Recurring concern

Failure to reliably diagnose and refer suspected DVT

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First reported 23 Oct 2013•Latest report 15 Sep 2025

Definition

What this concern includes

Includes failures in the dedicated suspected-DVT process, including assessment and documentation, interpretation of risk tools, consideration or completion of appropriate imaging, referral to emergency or specialist care, and coordination of DVT diagnosis and management.

Not included

  • Excludes thromboprophylaxis and other preventive measures intended to prevent venous thromboembolism where suspected-DVT diagnosis or referral is not the unsafe condition.
  • Excludes pulmonary-embolism treatment after suspected PE has been identified, unless the failure directly concerns recognition or referral of suspected DVT.
  • Excludes generic clinical documentation, communication or referral deficiencies without a material suspected-DVT diagnosis or referral context.
  • Excludes failures occurring after suspected DVT has been reliably diagnosed and referred, including downstream treatment failures.
Reports
5

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Barnsley Hospital NHS Foundation Trust1
Beckenham Beacon Urgent Care Centre1
Bromley Healthcare Community Interest Company1
Cator Medical Centre1
Department of Health and Social Care1
General Medical Council1
NHS South East London Integrated Care Board1
Royal College of General Practitioners1
the Shrewsbury and Telford Hospital NHS Trust1
University Hospitals Coventry and Warwickshire NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East Riding and Hull

    AI-generated summary

    Linda Janet Sharp · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Linda Janet Sharp had repeated presentations to healthcare professionals with symptoms consistent with thromboembolic disease before suffering a cardiac arrest at home and dying on 21 November 2023. The principal concern was that a low Wells score was treated as excluding deep vein thrombosis or pulmonary embolism, without further testing or empirical anticoagulation; expert evidence stated that a Wells score on its own does not exclude either condition.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to recognise that a low Wells score does not exclude DVT or PE

    Wider context from the report

    “Expert evidence was heard which stated that it is fundamentally flawed to conflate a low Wells score with there being no possibility of a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). A Wells score on its own does not exclude a DVT or PE. ”

    Source location

    Linda Janet Sharp · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop an e-learning module highlighting correct interpretation of the DVT Wells score.

    Verbatim wording from the response

    “The College has therefore commissioned some internal work through our eLearning team to highlight the specific issue of interpretation of the Wells score. We shall aim to publish this to be available to members in the first quarter of 2026 and the college will be responsible for the production and content of the eLearning module. We shall promote this through our members network and our regular Chair’s blog which reaches out to all 54,000 of our members.”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Promote the e-learning module through the members’ network and the Chair’s blog.

    Verbatim wording from the response

    “The College has therefore commissioned some internal work through our eLearning team to highlight the specific issue of interpretation of the Wells score. We shall aim to publish this to be available to members in the first quarter of 2026 and the college will be responsible for the production and content of the eLearning module. We shall promote this through our members network and our regular Chair’s blog which reaches out to all 54,000 of our members.”

    Source location

    Response from Royal College of General Practitioners
    Page 2 · response
    Published 19 September 2025

    Open published response
  2. Shropshire, Telford and Wrekin

    AI-generated summary

    Mark Richard HINTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record a differential diagnosis of DVT

    Wider context from the report

    “(3) Other matters arising. a) A second set of observations should have been made before Mark was discharged. This did not happen. b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review. c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category? d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded. e) A body map had not been completed at any time. f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain. g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not. h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff. i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E. ”

    Source location

    Mark Richard HINTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit ED staff compliance with documentation requirements and repeat the audit monthly.

    Verbatim wording from the response

    “Agreed. The Trust relies on the integrity of individuals to maintain professional standards of completing documentation. There are clear guidelines issued by both the NMC and the GMC which should be adhered to. An action from the RCA was to audit whether the ED staff were compliant in completing documentation. The initial audit results showed poor compliance and the plan is for the audit to be repeated monthly. The results have been discussed by the senior ED management team who are tasked with bringing improvement.”

    Source location

    2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
    Page 4 · response
    Published 14 June 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.

    Verbatim wording from the response

    “g. Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.”

    Source location

    2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
    Page 4 · response
    Published 14 June 2019

    Open published response
  3. Coventry

    AI-generated summary

    Mr Robert Dymond · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Robert Dymond underwent elective left knee replacement surgery on 9 March 2017 and suffered a massive thromboembolic event the following morning, dying on 11 March 2017. Concerns included the management and follow-up of suspected deep vein thrombosis, the apparent failure to communicate the November 2016 DVT investigations and treatment to the surgical and anaesthetic teams, and their omission from the second pre-operative assessment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the DVT investigation protocol to provide repeat proximal leg vein ultrasound scanning after a positive D-dimer test and negative proximal leg ultrasound scan

    Wider context from the report

    “(1) Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr Dymond, having a Wells score of 2, was assessed as being ‘likely’ to be suffering from a DVT – the investigations included a D-Dimer blood result of 0.97 – and he was discharged home with instructions to self-administer therapeutic LMWH (Clexane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed no evidence of a DVT and he was discharged back to the care of his GP. Although the clinical management appeared to conform with the UHCW protocol in place at the time, this protocol did not appear to conform with NICE Guideline 144 (specifically section 1.1.3) which (since 2012) advises a repeat proximal leg vein ultrasound scan 6-8 days later for all patients with a positive D-dimer test and a negative proximal leg ultrasound scan; ”

    Source location

    Mr Robert Dymond · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake routine extended whole-leg scans covering veins below the knee to the calf trifurcation.

    Verbatim wording from the response

    “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.”

    Source location

    2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
    Page 1 · response
    Published 2 December 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Contact high-risk patients with raised D-dimers after 5–7 days and arrange repeat scanning when symptoms have not settled.

    Verbatim wording from the response

    “Further, the Trust’s standard practice in patients with a high risk Wells score and raised D-Dimers is to contact the patient 5-7 days later and arrange a repeat scan if the symptoms are not settling. Only a small proportion of patients who present with isolated distal DVTs extend to the proximal veins. Those that do not extend, rarely lead to clinically significant emboli as recognised by the British Society of Haematology national guidelines, a copy of which is attached by way of information.”

    Source location

    2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
    Page 1 · response
    Published 2 December 2017

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Routine repeat scans are unnecessary because whole-leg scans are routinely performed and follow-up scans are arranged when symptoms fail to settle.

    Verbatim wording from the response

    “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.”

    Source location

    2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
    Page 1 · response
    Published 2 December 2017

    Open published response
  4. South Yorkshire (Western)

    AI-generated summary

    Captain James Michael Bedford · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consider full-leg scanning for suspected lower-leg DVT

    Wider context from the report

    “1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg. This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile. Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this. ”

    Source location

    Captain James Michael Bedford · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent practice regarding lower-leg scanning for deep vein thrombosis

    Wider context from the report

    “The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg. This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile. Hindsight strongly suggested that Captain Bedford was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedford although it was accepted that no-one could be certain of this. ”

    Source location

    Captain James Michael Bedford · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.

    Verbatim wording from the response

    “However, RSMVF also points out that the evidence for treating distal DVT alone is weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no benefit in treating symptomatic below knee DVT. RSMVF is of the opinion that even if Captain Bedforth had had a full leg scan, and had been found to have a below knee DVT in April 2015, the evidence is not clear on whether he should have been immediately anticoagulated at that time.”

    Source location

    2016-0368-Response-by-Department-of-Health
    Page 2 · response
    Published 18 October 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NICE is responsible for considering and responding on whether lower-leg scanning should be included in relevant clinical guidance.

    Verbatim wording from the response

    “The inquest heard that the scanning practice followed after Captain Bedforth’s first attendance in April 2015, was in accordance with NICE guidelines which do not include scanning the lower leg. As it became apparent there is mixed clinical practice on this point, your view is that some hospitals consider that lower leg scanning is worthwhile. As most hospitals are, or should be, working to NICE guidelines, I therefore advised that you should consider inviting NICE to respond to this case directly. My officials provided you with contact details and I understand that NICE are looking into this and will respond directly to you and copy me into their reply. I have also consulted the Royal Society of Medicine Venous Forum (RSMVF) and asked for their comments on this case.”

    Source location

    2016-0368-Response-by-Department-of-Health
    Page 2 · response
    Published 18 October 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The hospital will not change distal DVT ultrasound processes because additional scans may not detect all clots and empiric anticoagulation creates risks.

    Verbatim wording from the response

    “1. The current NICE guidance for Venous Thromboembolism advises proximal leg USS investigation for those patients who are high risk based on Wells scoring and those who are low risk with a positive D-dimer. If negative, the patient should undergo a second proximal leg USS in 6-8 days time to exclude proximal propagation of a clot from a distal DVT. The rationale behind the NICE guidance is evidence-based following multiple studies.”

    Source location

    2016-0368-Barnsley-Hospital-NHS-Trust
    Page 1 · response
    Published 18 October 2016

    Open published response
  5. Inner South London

    AI-generated summary

    Jacqueline Allwood · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of registration, assessment and referral documentation and consultation records to facilitate early diagnosis of DVT and low-threshold referral to A&E

    Wider context from the report

    “(1) The registration, assessment and referral forms and consultation records of and between the Urgent Care Centre and Cator Medical Practice may not facilitate the early diagnosis of DVT and the need for a low threshold of referral to A&E. ”

    Source location

    Jacqueline Allwood · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report
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Data last updated 7 September 2026