missed) we add a radiologist. Pulmonology enters when the treatment call itself is in dispute. The experts read alongside us, and the question they are asked to answer is not whether the outcome was tragic. It is whether the documented decision-making meets the standard § 51-1-29.5 sets.
Fourth, we tell you honestly what we found. If the chart supports a viable case under Georgia law, we say so and describe next steps. If it does not, we say that too. A records review that takes six weeks and returns “we don’t think this case is viable” is worth more to a family than a records review that takes six days and returns hope built on nothing.
Georgia deadlines, expert affidavits, and who can file
Four Georgia statutes govern the procedural side of a wrongful death claim arising from a missed pulmonary embolism, and they matter enough to name plainly.
O.C.G.A. § 9-3-71 sets the statute of limitations at two years from the date of the injury or death for medical malpractice claims. A separate five-year statute of repose caps the outside window regardless of when the injury was discovered. Exceptions may apply in specific circumstances, and the interaction between the limitations period and the repose period is often more complicated than it looks. Prompt records review matters for that reason.
O.C.G.A. § 9-11-9.1 requires that an expert affidavit be filed with the complaint at the outset of a medical malpractice case. The expert must practice or teach in the same specialty as the defendant provider. That means an emergency medicine expert must generally sign off before an ER case can be filed, and locating and retaining that expert is part of what a records review is for.
O.C.G.A. § 51-4-2 sets the wrongful death filing hierarchy. The surviving spouse has the first right to file. If there is no spouse, the right passes to the children. If there is neither, it passes to the parents. The statute governs who can bring an Atlanta wrongful death claim and how proceeds are apportioned, and it matters in blended-family or unmarried-partner situations where the hierarchy is not intuitive.
Questions Georgia families ask after a missed pulmonary embolism
What could be mistaken for a pulmonary embolism?
Pneumonia, panic attack or anxiety, myocardial infarction or heart failure, and musculoskeletal chest pain or costochondritis lead the list. What should have kept pulmonary embolism on the differential are features already in the chart: recent surgery or immobility, hormonal contraceptive use, pregnancy or the postpartum period, active cancer, unilateral leg swelling, or a prior DVT or PE.
What will the ER do for a pulmonary embolism?
A competent emergency department documents triage vitals, calculates a Wells score, applies PERC only when pretest probability is genuinely low, orders a D-dimer with the age-adjusted cutoff where applicable, orders CT pulmonary angiography when the clinical picture calls for it, stratifies risk with sPESI once PE is confirmed, and initiates anticoagulation or escalates to thrombolysis, catheter-directed therapy, or embolectomy based on hemodynamic status.
What is the 60/60 rule for pulmonary embolism?
The 60/60 rule is an echocardiographic finding: a right ventricular outflow acceleration time under 60 milliseconds combined with a tricuspid regurgitation pressure gradient under 60 mmHg. Taken together, the two findings suggest right ventricular strain of the kind seen in acute pulmonary embolism. It is one of several bedside echo signs used when CTPA is not immediately available.
What is the gold standard for diagnosing pulmonary embolism?
CT pulmonary angiography, per the American College of Radiology’s appropriateness criteria. A ventilation-perfusion scan is the recognized alternative when contrast is contraindicated by renal impairment, contrast allergy, or select pregnancy situations.
Is a missed pulmonary embolism always malpractice in Georgia?
No. Under O.C.G.A. § 51-1-29.5, emergency room care is judged by a gross-negligence standard proven by clear and convincing evidence. Some presentations genuinely mimic anxiety or musculoskeletal pain, and reasonable physicians can reach different judgments on the same facts. The question these cases turn on is what the record documents about the workup that was, or was not, performed.
How long do I have to file a wrongful death claim in Georgia after a missed PE?
Generally two years from the date of death under O.C.G.A. § 9-3-71, subject to a five-year statute of repose that runs from the underlying negligent act. Exceptions may apply. Prompt records review matters because the expert affidavit required by O.C.G.A. § 9-11-9.1 attaches at filing, and locating the right expert takes time.
If you lost someone shortly after an ER visit, we can review the records
An initial conversation with our office covers what happened at the emergency room visit, what documents you already have and which ones we would help you obtain, and what an expert-supported records review would look at in your specific case. It is a description of the work, not a commitment to any outcome, and it is confidential.
Davis Adams handles Georgia medical malpractice cases on a contingency-fee basis, with the specific terms and expenses outlined in the fee agreement. If you would like us to review the records of a Georgia emergency department visit that ended in a sudden death, you can contact Davis Adams to request a confidential consultation.
This article is for general informational purposes only and is not legal advice. Every case depends on its own facts, medical records, and expert review. Reading this page does not create an attorney-client relationship.
