On Feb. 11, 2009, a man went to see Orange, Virginia (VA), doctor Amy Cooley, complaining of a three-week case of heartburn and pain and pressure in his chest. Cooley, according to a report in the Fredericksburg Freelance Lance-Star, determined that the man had a blood pressure of 200/100 mm Hg and, despite having prescriptions for high blood pressure medications, was not taking the right steps to control his hypertension.

The man received new prescriptions from Dr. Cooley, heard a lecture on eating healthier and was sent home. Driving home from Cooley’s office, the man died in a single-car crash caused in part, the medical examiner determined, his heart condition. In other words, the man had a final heart attack just before crashing, and dying in, his car.

The Virginia Board of Medicine opened a case on Cooley and determined that her actions merited a reprimand and an order to complete 12 hours of emergency and urgent care training.

Classic heart attack symptoms include pressure in the chest, extremely high blood pressure and burning in the chest. That Cooley could miss these signs that the man was having a serious health crisis–especially considering his obvious history of hypertension–seems almost impossible. The disciplinary panel of the medical board might have been justified in going further than reprimanding Cooley. Failure to diagnose and provide appropriate therapy can result in limiting, suspending and revoking a medical license.

Traffic fatalities following medical crises are unfortunately fairly common. That a doctor had a prime opportunity to prevent such a tragedy simply by making a fairly obvious diagnosis and delivering standard care such as ensuring the man was taken to a hospital for emergency treatment, is rare. That the doctor did not make the right interventions is close to unforgivable.

My colleagues and I have represented many patients who have suffered severe consequences from missed and mistaken diagnoses. Doctors are not infallible, of course, but they do have professional, ethical and legal obligations to follow standards of care and identify and relieve patients’ problems. If they egregiously fail to meet those obligations, they should face a higher penalty than a reprimand and extra coursework.