Mary attends her local GP surgery complaining of pain in her legs. She is a 48-year-old mother of two children, obese and a heavy smoker with a history of excessive alcohol use.
Mary is seen by Dr G who records a history of pain in both legs over a period of three weeks made worse during walking and relieved with rest. The pain is worse in the left leg with “tingling pins and needles”. Mary has also noticed some swelling in the left leg but says this is improving.
Dr G examines the legs and finds some soft oedema in the lower left leg but no other abnormality. There is no calf tenderness and Homan’s sign (to detect DVT) is negative. Arterial pulses are not palpable on the feet but use of a Sonicaid detects a faint signal from the posterior tibial arteries in both legs. He also measures the ABPI (ankle/ brachial pressure index) and confirms a reading of 1.0 – i.e. no obvious circulatory impairment. Mary’s blood pressure is 180/120.
Dr G records a preliminary diagnosis of peripheral vascular disease (PVD), given Mary’s history of pain on exertion and the absent peripheral pulses. The doctor prescribes nifedipine for the high blood pressure and PVD and later refers her to a local consultant cardiovascular physician. Blood tests taken at the consultation show signs of impaired liver function consistent with alcohol excess.
The surgery receives a call from Mary’s husband requesting a home visit. A locum – Dr K – attends the patient who is complaining of a painful purulent cough, and chest and shoulder pain associated with breathing. She has a fever and auscultation reveals suspected pleurisy. Dr K notes Mary’s history of left lower leg pain and swelling. He makes a diagnosis of respiratory infection but also records: “? PE/DVT”.
Mary is prescribed amoxicillin and is advised to contact the surgery if there is no improvement over the next two days – at which time Dr K will arrange for an ECG and VQ scan (to rule out pulmonary embolism).
Mary attends the surgery for an emergency appointment and is seen this time by Dr G. She is still suffering from cough with bloodstained sputum. Dr G finds that her breath sounds are normal though she claims her chest is still very sore. Dr G tells her to keep taking the antibiotics and come in again if the infection is not settling.
Just before bedtime Mary collapses at home. Her husband calls 999 but the ambulance team is unable to resuscitate her and she is pronounced dead at 2310 hours. A post mortem determines the cause of death as pulmonary embolism consequent with deep vein thrombosis. The pathologist also reports swelling of the left leg.
FOUR months later the surgery receives a letter from solicitors acting for Mary’s family alleging clinical negligence in her care against both Dr G and Dr K. MDDUS, acting for Dr K, commissions medical reports on the case from both a primary care expert and a consultant vascular surgeon.
The primary care expert finds Dr G at fault for not considering more seriously the possibility of DVT at the initial consultation. The use of Homan’s sign is criticised as it has fallen out of favour in ruling out DVT. A call to a local vascular surgeon would have confirmed PVD was unlikely in light of a normal ABPI and that referral to an outpatient clinic would have been appropriate to assess the cause of the presenting complaint.
Another opportunity was missed when Dr K attended the patient at home. Dr K had considered the possibility of pulmonary embolism but adopted a wait-and-see approach which was unduly risky given the possible outcome.
A third chance to act was missed when Mary again attended Dr G at the surgery with blood-stained sputum and continuing chest pain, but the decision was made to persist with antibiotic treatment although there was sufficient clinical uncertainty to warrant admission to hospital for a VQ scan. The consultant’s opinion was that had Mary been referred earlier and treated with controlled anti-coagulation therapy this may have prevented extension of the pulmonary embolus and subsequent death.
MDDUS advisers and lawyers discuss options with Dr K and decide the best course of action is to settle the claim out of court with costs shared with Dr G’s medical defence organisation.
• Always weigh up potential risks/ outcomes involved in not referring a patient.
• Do not ignore inconvenient signs that may counter an “obvious” diagnosis.
• Maintain a high index of suspicion in respiratory symptoms combined with leg pain.