10. Miss A says the Trust failed to carry out the necessary tests to identify DVT or provide treatment for DVT soon enough to prevent it developing into a PE. In its complaint response the Trust said it did request the appropriate investigations and it started the appropriate treatment for DVT after Mr B was admitted. However he suffered a sudden, unexpected cardiac arrest and sadly died before the Trust could complete all of the necessary investigations.
11. The NICE DVT and PE guidance states:
‘Diagnosis and initial management
For people who present with signs or symptoms of DVT, such as a swollen or painful leg, assess their general medical history and do a physical examination to exclude other causes.
If DVT is suspected, use the 2 level DVT Wells score (a clinical decision tool to estimate the probability of DVT in patients) to estimate the clinical probability of DVT.’
12. The GMC guidance says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values
• promptly provide or arrange suitable advice, investigations or treatment where necessary.
In providing clinical care you must:
• prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs
• provide effective treatments based on the best available evidence.’
13. The NEWS standard is used to assess and track the condition of a patient and identify and respond to signs of deterioration. It does this by measuring the patient’s respiration rate, oxygen saturation level, blood pressure, pulse rate, level of consciousness and temperature at regular intervals and allocating a score to each parameter. The NEWS standard estimates a patient’s risk of deterioration as follows:
• low risk - a combined score of 1 to 4 • low to medium risk - a score of 3 in any single parameter • medium risk - a combined score of 5 to 6 • high risk - a combined score of 7 or over.
14. The records indicate when Mr B attended the ED his respiratory rate, oxygen saturation levels and blood pressure were noted to be normal. His heart rate was slightly increased at 98 beats per minute and the Trust noted evidence of skin damage. The Trust recorded an initial NEWS of 1.
15. Our ED adviser said the records indicate Mr B was seen relatively promptly on arrival and the Trust identified significant swelling and redness of his legs with broken down and inflamed skin in his groin and perineal area. The records indicate the Trust performed a physical examination in line with the NICE DVT and PE guidance and identified additional symptoms consistent with a provisional diagnosis of infection. These symptoms included wheezing, chest crepitations (crackling sounds in the lungs), a raised white blood cell count (an indication of the body’s immune response to infection), elevated lactate levels and increased C-reactive protein (CRP, a protein produced by the body in response to inflammation) levels.
16. The records indicate the Trust provided treatment with intravenous fluids, broad spectrum antibiotics (antibiotics that act against a wide range of bacteria, used when an infection is suspected but the cause is unknown or when infection with multiple groups of bacteria is suspected) and salbutamol (a medication to open up the airways) before transferring Mr B from the ED to the hospital.
17. Our ED adviser said the evidence in the records supports the view the examinations carried out and the treatment provided by the Trust in the ED was consistent with the NICE DVT and PE guidance and the GMC guidance. The records of Mr B’s symptoms when he arrived at the ED are consistent with the Trust’s provisional diagnosis of infection and the Trust provided appropriate treatment for infection before admitting him to hospital for further investigations.
18. The NICE DVT and PE guidance states that if a DVT is suspected, use a Well’s score to estimate the probability of a DVT. As a DVT was not suspected by the Trust whilst Mr B was being treated in the ED, and as the provisional diagnosis was of infection, there is no evidence to indicate the Trust should have calculated a Wells score in the ED.
19. The NICE DVT and PE guidance states:
‘If a proximal leg vein ultrasound scan result cannot be obtained within 4 hours, offer people with a likely DVT:
• a D‑dimer test (a blood test that measures the presence of D-dimer, a protein fragment released when a blood clot dissolves, helping to assess clotting disorders)
• interim therapeutic anticoagulation (blood thinning medication)
• a proximal leg vein ultrasound scan with the result available within 24 hours.’
20. After Mr B was admitted to hospital, during the first ward round, the doctor requested blood tests and an ultrasound scan to investigate DVT due to the swelling in his left leg. The doctor prescribed dalteparin (a blood thinning medication) and revised Mr B’s antibiotic medication to focus on cellulitis (a bacterial infection of the skin).
21. Our physician adviser said the Trust’s plan of investigation and treatment was consistent with the NICE DVT and PE guidance and the GMC guidance. Our physician adviser said the records show Mr B was stable at the time of his transfer from the ED (NEWS of 0) and the doctor suspected a DVT following his examination during the initial ward round. Based on this suspicion the Trust started treatment with blood-thinning medication whilst awaiting an ultrasound scan of his leg and further blood tests to investigate DVT.
22. Miss A says the Trust failed to document a Wells score or perform a D-Dimer test and this was a missed opportunity to confirm the diagnosis of DVT sooner. She says the Trust requested a D-dimer test but as the blood samples taken for testing had haemolysed (where the red blood cells in the sample rupture) it was unable to perform this test and it was never repeated. In its complaint response the Trust has acknowledged it did not document a Wells score. The Trust also confirmed repeat blood tests were requested but Mr B sadly died before they could be completed.
23. A Wells score is used to estimate the probability of DVT. Our physician adviser said the records indicate the Trust already suspected DVT and started treatment whilst waiting for further investigations to be arranged. Our physician adviser said the investigation and treatment plan put in place by the Trust following the initial ward round is the same plan that would be put in place if a Wells score had been completed and a diagnosis of DVT confirmed. There is no evidence to indicate the omission of a Wells score had a detrimental impact on the Trust’s understanding of Mr B’s condition or the care and treatment it provided.
24. A D-dimer test is used to rule out the possibility of a DVT or PE if there is a low clinical suspicion of this. However, in Mr B’s case the suspicion was not low and following his admission to hospital the Trust suspected a DVT and provided treatment for it. Our physician adviser said a negative D-dimer test result would not have ruled out a DVT in Mr B’s case, and a positive result would not have altered his management as the Trust was already investigating and providing treatment for DVT.
25. Miss A says the Trust were focused on her father’s cellulitis and history of alcoholism and did not take into consideration his previous history of DVT and PE despite her father mentioning it several times throughout his admission.
26. Our ED adviser said there is no evidence in the records which would indicate the Trust overlooked Mr B’s symptoms whilst he was in the ED or that his signs of a DVT were missed because the focus was on his cellulitis and previous history of alcoholism. The records support the view his symptoms and initial examinations in the ED were consistent with the provisional diagnosis of infection which the Trust provided initial treatment for.
27. Our physician adviser said the records support the view Mr B’s symptoms were readily appreciated by the medical team following his transfer to hospital. Our physician adviser said there is no evidence in the records that would indicate the Trust solely focused on Mr B’s cellulitis and history of alcoholism or that it failed to consider his previous history of DVT and PE. The records show the Trust suspected DVT, provided treatment for it and started further investigations to confirm the diagnosis and inform the treatment plan.
28. Our physician adviser said the records support the view that Mr B did not display any clinical symptoms or signs of a PE or of a deterioration in his condition prior to his sudden cardiac arrest (NEWS of 0). At the time of his cardiac arrest the records indicate he was receiving full treatment for DVT and the Trust was arranging investigations to further explore the cause of his condition. The records support the view that despite the treatment provided by the Trust, Mr B suffered a sudden deterioration which was unexpected and could not have been predicted and he sadly died before the Trust could complete its investigations.
29. We carefully considered Miss A’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust failed to request the necessary tests for DVT. Regrettably it seems Mr B suffered an unexpected cardiac arrest and died before these tests could be completed.
30. We found the Trust had already started treatment for DVT whilst awaiting the further investigations. We found no evidence to indicate there was anything more the Trust could have done to treat Mr B or investigate his symptoms prior to his sudden deterioration. We found no evidence to indicate his sudden deterioration could have been predicted or prevented. We found the Trust acted in line with the NICE DVT and PE guidance and the GMC guidance.