A 26-yer-old woman died of deep vein thrombosis two days after misdiagnosis by a nurse, who mixed up leg pain with calf pain, an inquest in England was told.
Nurse Claire Firkin, at Nottingham walk-in clinic run by the NHS, selected the wrong set of questions on her computer and was led to the wrong conclusion.
Marketing executive Rebecca Cain had identified the condition herself after ten minutes' research into her symptoms on the internet.
But the nurse, instead of ordering an immediate blood test, wrongly diagnosed a minor muscle problem and sent her home to rest.
Apparently Ms Fikrin had taken her instructions from her computerized guide. Nurses fall back on the guide in the absence of doctors. Unfortunately for the patient, the nurse looked up entries relating to calf pain and not leg pain.
Rather than rely on her 16 years' experience, nurse Claire Firkin 'gave far too much weight' to a computerised guide, it was stated at the court.
The guide used by the Department of Health is designed to help nurses to ask the appropriate questions. They tick boxes for 'yes' or 'no' answers and get directed to the next question.
The system, also used in NHS call centres, is supposed to 'support' the nurse's judgment rather than determine it, Chris Brooke reported for Daily Mail.
Mrs Cain's husband Gareth, a 28-year-old architect, told the inquest his wife had woken on Saturday June 6 last year with pain in her right calf.
Mr Cain said she was very concerned when she was still in pain on Thursday, especially as the leg had swollen and her mother had suffered DVT at 21.
Deep vein thrombosis is a condition where blood clots develop in the deep veins of the legs.
One in every 100 people who has DVT dies as a result of a blood clot travelling from the legs to the lungs.
Mrs Cain was taking a contraceptive pill called Dianette which carries a 'significant' risk of DVT and the inquest was told this 'must have been a factor' in her developing the condition.
After looking at the NHS Direct website Mrs Cain 'was convinced it was DVT.'
She took aspirin 'to thin her blood' and made the earliest available appointment with her GP for the following Monday.
But as the pain became worse, and she went to Nottingham city centre walk-in clinic Friday itself, only to be wrongly diagnosed.
Two days later, she died. A post-mortem examination confirmed the death was the result of a blood clot to the lung caused by deep vein thrombosis.
The nurse tried to defend herself by saying the patient had not mentioned the DVT possibility, but the defence was brushed aside as inconceivable, given the circumstances.
Recording a narrative verdict, coroner Geoff Fell concluded Mrs Cain's symptoms at the clinic were 'indicative of DVT' but 'went unrecognised', resulting in a 'failure to receive appropriate medical treatment.'
He said he would be asking NHS Nottingham City to carry out a serious case review.