According to a report by the public services watchdog, the hospitals in Scotland are failing to properly diagnose the clinical presentations of patients with potentially fatal condition known as 'Deep vein thrombosis' (DVT), wherein a blood clot develops in the vein, usually in the leg.
An enquiry that was conducted in the cases of two women, both of whom died from DVT, found that the failure to diagnose the condition had resulted in the life saving treatment not having been given. One case a 23 yr old student, Katie McPherson reportedly consulted her GP and doctors in two hospitals, but each time she was sent away. Seven days later she died from DVT. The other case was against Dr Grey's hospital in Elgin by the daughter of a patient who died of DVT one month after the doctors failed to carry out the proper investigations and discharged her
as 'being well'.
The parents of Katie said yesterday the report by Professor Alice Brown of the Scottish Public Services Ombudsman SPSO, has confirmed their belief that their daughter could have been saved. SPSO also has upheld a series of complaints against NHS Grampian made by the dead woman's daughter.
Prof Brown explained that she would be bringing the matter to the attention of the Executive and NHS Quality Improvement Scotland for asking them to consider the need for a full Scotland wide guidance on the management of suspected DVT. While acknowledging that DVT is difficult disease to diagnose, she felt that as it is not an uncommon condition or an unique condition within the NHS in Scotland, she urged that all the health boards to review their treatment lines for the management of suspected DVT.
DVT is a condition that has been linked to the travel of long distances on flights and a majority of cases are seen in patients in hospitals who are immobilised for a long time. It is estimated that 1 in 2, 000 people in UK develop DVT each year. It is known to be very fatal if the clot travels p to the lungs.
It was reported that Katie who was an occupational therapy student had gone 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 that involved injecting a dye into a vein. The specialist registrar found no thrombosis, and recorded a "low probability of DVT" in his report. Her GP whom she consulted on the following day accepted the report and diagnosed her with muscle injury. Still doubtful she had gone the next day to the A&E at the Royal Alexandra Hospital in Paisley, but there too she was discharged and told to return if she got worse. On 26th January she started experiencing breathing difficulties and was rushed to a hospital in Greenock, but her condition deteriorated badly and she passed away. The post-mortem report reeled that the clot in her leg would have probably been there fro several days.
Prof Brown had expressed concern about the failure of the doctors to provide an objective second opinion, instead taking for granted the accuracy of the venogram. Stating that 'It confirms everything we always suspected' Jane McPherson Katie's mother said that they had waited for 3&1/2 years to find out why Katie died. She said that they had always suspected that had the doctors given her an injection of heparin, she could still be alive. Regarding the case of the other woman to, Shona Robison MSP, the SNP's spokeswoman on health, said the report has highlighted serious failures in the system.
Dr Charles Swainson, medical director of NHS Lothian, said diagnosing DVT could be very difficult and the ERI have already reviewed their procedures to make sure patients know when to return if symptoms got worse. A Scottish Executive spokesman said that they will be looking to the boards involved to see that the actions they are planning to take are adequate and are properly implemented.