5. Mr R complains that in May 2024, a GP at the Practice failed to appropriately investigate and treat Mrs R's symptom of pain in her left calf and leg.
6. Mr R says that as a result, Mrs R died of a pulmonary embolism. He says that the sudden and traumatic nature of her death caused him much distress.
7. As an outcome, Mr R seeks a financial payment and service improvements.
8. Mrs R was first seen at the Practice on 16 May 2024, with pain in her left calf. She was examined and, since Deep Vein Thrombosis (DVT) was suspected as a possible cause for her pain, was referred for an ultrasound scan and blood tests. In addition, she was prescribed blood-thinning medication (apixaban).
9. On 20 May, Mrs R had an ultrasound scan of her left leg, which was reported as showing no sign of DVT.
10. On 24 May, a GP at the Practice contacted Mrs R to advise that the scan result was negative for a DVT. Therefore, they advised Mrs R to stop taking apixaban and arranged a follow-up consultation for 31 May.
11. At the 31 May consultation, Mrs R reported that her symptom was unchanged. The GP did a further blood test to check for signs of a blood clot: this was negative. However, given Mrs R’s ongoing pain, the GP offered her a further ultrasound scan. Mrs R declined this, preferring to monitor symptoms and return if there were further concerns.
12. Sadly, on 14 July, Mrs R became suddenly unwell and died of a pulmonary embolism.
16. Before we decide if we should conduct a detailed investigation of a complaint, we look at a few different factors. We consider whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. We also look at whether what happened had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
17. If we think there was a failing, and that this had an impact that has not been put right, we will usually investigate in more detail.
18. Mr R told us that he was concerned that the GP advised Mrs R to stop taking apixaban and that this might have contributed to the formation of a clot. He noted that online NHS guidance in relation to apixaban at that time stated that if a patient stops taking it, the chance of a blood clot returns to what it was before they started taking the medication and that this means they may be at increased risk of DVT, pulmonary embolism, heart attack or stroke. Mr R felt the GP advice to stop taking apixaban contradicted NHS guidance about this medication and that advice contained in the ‘NHS Sussex Suspected DVT patient information leaflet’ implied that the dose should be tapered (gradually reduced), rather than stopped.
19. The Practice explained that the GP followed local protocol by advising Mrs R to stop taking apixaban after the ultrasound result was found to be negative for DVT. The Practice acknowledged that although the NHS Sussex Suspected DVT patient information leaflet advises continuing the medication after a negative scan, this is only until the patient’s GP has reviewed the results and decided on the best course of action. The Practice said it could see why the wording of the leaflet could lead to confusion but assured Mr R that it does not mean that tapering should be done.
20. The ICB explained that the blood thinning medication (apixaban) was stopped when the clinical risk was revised, and the scan was negative. They added that there is no recommendation to wean off anticoagulation (blood thinning) and that stopping the medication for Mrs R was the correct management.
21. The Guidance states that for patients who present with signs or symptoms of DVT, such as a swollen or painful leg, the GP should assess their general medical history and do a physical examination. If DVT is suspected, the clinician should use the 2-level DVT Wells score to estimate the clinical probability of DVT. The Wells score tool lists clinical features and assigns a point to each. The overall score then informs the clinician of the chances the patient has DVT.
22. The first contact the GP had with Mrs R about this issue was a telephone consultation on the afternoon of 16 May 2024. In this, the GP sought details from Mrs R about how the pain had arisen and whether there was redness or swelling in her left leg, compared with her right leg. The GP also noted that Mrs R had consulted the Practice a week or so earlier about swelling in her feet, and that this had been reported as improving after lying down overnight. The GP checked that Mrs R did not have any chest pain or had not coughed up any blood. Given the GP’s concern about the pain in Mrs R’s leg, they arranged to see her in person later that same day.
23. In that face-to-face consultation, the GP did a physical examination, including measuring both Mrs R’s calves. They found the calves to be of equal size and that there was a lack of swelling. The GP noted that there were no other visible symptoms on the affected leg. They also pressed on the calf and determined that though there wasn’t excess fluid in it, the calf was tender. Additionally, the GP measured Mrs R’s observations (temperature, pulse, heart rhythm, oxygen level) before calculating her Wells score.
24. Her Wells score was 1, corresponding to ‘DVT unlikely’ on the Wells scale.
25. So, in their initial consultations with Mrs R, the GP did the three things (history, physical examination and Wells score) recommended by the Guidance. This means the GP appropriately checked Mrs R for DVT.
26. The Guidance goes on to say that for patients with a Wells score of 1 or less, as was the case for Mrs R, the recommended action is to conduct a D-dimer test. This looks for the protein fragment called D-dimer in the blood. Higher levels of this can indicate blood clotting.
27. For patients with a Wells score of 2 or more (DVT likely), the recommendation is to offer an ultrasound scan, followed by a D-dimer test if the scan result is negative. In both cases, the advice is to start blood-thinning medication in the interim while awaiting the outcome of the investigations, if they cannot be done within four hours.
28. During the 16 May appointment, the GP decided to refer Mrs R for an ultrasound scan to check for clots in her deep leg veins and prescribed apixaban, to protect Mrs R from a pulmonary embolus while the investigations into DVT were in progress. Our adviser explained that an ultrasound scan is a more accurate means of testing for DVT than a blood test.
29. The GP also requested a blood test for full blood count, kidney function, liver function, C-reactive protein and clotting screen. So, having completed the three initial recommended steps, it appears that the GP then followed the recommendations for a patient for whom DVT is likely.
30. In other words, the GP did more than was required for someone with a Wells score of 1, which is what Mrs R had. Instead, they exercised additional caution by doing what the guidance says should be done for someone who is likely to have DVT. Although incredibly sadly, the tests did not reveal any problems, we think this shows that the GP was concerned for Mrs R and did their utmost to rule out a DVT.
31. The Guidance says that with a Wells score of 1 or less, if the leg vein ultrasound scan is negative, as was the case for Mrs R, then the advice is to stop the interim blood thinning medication.
32. Our adviser said that as Mrs R’s Wells score was 1 and she had received a negative ultrasound result for DVT, the decision to tell Mrs R to stop taking apixaban was correct, in line with the Guidance. Our adviser confirmed that the Guidance does not require that this medication is reduced gradually, rather than being stopped. For this reason, we think it was right for the GP to advise Mrs R to stop taking it when they did and that she did not need to taper off it. Finally, our adviser confirmed that in their view, the GP did not miss any tests that should have been done or any obvious diagnosis that should have been made.
33. In summary, we are satisfied that, despite the terrible outcome, the GP followed the Guidance when investigating Mrs R’s symptoms and did everything they should have to try and rule out DVT. Nothing we say will likely change how Mr R feels about what happened, but we hope that with time, he can take at least a small degree of comfort in knowing that the GPs did all they could for his wife.
1. We have carefully considered Mr R’s complaint about the Practice.
2. We are sorry to learn of the death of Mrs R and the effect it has had on Mr R. We know that Mr R has suffered beyond the initial shock of losing Mrs R so suddenly and that his concerns about the treatment she received have caused him additional distress.
3. This is a case where with hindsight, it can be assumed that the leg pain Mrs R had was from a DVT, which then led to the pulmonary embolism which tragically took her life. Our role is to look at what the GPs did knowing only what they knew at the time of the events. We cannot apply the benefit of hindsight to their actions. Having done this, we think that the Practice acted appropriately in its investigation and treatment of Mrs R’s left leg calf pain. Incredibly sadly, if her leg pain was caused by a DVT, it just did not show up on any tests and so it was not possible for the GPs to have reasonably known about it.
4. We have, therefore, decided not to investigate in more detail or take any further action. We have explained the reasons for our decision below.