Ayrshire patient died from dangerous blood clot after being misdiagnosed by GP with anxiety

An Ayrshire patient died after they were misdiagnosed with anxiety rather than a dangerous blood clot.

Anxiety can be mistaken for a pulmonary embolism, where a clot blocks arterial blood flow to the lungs.

While there are similar symptoms, GPs are meant to take account of patients presenting with multiple risks associated with a pulmonary embolism and investigate further.

In this case, the unnamed Ayrshire GP should have taken further steps as the patient, named A in a report by the Scottish Public Services Ombudsman (SPSO), had multiple risks around BMI levels, use of a prescribed combined oral contraceptive and their family’s medical history.

The patient’s parent had taken the case to the Ombudsman, with concerns that the diagnosis and treatment for anxiety had led to their death.

The patient had a telephone appointment with a GP due to shortness of breath, breathlessness and feeling faint when walking upstairs and when putting on their shoes.

The patient was diagnosed with anxiety and prescribed a beta blocker, a drug that blocks the action of hormones such as adrenaline to counter anxiety.

Later that week, the patient died suddenly due to pulmonary embolism, a blood clot that blocks and stops blood flow to an artery in the lung.

There were concerns that there was a delay in receiving proper treatment due to the anxiety diagnoses and that the medication prescribed was inappropriate, leading to greater harm.

The Ombudsman’s report stated: “We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health.

“We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive.

“Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case.

“We found that the health centre failed to provide A with reasonable medical care and treatment.”

The Ombudsman has ordered the medical practice to apologise for its failings.

The practice has also been told that patients presenting with similar symptoms should be carefully considered and that, where appropriate, face-to-face appointments should be offered.

They added that “prior to prescribing the combined oral contraceptive pill for patients who have two or more risk factors for pulmonary embolus, careful consideration should be given to the risk factors”.

The health centre has also been told to ensure that all complaints are handled in line with the NHS Model Complaints Handling Procedure (MCHP), particularly in terms of the requirement to respond in a timely manner.

Vicki Campbell, Head of Primary and Urgent Care Services, East Ayrshire Health and Social Care Partnership said: “I am sorry that we did not meet the high standards of care that we strive for in NHS Ayrshire and Arran for this patient, and offer my deepest condolences to their family.

“In addition to a formal apology to the family of patient A, I can advise that the GP practice has fully accepted the recommendations in the Scottish Public Services Ombudsman (SPSO) report.

“In order to ensure learning across the organisation, we will share the findings from the report with staff and assurance to our clinical governance teams that the necessary actions have been completed.”