Missed deep vein thrombosis

Medical history

The patient visited her GP complaining of intermittent pain in her left calf which became worse when she was standing. The GP noted that she was overweight, and also that she was taking the combined oral contraceptive pill. He examined her and noted that her left lower calf was tender. He performed a Homan's test, which was inconclusive.

The GP advised her to go immediately to hospital in case there was a deep venous thrombosis (DVT). However, she refused to do so because she had no one to look after her children. The GP advised her to rest and prescribed analgesics.

She visited the GP again the following day with continued pain. The GP examined her and found no discernable change in her condition. He again discussed the possibility of a DVT, though he decided that it was probably a muscular problem. He asked the patient to return in three days. This time the patient told the doctor that there was some improvement in the pain, though her calf had ached after she went shopping.

Two weeks later, she saw another GP at the surgery. She complained of a cough with phlegm which, on examining her, the GP attributed to tracheitis. The GP prescribed erythromycin.

She also said she did not "feel herself" with the contraceptive pills which she was taking, though she did not complain of any specific problems. The GP prescribed a different brand of combined oral contraceptive pill.

She told the GP that she was no longer experiencing pain in her leg, and so the GP issued a final medical certificate for her to return to work four days later.

A fortnight later, the patient collapsed at home. On arrival at hospital, she had a respiratory arrest with bradycardia and then asystole. Attempts to resuscitate her failed.

At post mortem, the cause of death was certified as (1a) pulmonary embolism, and (1b) venous thrombosis.

Negligence alleged

It was alleged that both GPs had failed in their duty of care to the patient and had negligently failed to diagnose a deep venous thrombosis.

Expert opinion

The MDU sought the advice of a number of experts. They were unanimous that the first GP (who belonged to another defence organisation) had been negligent. It was agreed that, once a diagnosis of DVT is suspected, a patient must be referred to hospital for further investigations and told to stop taking the pill. The GP was criticised for not making a note of his initial advice to her, and for not making a further attempt to persuade her to go to hospital when he saw her a second time.

The experts had different views about the role of the second GP (who belonged to the MDU). She was defended by one GP expert:

"The patient had consulted the GP about a new problem and, in view of the fact that she was no longer complaining about her leg, I am not at all surprised that the second GP did not review the first GP's diagnosis of muscular pain".
However, other experts felt that the second GP was also liable, though to a lesser degree. A professor in primary health care said:

"The second GP's responsibility is less, in that the original episode of leg pain had been dealt with on a number of occasions by her partner. She could reasonably have been expected to concentrate on the questions of the minor respiratory symptoms and the patient's wish to change the contraceptive pill. Nonetheless, had she been more vigilant, she would have realised the potential link between these symptoms and the episode of leg pain dealt with by the first GP."
This expert argued that the second GP should have referred the patient for further investigations which would have led to a correct diagnosis and the initiation of treatment with anticoagulants. She would also not have prescribed the oral contraceptive pill which is contraindicated in the presence of a thrombotic process.

Outcome

The patient's husband accepted a six figure out-of-court settlement. One quarter of this amount was met by the MDU on behalf of its member.

Risk management advice
It is always a good idea to start afresh when seeing a patient, rather than relying on a diagnosis made by a colleague previously. This should, where appropriate, include a further examination.

If a patient refuses advice to go into hospital it is important that you continue to try to persuade him or her. You should consider whether the patient is competent to make such a decision and record this and a summary of your conversation and advice in the notes.


This guidance was correct at publication 01/05/2003. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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