Man's death from blood clots could have been avoided

What happened

Mr D was in his seventies. He fell and injured his hip and was taken to hospital, where doctors diagnosed that he had fractured his greater trochanter (a 'knuckle' of bone that sticks out from the top of the thigh bone).

Mr D did not need an operation and Trust staff discharged him after two mobility assessments. Doctors advised Mr D to try to move around at home.

Once at home, Mr D's condition rapidly deteriorated. His leg swelled and he was unable to move from his chair, and he later developed chest symptoms. Mrs D was sufficiently worried to call GPs to visit him on three occasions over several weeks. Three GPs came to see him but none properly identified his risk of developing blood clots. Mr D developed a blood clot in his lungs and died hours after the third GP's visit.

What we found

We partly upheld this complaint. There were some shortcomings in the Trust's discharge planning process. But the shortcomings were not serious enough to amount to service failure. Crucially, the Trust's staff would not have been able to predict Mr D's rapid deterioration at home, based on the assessments they had made while he was in hospital.

At the second and third GP visits, given Mr D's risk factors and clinical symptoms, doctors should have thoroughly considered the possibility of blood clots. They excluded this too readily, or did not properly consider it in line with established good practice. The GPs did not take adequate steps to prescribe drugs that could have helped prevent blood clots developing. Mr D's death could have been avoided had GPs taken appropriate action, particularly at the second visit.

Putting it right

The GP Practice wrote to Mrs D to acknowledge and apologise for the service failure we identified. It also paid £15,000 compensation and prepared an action plan to demonstrate learning from the complaint.