Inadequate assessment by two GPS of a patient suffering with a blood clot was found to be the cause of death following an investigation by the Parliamentary and Health Service Health Ombudsman.
According to the Ombudsman, a male patient was “left in considerable pain over a long period of time” and unable to leave his chair for two weeks. Over consecutive days, two GPS visited the man at his home but they failed to make an adequate assessment for Deep Vein Thrombosis (DVT).
Both doctors also neglected to provide or arrange for further investigation and treatment, which the patient required. As a consequence of failing to act, the patient died when the blood clot travelled to his lungs, causing a blockage of the blood to the lungs, known as a pulmonary embolism (PE).
The Ombudsmen reports that following on from the failure by “two healthcare professionals in their duty of care to carry out a proper assessment”, action has been taken to ensure the same mistakes do not happen again. In addition, all the GPs at the practice have improved their awareness of managing DVT and one of the GPs has attended a workshop for the prevention of PE.
It was also found by the Ombudsman investigation that there was a strong probability that even if the failings of the two GPs had not occurred the patient might not have survived, but the wife will now never know for certain. The GPs have since apologised to the deceased man's wife and paid £2,000 in recognition of the distress she experienced.
DVT can be difficult to diagnose at the early stages and a doctor is required to conduct further tests to confirm the condition. Among the techniques available to diagnose for DVT include, special blood testing, CT and MRI scanning.
An estimated 25,000 people admitted to hospital die from preventable blood clots, each year, according to a NHS England report, 2014.