Patient's death from deep vein thrombosis could have been avoided

What happened

Mrs G suffered a deep vein thrombosis (DVT) in late 2011. She then took blood thinning drugs for six months.

In summer 2012 Mrs G telephoned the Practice because her left ankle was swollen. She was seen that day by Dr A, who asked for advice from Dr B. Neither doctor felt that Mrs G's symptoms were a sign of DVT.

Three weeks later, Mrs G returned to the Practice. Her left ankle was still swollen. Her usual GP, Dr C, examined her but again felt that Mrs G's symptoms were not a sign of DVT. Dr C told Mrs G to return for a follow- up appointment in two weeks. Mrs G died at home one week later.

What we found

At both appointments the GPs who saw Mrs G failed to follow the relevant medical guidelines on investigating a possible DVT. They also failed to investigate her symptoms properly. We decided that, on balance, Mrs G's death could have been avoided.

Putting it right

The Practice accepted our recommendations. As a result it completed an action plan that explained how it will comply with the relevant medical guidelines for DVT. It also explained how the doctors involved had learnt from the complaint and what action they had taken to improve their practice as a result of it. They provided Mrs G's relatives with evidence of what they had learnt from the complaint and apologised to them.