Patient's blood clot missed in A&E

Summary 1058 |

The Trust should have done further tests to check for a blood clot in Mrs N's lung before discharging her.


What happened

Mrs N went to her local A&E department because she was feeling unwell. A doctor examined her and said she could go home. She remained unwell, and saw another doctor privately who diagnosed her with a pulmonary embolism (a blood clot in the lung) a week later. Mrs N was distressed that the Trust had left her without treatment for a potentially serious problem.

Mrs N complained to the Trust. It accepted that it should have carried out further tests to check whether she had a clot, and also sent her statements from the doctors involved in her care. Mrs N was unhappy with the Trust's explanations and the time it took to respond to her complaint, so she came to us.

What we found

We partly upheld this case. The Trust should have done further tests to look for a blood clot before discharging Mrs N. It was appropriate for the Trust to acknowledge that, but it had not explained what it had done to stop something similar from happening again.

The Trust took too long to respond to Mrs N's complaint and the doctors' statements that it sent to her were contradictory. It should have clarified which statement it considered accurate.

However, the doctor who saw Mrs N in A&E told her to come back to hospital if she was still unwell. If she had done so, we thought that the Trust would most likely have found her clot then.

Putting it right

The Trust paid Mrs N £100 in recognition of the avoidable distress she experienced, and apologised for the shortcomings in its handling of the complaint. It also produced an action plan to show how it would stop something similar from happening again. 

Health or Parliamentary
Health
Organisations we investigated

Dartford and Gravesham NHS Trust

Location

Kent

Complainants' concerns ?

Did not apologise properly or do enough to put things right

Did not take sufficient steps to improve service

Result

Apology

Compensation for non-financial loss

Recommendation to learn lessons or draw up an action plan