A medical practice in the Staffordshire area

3. Mr R complains the Practice failed to spot signs he had a new DVT and was at risk of pneumonia during appointments in July 2021. Instead, he says, it only prescribed an ointment for blisters on his leg and suggested he take paracetamol for his cold symptoms. He adds the practice nurse refused to prescribe paracetamol at this time, even though he had a regular prescription for this.

4. He also complains that after he submitted a complaint about his care on 27 August, the Practice did not issue a full response until 2 February 2022. When he later raised points he felt the response did not properly address, the Practice did not reply.

5. Mr R says if these signs were not missed, he would have had ‘clot busters’ and antibiotics sooner. This means he could have avoided getting a pulmonary embolism and worsening pneumonia which resulted in a hospital stay from 20 to 26 August. He was alarmed to learn the embolism could have been fatal. He says he has experienced more blood clots leading to a triple heart bypass in September 2022. He thinks these symptoms could have been avoided or reduced if the Practice had prescribed appropriate treatment in July 2021.

6. He also says it was frustrating that the paracetamol was not prescribed.

7. He adds the complaint handling further reduced his confidence in the Practice.

8. By bringing his concerns to us, Mr R would like the Practice to pay him financial compensation. He would also like the Practice to show it has learned from what happened by making service improvements.

9. Shortly before the events of this complaint Mr R was unwell and hospitalised with a DVT and pneumonia.

10. In July 2021, Mr R contacted the Practice to arrange a GP appointment. He wanted to discuss blisters which had appeared on his leg, and a continuous cold which he had had since the beginning of the year. He emailed pictures of the blisters to the Practice and was given an appointment with a nurse.

11. The nurse called a doctor into the appointment to look at the blisters and suggested paracetamol for the cold symptoms. The doctor prescribed ointment for the blisters. Mr R asked the nurse to add the paracetamol to his prescription. She refused to do so, on the basis that the NHS had advised GPs to stop issuing prescriptions for paracetamol.

12. Mr R’s symptoms worsened over the next few weeks and in the early hours of 20 August he attended his local A&E. Investigations found Mr R had a pulmonary embolism and pneumonia. He was discharged on 26 August after treatment, with a request for the GP to review the anticoagulant medication (to stop blood clots) in one month’s time.

13. On 27 August Mr R complained to the Practice that it had missed signs of the DVT and developing pneumonia, including a copy of the hospital discharge letter. He contacted the Practice on 2 September to request a GP appointment and learned that the discharge letter had not yet been added to his records. He was told the request for an appointment would be dealt with soon.

14. Mr R wrote to the Practice on 9 September about events that day. He had arranged a telephone appointment with a GP but was contacted first by a nurse, who prescribed apixaban – a blood thinner. When Mr R asked about the antibiotics needed for his ongoing pneumonia, he was told the GP’s appointment could go ahead as the GP would need to deal with this.

15. On 29 September Mr R was due to get a call from one of the Practice doctors, but this did not happen. The next day he emailed the Practice to chase a response to his two complaints and ask why he did not get a call the day before. He got a holding response to the complaints shortly afterward, although it was dated 27 September. The Practice explained that due to the absence of key staff it was taking longer than expected to investigate his complaint. Mr R wrote again on 2 October suggesting the response was backdated, as the envelope was franked on 30 September.

16. In November the Practice contacted all patients to advise that it may have to close due to staff shortages.

17. Mr R asked the Practice for a copy of his medical record on 9 December. On 9 January 2021 he emailed the Practice again to chase this up, and to remind it he had not had a satisfactory response to his complaints. The next day the Practice emailed him to say the practice manager had left. On 2 February he received a first and final response to the complaints.

18. On 25 February Mr R submitted a further complaint repeating his concerns that an opportunity to diagnose his DVT and pneumonia was missed in July 2021. He also set out his concerns over the Practice’s complaint handling.

19. As of the date of this report the Practice has sent no response to that complaint.

21. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mr R to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look in to.

Diagnosis of DVT/pneumonia

22. Mr R is seeking financial compensation and service improvements. There is a legal route to achieve financial compensation, as he is claiming that the Practice failed to identify signs of a DVT which led to a worse outcome for him. This means that he can consider a clinical negligence claim. As well as being a route to financial compensation, this is likely to encourage service improvements as the Practice tries to avoid similar claims in future.

23. As a by-product of legal action, Mr R may get answers which he was seeking from his complaint.

24. Mr R told us he cannot afford legal action himself but that he had contacted a ‘no-win no-fee’ firm. This firm suggested he wait for our report as a basis for legal action. He also said that, due to his recent heart bypass, he has been told to avoid stress.

25. Mr R was unsure about how much he is seeking to put right his complaint, other than it would be more than a few hundred pounds. He told us he wants to avoid this situation happening to other people but also thinks that only financial compensation will put things right for him. We consider both seem equally important to him.

26. Having established there is a legal route for Mr R to pursue the main part of his complaint, we considered whether it was reasonable for him to do this.

27. Mr R could use a ‘no-win no-fee’ firm to pursue a legal action and this would address the cost issue, so we do not consider cost to be a barrier to Mr R. Although the firm Mr R contacted suggested he get our report first, this does not mean that he cannot pursue this route. He could approach other firms or explain that we will not consider his complaint as there is a legal route open to him.

28. Although it could be stressful to pursue legal action, it does not seem likely it would be any more stressful or difficult than following the complaint process. Most clinical negligence claims against the NHS are settled before going to court. Therefore, this does not appear to stop Mr R from pursuing legal action.

29. As a legal route could address the most important aspect of Mr R’s complaint and it is reasonable to pursue, we have decided we should not consider this aspect of his complaint further at this time.

Paracetamol and complaint handling

30. We think it is unlikely Mr R would be satisfied with us reaching a decision purely about the paracetamol and complaint handling aspects of his concerns. And, this would not be a good use our resources.

31. While not wishing to minimise the impact of these aspects of his complaint, it was clear to us these issues added to the impact of the claimed failure to identify his DVT and pneumonia. Considered alone, the impact of these issues seems to be less. We have therefore decided not to look at these concerns at this time.

32. We were sorry to hear about Mr R’s experience. We recognise the importance he places on his complaint and that the legal route may not achieve everything he is seeking. If legal action is unable to resolve his concerns, it remains open to him to bring his outstanding concerns back to us to consider.

1. We have carefully considered Mr R’s complaint about a medical practice in the Staffordshire area (the Practice). We consider Mr R could take legal action about his main complaint that the Practice failed to treat his deep vein thrombosis (DVT) and pneumonia symptoms. We have decided it would not be right to address his other concerns at this time, and to address these in isolation would not give Mr R a good outcome.

2. We are sorry to learn about Mr R’s concern that he could have avoided the pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung) and later heart bypass, if the Practice had treated him differently. We have no doubt these events were alarming, and that alarm was made worse by the Practice’s seeming failure to properly answer his complaint.