1. Failure to Escalate Abnormal Observations Despite the patient presenting with a significantly elevated heart rate, high respiratory rate, and reduced oxygen saturations — all indicative of physiological instability — there was no escalation to secondary care or referral to the emergency department. There appears to have been no formal threshold or protocol in place to ensure that abnormal observations of this nature trigger an urgent clinical response.
2. Lack of Structured Risk Assessment for Pulmonary Embolism Although pulmonary embolism was a relevant clinical possibility, no structured risk assessment tool (such as the Wells score) was used or documented, and there was no attempt to apply an evidence-based diagnostic pathway as recommended by NICE guidance (NG158).
3. Unclear Use or Misunderstanding of Clinical Decision Tools Evidence suggested uncertainty about the appropriate use of the Pulmonary Embolism Rule-out Criteria (PERC) in primary care settings, with potential misapplication outside of the specific context recommended by NICE (i.e., in low-risk patients only and following validated pre-test probability assessment). There appears to be a lack of clarity or training regarding the scope and limitations of such tools in the primary care context.
4. Risk of Repetition in Similar Settings The inquest heard no evidence that the walk-in centre has a specific protocol or decision-support mechanism in place for the recognition and escalation of potentially life-threatening conditions such as pulmonary embolism. There is a risk that similar failings could occur in future, particularly where patients present with non-specific symptoms and abnormal vital signs.