Hospitals 'failing victims of DVT'

Published on Wednesday 31 May 2006 00:50

Key quote "I note that although DVT is difficult to diagnose, it is not an uncommon condition and that these events are unlikely to be unique within NHS facilities in Scotland. I therefore urge all health boards to introduce or review their protocols for the management of suspected DVT," - Professor Alice Brown

Story in full SCOTTISH hospitals are failing to diagnose properly patients with potentially fatal deep vein thrombosis, according to a critical report by the public services watchdog.

An investigation into the cases of two women who died from DVT - where a blood clot develops in a vein, usually in the leg - found that failure to diagnose meant life- saving treatment was not given.

In one case Katie McPherson , a 23-year-old student, saw her GP and doctors in two hospitals. She insisted that she had DVT, but each time she was sent away. Seven days later she died from DVT.

Yesterday her parents said the report by Scottish Public Services Ombudsman, Professor Alice Brown, confirmed their belief that could have been saved.

In a separate complaint against Dr Gray's Hospital in Elgin the report found that doctors failed to carry out a scan and "turfed" a woman out of her bed who later went on to die of DVT. The SPSO upheld a series of complaints against NHS Grampian made by the dead woman's daughter.

Prof Brown said that she would be drawing the matter to the attention of the Executive and NHS Quality Improvement Scotland to ask them to consider the need for Scotland-wide guidance on the management of suspected DVT.

"I note that although DVT is difficult to diagnose, it is not an uncommon condition and that these events are unlikely to be unique within NHS facilities in Scotland. I therefore urge all health boards to introduce or review their protocols for the management of suspected DVT," she said.

About one in 2,000 people in the UK develop DVT each year. It can prove fatal if a clot travels up the vein to the lungs.

The condition has been linked to long-haul flights, but the majority of cases occur in hospital patients who are immobilised for long periods.

In the McPherson case, the occupational therapy student went to A&E at Edinburgh Royal Infirmary on 20 January 2003 with a painful lower leg. She tested positive in one test for DVT and went on to have a venogram, which involves injecting a dye into a vein.

The specialist registrar found no thrombosis, recording a "low probability of DVT".

Ms McPherson then saw her GP on 21 January who accepted the results of the tests and diagnosed a muscle injury.The following day she went to the A&E at the Royal Alexandra Hospital in Paisley, but was discharged and told to return if she got worse.

On 26 January, the student began suffering breathing difficulties and was taken by ambulance to hospital in Greenock, but deteriorated rapidly and died. The post-mortem examination revealed that the clot in her leg had probably been there for several days.

Prof Brown expressed concern about the failure of doctors to provide an objective second opinion, instead taking for granted the accuracy of the venogram.

"We have waited three-and-a-half years to find out why Katie died," said her mother, Jane McPherson, from Langbank. "It confirms everything we suspected.. When Katie died we knew there had been a mistake made because if there had been an injection of Heparin (a blood thinning product) she would still be here."

In a separate case a woman complained that staff at Dr Gray's Hospital in Elgin failed to diagnose DVT and carry out a scan on her mother before she was discharged from hospital and later died. Shona Robison MSP, the SNP's spokeswoman on health, said the report highlighted "serious failures".

Dr Charles Swainson, medical director of NHS Lothian, said diagnosing DVT could be very difficult and the ERI had already reviewed its procedures to make sure patients know to return if symptoms got worse.

A Scottish Executive spokesman: "We will be looking to the boards involved to see that the actions they plan to take are adequate and are properly implemented, as well as drawing the wider lessons to the attention of all boards."