Undetected pulmonary embolism in a mildly asthmatic patient

Medical history

A female patient in her forties attended her surgery for a routine appointment with her own GP, with a four-day history of a cramp-like pain on walking, but otherwise in good health. She had a history of mild asthma, using a salbutamol inhaler for symptomatic relief as necessary. She was overweight (BMI 31) but not on the oral contraceptive pill, with a past history of phlebitis, a superficial vein thrombosis in her left leg (3 years ago) and of anxiety.

On examination, she was found to have tenderness over the superficial calf veins of her left leg, with localised erythema. Her GP diagnosed further phlebitis and prescribed a course of penicillin V and a non-steroidal analgesic. She made a contemporaneous note in the patient's record that there was no deep-calf tenderness, and no sign of DVT – although the note did not specify whether this had been determined by an actual examination or measurement. There were no chest signs or symptoms at this time.

Two days later, the patient requested a home visit. Attended by another GP from an out-of-hours service, the patient was now complaining of shortness of breath and "pressure" in the chest and was found to be slightly wheezy.

The GP put the symptoms down to the non-steroidal analgesics exacerbating the patient's asthma and advised her to cease medication and see her own GP again if the symptoms persisted or developed further.

Six days later, the patient attended the surgery again and was again seen by her own GP. She was now complaining of constant "tightness of the chest", which was intermittently "uncomfortable". Noting a slight tachycardia but nothing else on examination, the GP put the symptoms down to anxiety and reassured the patient but did not arrange further investigation.

That night, the patient requested a further home visit, as the chest pain had become persistent and the dyspnoea worse. She described her symptoms over the phone to the duty doctor who, concerned that the pain might be cardiac, arranged for an ambulance to be sent to her address.

Shortly after the paramedics arrived (some 15 minutes later) the patient collapsed and the paramedics were unable to resuscitate her. At post-mortem, she was found to have fresh thrombi in both main pulmonary arteries, originating from an extensive deep vein thrombosis in her left leg.

Negligence alleged

The patient's husband later brought a claim against both the patient's own GP and the out-of-hours GP (both MDU members), alleging that they were negligent for failing to diagnose the cause of his wife's symptoms. The claimant's legal team argued that it should have been apparent to both doctors that the patient was at risk of pulmonary embolism and that measures should have been taken to exclude it as a diagnosis. In the doctors' defence, it was argued that the superficial phlebitis and the patient's history had caused them to minimise the significance of the respiratory symptoms.

Expert opinion

The MDU's GP expert accepted that:

"… In relation to the initial home visit, I believe the management would be defensible, in that the patient was known to be asthmatic, and the wheeziness found on examination was, not unreasonably in my opinion, attributed to the recently started non-steroidal anti-inflammatory medication".

However, the expert had concerns with regard to the second visit to the practice, in that the patient had several risk factors for pulmonary embolism and was still dyspnoeic with possible pleuritic pain. While accepting that this could be viewed as a difficult diagnosis to make, given that GPs will see many patients with mild asthma and a BMI >30, the expert pointed out that no further examination was made at that time, which might have led to the detection of the deep vein thrombosis, and suggested that:

"…a successful defence might be difficult, given that the possibility of pulmonary embolus was not obviously considered and excluded when the patient attended the practice on the second occasion".

In relation to causation, the expert concluded:

 "... I am bound to say that there is no satisfactory evidence to defend the management in relation to timing, as there is no precise time when a patient becomes safe from the risk of further pulmonary emboli".

The outcome

On the basis of this – and other – expert evidence, and with the members' agreement, the claim was eventually settled for a moderate sum.

This page was correct at publication on 31/08/2004. Any guidance 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.