GP missed blood clots over almost two years that led to death of patient

A doctor failed to diagnose a woman with blood clots in her lungs. The woman later died. Photo / 123rf

A woman died after a doctor failed to diagnose and treat her for blood clots in her lungs despite her displaying symptoms of a pulmonary embolism for 22 months.

The woman, in her 60s, was generally healthy and had no significant medical history when in 2018 she sought treatment for leg pain.

She told the 24-hour clinic she had been experiencing pain in the back of her knee and calf for around three weeks and the pain was travelling up her leg.

Her leg was also red, warm and swollen, and the woman reported having shortness of breath.

A doctor at the clinic diagnosed the woman as having deep vein thrombosis and also noted a pulmonary embolism (PE) was possible, Deputy Health and Disability Commissioner (HDC) Dr Vanessa Caldwell said in investigation findings released today.

The woman, who is not named in the decision, had undergone a number of tests, was prescribed medication and advised to follow up with her GP.

A few days later, she went to her GP who performed tests in relation to the continued shortness of breath but did not pursue a diagnosis of a pulmonary embolism (PE).

The GP, who is also not named, told the HDC she saw the comment made by the doctor at the 24-hour clinic about the possibility of a PE but presumed that because that doctor did not refer the woman for a CT scan that looks for blood clots in the lungs, an embolism was unlikely.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell investigated the woman's care. Photo / Supplied

During the following months, the GP saw the woman on a number of occasions and recorded issues such as persisting allergies, an occasional cough while walking, pain, weakness, and heaviness in her leg while walking, and nose bleeds.

The woman had also told the GP she had stopped taking medication that reduced the risk of blood clots forming.

On one occasion, she had a telephone consultation, due to Covid-19 restrictions, with another doctor at the centre, whose location is not provided in the decision, and reported ongoing shortness of breath and leg swelling.

That doctor ordered a number of tests but did not suspect a PE.

In the two months preceding the woman’s death, she was experiencing shortness of breath with any exercise and was afraid to go walking as it made her feel sweaty and weak.

Following a telephone consultation, her GP sent a referral for an urgent CT scan to investigate a potential embolism but mistakenly requested a CT chest scan rather than a CTPA, a specific scan to search for an embolism.

The referral was declined and the GP was advised to add additional detail and resubmit it, but she failed to do so.

“[The GP] told HDC that she cannot explain why she did not pursue this with either a referral for the correct investigation or discussion with a hospital colleague,” the findings stated.

“[She] said that her recollection is that she interpreted the declined referral as an indication that the investigation was not required according to the information she had provided.”

The GP told the HDC that in hindsight, she should have pushed for a CTPA or for the woman to be seen in the hospital emergency department.

As the woman’s symptoms persisted, further consultations took place and more tests were undertaken and the GP was considering diagnostic possibilities including heart failure and asthma.

But within weeks, the woman died suddenly at her home.

A coroner concluded she died as a result of acute and chronic PE arising from leg deep vein thrombosis.

The autopsy showed blood clots in the lungs, most of which were acute, but some of which were chronic.

The failings were so serious the coroner referred the case regarding health services provided to the woman to the HDC.

The GP told the HDC the woman’s “presentation was not the typical presentation I had seen for pulmonary embolus in my practice in the past”.

She remained “very saddened, shocked, and sorry” about the woman’s death, she told the HDC.

Caldwell found the GP breached the Code of Health and Disability Services Consumers’ Rights for inadequate management of the woman’s symptoms following the deep vein thrombosis diagnosis.

The breach covered a number of events over the 22-month period the woman’s symptoms were present.

“During the initial consultation, the doctor failed to pursue a diagnosis of PE,” she said.

“At a later date, the doctor failed to expedite a face-to-face assessment (by way of referral to ED for urgent assessment and imaging).

“The doctor also failed to review the management decisions after receipt of a declined referral for CT chest scan and to take appropriate steps to exclude PE as a diagnosis.”

Caldwell said the circumstances the GP was operating in were challenging due to staffing shortages and Covid-19 restrictions.

“[But] collectively the deficiencies in care show inadequate management of the woman’s symptoms, resulting in her not receiving the right investigations in a timely manner.

“The outcome for the woman and her whānau was devastating.”

Caldwell was also critical that the GP did not inform the woman she’d made an error requesting a CT chest scan, or that this had been declined and why.

Accordingly, she found the GP also breached the patient’s right to information.

In light of changes already made by the GP, and the fact she intended to retire from practice in the near future, Caldwell recommended she undertake further training on the diagnosis of PE should she return to general practice.

Caldwell recommended that the cent review its policy and processes regarding nursing management of tasks and recalls, and that the other doctor from the centre involved in treating the woman provide evidence he has revised his knowledge around ruling out a PE.

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff where she covered crime and justice, arts and entertainment, and Māori issues.