West Hertfordshire Teaching Hospitals NHS Trust

4. Mrs B complains about care and treatment provided to her husband Mr B on 24 February 2023 at the Trust. She says Dr F, a doctor at the Trust:

• did not ask the right questions or do the correct tests • misdiagnosed Mr B and missed the presence of a blood clot in his lungs • wrote misleading information on Mr B’s healthcare records.

5. Mrs B says her husband died avoidably from a blood clot which, if it had been identified in time, could have been treated. Mrs B became a widow, and her young children lost their father. She says Mr B worked full time and his death has impacted the family financially.

6. Mrs B wants Dr F and the Trust to be held accountable for their actions and for Dr F to be retrained on identifying pulmonary embolism (a blood clot in the lungs). Mrs B says other patients at the Trust may die without this accountability. Mrs B also seeks a financial remedy in recognition of the impact of her husband’s death on herself and their children.

7. On 24 February 2023, Mr B was feeling unwell with progressive breathlessness. He attended an urgent treatment centre in a hospital run by the Trust, arriving at 10.29am.

8. Dr F recorded Mr B’s symptoms as shortness of breath and cough with green phlegm, with a history of these symptoms for the previous seven days. Mr B was sent home at 2.31pm with a prescription for antibiotics and advised to call 111 or go to the Accident and Emergency department if his symptoms got worse.

9. Later that day, Mr B’s condition worsened, and Mrs B called an ambulance. Sadly, Mr B died at home while being helped to the ambulance by the ambulance crew.

10. A post-mortem found Mr B had a large clot in a main artery in his lungs, which had caused his death from pulmonary embolism. The post-mortem concluded this had been caused by deep venous thrombosis, a blood clot in the deep veins of the legs.

Care and treatment at the Urgent Treatment Centre

12. Mrs B wants Dr F to take accountability for their actions and to have training on recognising signs and symptoms of pulmonary embolisms. She also has concerns Dr F recorded misleading and inaccurate information in the healthcare records. She says her husband did not have a cough and was not coughing up green phlegm, and that he had been very short of breath when he arrived at the Urgent Treatment Centre.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us, and also by other organisations. We have considered whether another organisation is better suited to giving an answer to the complaint and whether it can provide the outcome Mrs B seeks.

14. The General Medical Council (the GMC) sets the standards doctors need to meet in order to deliver good, safe patient care in the UK. It manages the UK medical register to ensure every doctor has the right knowledge, skills, qualifications and experience to work across the UK. The GMC can investigate serious concerns about a doctor’s behaviour or performance, including those related to patient safety.

15. Mrs B’s concerns are related specifically to the actions taken by Dr F and the information they recorded on Mr B’s healthcare records, which she says are inaccurate and misleading. Mrs B feels the Trust should also take accountability as it accepted what Dr F had recorded on the healthcare records without question.

16. We would not challenge what is recorded in the healthcare records. As Mrs B is concerns specifically related to Dr F, we think the General Medical Council is better placed to consider her concerns and to take action on them if required.

17. We recognise Mrs B may be disappointed by our decision. We know Mr B’s death has had, and continues to have, a devastating impact of Mrs B and their children and we hope Mrs B finds answers to her concerns and closure in the future.

1. We have carefully considered Mrs B’s complaint about West Hertfordshire Teaching Hospitals NHS Trust (the Trust), in relation to care and treatment provided to her husband, Mr B.

2. We were very sorry to hear about the circumstances of Mrs B’s complaint, and Mr B’s sad death. We recognise this has had, and continues to have, a devastating impact on Mrs B and their children.

3. We have decided that another organisation, the General Medical Council, is better suited to deal with Mrs B’s concerns.