15. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong, or we where we have found something had gone wrong, we have decided that mistake did not have an impact on Mr A’s health.
Consultation: 15 April 2024
16. Mr A complains the Practice failed to consider his medical history and adopt a holistic approach when assessing his condition, and it failed to carry out an urgent blood test, or refer him to hospital, to identify the pulmonary embolism he was later diagnosed with.
17. GMC guidelines say doctors must give a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• properly assess the patient’s condition, looking at their history (including their symptoms and psychological, spiritual, social and cultural factors), their views and values; and, where necessary, examine the patient • quickly give or arrange suitable advice, tests or treatment where necessary • and refer a patient to another practitioner when this would be better for the patient.
18. When Mr A attended the Practice on 15 April 2024, the doctor took a note of his history, specifically ‘woke this morning a pain at the right side of his neck, says this pain seemed to move from neck down the right side of his chest, worse on movement and on breathing deeply though the pain has fully resolved now and was short lived. Though the pain has now resolved, he admits ongoing anxiety following stroke in December so came for checkup due to this new pain.’
19. The medical record shows that when the doctor took Mr A’s medical history, they explored with him the pain he experienced after his stroke, and whether he had any new weakness or stroke symptoms that day.
20. The doctor examined Mr A and took his vital signs. They noted Mr A did not have shortness of breath or a cough, no signs of respiratory distress, no chest wall or arm tenderness, no deep vein thrombosis, full range of movement in the neck and right shoulder, and no new neurology symptoms. Our adviser explained this shows the doctor did consider his recent medical history.
21. The doctor recorded that the examination did not show any new or acute findings, and they did not identify any symptoms which would suggest venous thromboembolism (a condition where blood clots form in the veins). The doctor diagnosed Mr A with muscular pain in his neck and chest.
22. The medical record says the doctor arranged blood tests to check his creatine kinase levels which can be used to assess muscle damage, and urea and electrolytes to check his kidney function.
23. Our adviser said Mr A’s symptoms and the findings of the GP’s examination were consistent with a diagnosis of muscular pain. They explained that shortness of breath is the main symptom of a pulmonary embolism, and oxygen levels are also typically reduced when a patient has a pulmonary embolism. Mr A did not present with these symptoms at that time, and his oxygen level was 97% which is within normal range.
24. The doctor provided appropriate treatment for that diagnosis, and correctly safety netted Mr A by advising him to return to the Practice if the pain returned or if he became unwell.
25. The pulmonary embolism CKS says the signs and symptoms are non-specific, but symptoms typically have a sudden onset. The key diagnostic features include shortness of breath, coughing up blood, a sharp stabbing pain that worsens with breathing (pleuritic pain), fainting or feelings of faintness, rapid breathing or features of deep vein thrombosis (DVT).
26. Sadly, Mr A did not have any of those symptoms when he first attended the Practice. We recognise this may be upsetting for Mr A. We understand our explanations do not make what happened any easier for him, we are truly sorry for how events unfolded.
27. We consider the Practice carried out the examination in line with relevant standards. It assessed Mr A in line with the GMC guidance. We can see no indication the Practice did anything wrong at this consultation. For those reasons, we will not be looking into this part of the complaint further.
Consultation: 17 April 2024
28. Mr A complains that when he returned to the Practice it still did not adopt a holistic approach in considering his medical history. He says the doctor incorrectly calculated his Wells score and they were reluctant to provide further treatment. Mr A says the doctor arranged a blood test because his partner raised her concerns about his poor health.
29. When Mr A attended the Practice on 17 April 2024, the doctor took a note of his history, specifically ‘[right] sided chest pain which he says has been worse in last 2 days and notices this when lying down and when breathing though pain has gone again this morning, no [shortness of breath], no cough, no haemoptysis [coughing up blood].’
30. The doctor examined him, took his vital signs and explored whether he had a family history of DVT. The doctor noted his relevant family history, and that whilst the pain had gone again, similar to when he was seen two days earlier, the pain was worse and pleuritic when it came on. Pleuritic pain, relating to the lining of the lungs, is a symptom of pulmonary embolism.
31. The medical records say the doctor calculated his Wells score as 0.
32. The doctor set a treatment plan of a same day D-dimer blood test. D-dimer in the blood indicates the presence of a blood clot and it is measured to diagnose DVT or pulmonary embolism. The medical records say the doctor told Mr A he would need a scan if he had a positive result and advised him to contact A&E if he was unwell or had shortness of breath in the meantime.
33. Mr A says the Practice carried out the blood test as his partner pressed for further investigations. Whilst the medical records do not reflect this, we do not dispute what Mr A has told us. We understand it was a very worrying time for him and his partner. We are unable to reach a robust decision on this aspect of his complaint as we were not present at the time of the consultation to witness what was said by whom, to whom and in what context. But we have considered the action the Practice took and whether this was in line with relevant guidelines.
34. The thromboembolism guidelines say if pulmonary embolism is suspected, clinicians should use the Wells score to estimate the clinical probability of a pulmonary embolism. We explored Mr A’s Wells score with our adviser to help us consider whether the treatment the Practice provided was in line with the relevant guideline.
35. Our adviser said Mr A did not have the clinical signs and symptoms of DVT, an alternative diagnosis of muscular pain was more likely than a pulmonary embolism given his clinical presentation, that is: his heart rate was less than 100bpm (76bpm); no immobilisation for more than three days or surgery in the previous four weeks; no previous DVT or pulmonary embolism and there was no haemoptysis or malignancy. Based on Mr A’s clinical presentation, he had a Wells score of 0 at the time of this examination as he had none of those symptoms in his presentation.
36. The thromboembolism guidelines say that with a Wells score of four points or less, a pulmonary embolism is unlikely, and:
‘Offer people with an unlikely PE Wells score (4 points or less):
• a Ddimer test with the result available within 4 hours if possible or • if the Ddimer test result cannot be obtained within 4 hours (in any setting), offer interim therapeutic anticoagulation while awaiting the result.’
37. Our adviser told us that some Practices can perform D-dimer tests using point of care testing devices which provide rapid results but, where these devices are not available, blood tests are sent to a laboratory which can result in longer processing times.
38. The thromboembolism guidelines say organisations should consider a point-of-care test if laboratory facilities are not immediately available. The medical records show the Practice carried out the blood test at 10.38am, and the sample was sent to the laboratory to be processed. The Practice did not provide any further treatment at that time, and told Mr A he would need to be available for urgent treatment if he had a positive result.
39. Mr A says he received a telephone call from a doctor at around 8.15pm asking him to attend the urgent primary care services because he had a highly elevated result, he then went straight to A&E for a chest X-ray and anticoagulant treatment. The D-dimer result was entered on his medical records at 9.04pm with a note that the required action had been taken.
40. The Practice arranged the D-dimer test in line with NICE guidelines, but the result was not available within four hours. In these circumstances the Practice should have offered interim therapeutic anticoagulation whilst Mr A was waiting for the result. The Practice did not do that. Instead, the doctor safety netted Mr A by advising him that he would need to be available for urgent treatment if he had a high result, and to attend A&E if he was unwell and or had shortness of breath.
41. Our adviser said the Practice not providing interim anticoagulation did not have a clinical impact on Mr A because he attended hospital later that day and received an injection of anticoagulant medication. Mr A then went home and returned to hospital the next day for a CT scan which found the pulmonary embolism. The hospital prescribed further anticoagulant medication and discharged him.
42. We seen no indication that the short delay in anticoagulation had an adverse impact on Mr A’s health because there is no evidence of Mr A experiencing any complications at that time. Complications from a pulmonary embolism include collapse, heart failure and hospitalization, we have not seen any indication that happened to Mr A. We understand that Mr A was very unwell at that time, and our decision is not intended to detract from the serious health condition that he faced.
43. We recognise Mr A will have experienced some anxiety and distress when he was diagnosed with a pulmonary embolism, and we appreciate Mr A has been through an extremely difficult time and his health continues to be challenging for him. Given the advice we have received, we do not consider that the short delay in anticoagulation had a detrimental impact on his health, and for that reason, we will not be taking any further action on Mr A’s complaint.
44. We realise how difficult and distressing this matter has been for Mr A. We thank Mr A for bringing his concerns to our attention. We recognise Mr A may be disappointed with this decision and we are sorry for any distress it causes. We hope we have been able to clearly explain the reasons for our decision.