When Mrs H, in her early fifties, saw her GPs with pain and swelling in her leg, they failed to carry out sufficient investigations to identify or rule out a deep vein thrombosis (DVT). Mrs H died of a pulmonary embolism (a blood clot in the lung) shortly afterwards.
What happened
Mrs H went to the Practice in summer 2012 with pain and swelling in her left leg. The first GP warned her of the possibility of a DVT and prescribed painkillers. Mrs H was still in pain and returned to the Practice a few days later. She saw a second GP who thought she might have a cyst behind her knee, and prescribed more painkillers.
Mrs H remained unwell and was admitted to hospital nine days later. The following morning she had a pulmonary embolism and died.
Her husband, Mr H, complained to us.
What we found
We found that, having considered the possibility of a DVT, the two GPs did not carry out enough tests to either diagnose or rule this out. This meant there were two missed opportunities to arrange urgent care and follow up, which very likely would have avoided Mrs H having her fatal pulmonary embolism.
Putting it right
Following our investigation the Practice apologised to Mr H and paid him £15,000. It put a plan in place to learn lessons from what happened to avoid the same thing happening again.
In October 2015 the Practice followed up on our investigation and told us that staff are now doing more D-dimer tests (one of the tests for DVT) as a result of their raised awareness of this issue. The Practice reported that it had found DVT in patients where it had not expected to.
A GP practice
Cheshire
Delayed replying to complaint
Apology
Compensation for non-financial loss
Recommendation to learn lessons or draw up an action plan