Parliamentary and Health Service Ombudsman: Hospital’s failing led to postman’s death following football injury (13 November 2023)

Summary

A pulmonary embolism happens when a blood clot breaks off and travels to the lungs where it blocks the flow of blood. Although life-threatening, when diagnosed promptly survival rates are good. This report from the Parliamentary and Health Service Ombudsman (PHSO) looks at the case of a man who died of a pulmonary embolism after doctors failed to test for deep vein thrombosis.

Content

The patient in this report was a 46-year-old who had been playing football with colleagues when he damaged his knee. Four days later he went to Accident and Emergency at Queen’s Hospital in Romford and had surgery that day.

Following the operation, he was struggling to walk and had a lot of pain in his leg. Two weeks after the surgery, he went back to Accident and Emergency where a doctor questioned whether he might have deep vein thrombosis (DVT). An X-ray and blood tests were carried out but no tests for DVT were done and he was sent home. Two weeks after that, the man had tightness in his chest and fainted. His family called an ambulance, but his heart stopped while on the way to the hospital. Sadly, despite attempts to revive him, he never came round and died in hospital.

The Ombudsman found that doctors at Barking, Havering and Redbridge NHS University Hospitals Trust went against national guidance by not carrying out the relevant tests to rule out DVT. The investigation concluded that if the tests had happened, DVT would have been found and treated, which would have prevented the fatal pulmonary embolism.

Further reading on the hub:

• Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards)
• HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
• Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, December 2022)
• Venous thromboembolism (VTE): deep vein thrombosis and pulmonary embolism (NHS Resolution, May 2023)