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PE negligence not proven

01 February 2005

Dr B had agreed to visit Mr G at his home one morning after hearing that he was experiencing body aches and feeling feverish. Upon her arrival, Dr B saw that Mr G was confined to his bed; she examined him and noted a congested throat, a runny nose and some crepitations and mild wheezing in the lower half of the chest. She diagnosed acute respiratory infection and prescribed oxytetracycline.

Dr B also noticed that Mr G’s right knee was bandaged; he explained that this was because of an accident at work which had been treated at the local emergency department. He was due to visit the hospital for a follow-up the next day, but in the event he did not do so.

The following evening, Mr G was admitted to the emergency department with chest pains, breathlessness and sweating. He was later diagnosed with a pulmonary embolism and died after suffering a cardio-respiratory arrest. According to the postmortem, the primary cause of death was pulmonary embolism and infarction with idiopathic DVT.

Mr G’s widow brought an action against Dr B, alleging that the GP had been negligent in failing to diagnose a pulmonary embolism and refer Mr G to hospital for investigations.

Expert opinion

We asked a GP to comment on the alleged breach of duty, and sought the views of a chest physician and a pathologist on causation.

Our GP expert felt that the nature of the complaints Mr G described to Dr B when she attended him was a key issue. If there had been no complaint of chest pain or shortness of breath, and instead a description of sore throat, fever, headaches and generalised aches and pains, then ‘one would not expect Dr B to be alerted to the possibility of deep vein thrombosis or pulmonary embolism’. He drew the conclusion that the character of the pain noted by Dr B and the alternative diagnosis of a chest infection could excuse the doctor from referral.

Mr G’s widow – who incidentally was not present at the consultation – had made a statement claiming that Mr G was suffering from pains on each side of his chest, near the lower ribs. This, her representatives claimed, should have been sufficient cause for Dr B to refer him to hospital even in the absence of physical findings, particularly in view of the fact that the patient was immobilised with a leg injury and therefore faced an increased risk of pulmonary embolism.

A chest physician described the documentary evidence as ‘very characteristic’ of a flu-like illness or other infection, and not characteristic of symptoms of PE.

This was at odds with a statement given by a haematologist on behalf of Mrs G who had asserted that the breathing difficulties, grey pallor and chest pains described in the evidence given by the deceased’s wife did indeed suggest the possibility of a pulmonary infarction. He added that if this condition had been recognised by Dr B and the patient had been admitted to hospital for heparin therapy, Mr G’s life might have been saved.

MPS’s Claims Committee took the view that the expert opinion sought on Mr G’s behalf did not overwhelmingly support the allegations made against Dr B. They therefore decided that we should defend the claim.

The trial lasted four days. The judge found that Dr B should have referred Mr G to hospital after visiting him.

He thought that, on the balance of probabilities, the DVT had been present for a number of days, and that microemboli would have been breaking off and migrating to the lungs by the time Dr B had seen the patient.

Furthermore, he judged that if an immobilised patient complains of chest pain and breathlessness to a GP, then that GP should consider that the patient may have been suffering from a DVT and possibly a pulmonary embolism, and refer the patient for investigation.

Despite this finding of breach of duty of care, the judge concluded that even if Mr G had been hospitalised and given anticoagulants this would not, on the balance of probabilities, have prevented his death. In this respect, the opinion given by our causation expert proved to be crucial.

He had put forward his view that administering heparin would simply have prevented propagation of the thrombus. If the drug had been administered following admission on the day in question, he claimed, then by that time 90% of the thrombus would have been formed.

Accordingly, if the thrombus had dislodged – as it did in fact do – then it was likely that the ensuing embolus would have killed the patient in any event.

The judge concluded that causation was not proven and dismissed the claim.