Jacqueline Allwood · Prevention of Future Deaths report

On 24.01.12 I opened an inquest into the death of Jacqueline Allwood, case ref 126/12, aged 47, on 14th January 2012. The inquest was heard on 7th October 2013. The conclusion of the inquest was given by a narrative verdict:

Mrs Allwood attended Cator Medical Centre where she saw a GP on Tuesday 3rd January 2012, limping with several days of calf pain. She received a brief examination and was given advice and a diagnosis of musculoskeletal pain. Failure to take an adequate history (which would have elicited a strong family history of thrombosis) and failure to refer to Accident and Emergency Department to exclude a possible Deep Vein Thrombosis (DVT) amounted to neglect. Death occurred at 01.25 on 14/1 at Lewisham Hospital, having collapsed at home with unsuccessful emergency resuscitation. Death was caused by pulmonary thromboembolism secondary to a DVT, which would have been preventable if she had been referred to hospital on 3rd January.

1. Circumstances related to presentation to the Urgent Care Centre

The patient attended the Urgent Care Centre, Beckenham Beacons having awoken with calf pain three or four days previously. Her daughter says that she filled in a registration form and was then asked to go round to the general practice as she had not injured herself, where there was a service of direct access to patients of any practice, by agreement with the Urgent Care Centre. An urgent care centre registration form was inspected and other than demographic or contact details only requested information about “reason for visit today”. The GP receptionist advised that there would be a two hour wait and entered the reason for visit under “Reported condition” as pain in right calf. The GP did not see the UCC registration form, advised that the information from it may or may not be entered on the computer system, and would be shredded. He gave evidence that he did not see the section in his practice’s electronic record that requests medications and past history, but it was blank in this instance, as it often was.

The A&E expert, Dr Metcalfe, gave evidence that patients presenting to an urgent care centre, walk in centre or out of hours are a much higher risk group than those who present to their own GP surgery. As a consequence, his statement continued, there must be clinically agreed protocols at the front end of any facility that receives undifferentiated patients that manage this higher risk population. Patients that present with certain high risk conditions such as chest pain, shortness of breath or calf pain must be directed to a facility that can exclude serious illness and this is usually the nearest Accident & Emergency Department.

A witness from the UCC provided evidence of the UrgentCare Pathway and Reception Streaming Assessment form, which Mrs Allwood does not remember her mother completing. It identifies several serious conditions or symptoms, but not including calf pain or DVT.

The GP, supported by the GP expert, Dr Harborough, gave evidence that the risk of missing a diagnosis of possible DVT would be reduced, especially for busy GPs, if the patient could be asked to list past medical history, family history and medication, and to hand the form to the doctor at the start of the consultation.

2. Circumstances related to the consulting GP:

The GP was informed that the patient attended due to fear of having a DVT in view of family history. He considered DVT as a possible diagnosis but did not enquire further and so did not discover that four and possibly five members of the family had suffered from thromboembolism. The GP expert witness, Dr Harbow, said that ascribing the pain to a history of getting decorations from the attic was insufficient to conclude as an alternative cause of pain when she reported no pain at the time. There was no record of the risk factors that were considered in this case other than no swelling. A daughter who accompanied the patient to the GP said that he concluded that there could not be a DVT as the calf would need to be severely swollen. Whilst the GP denied he said this, I accepted on the balance of probabilities the evidence of the daughter.

The GP expert said that the patient should have been referred to hospital solely on the basis of the history. He identified a third failure, which did not contribute to death, which was the failure to examine the patient adequately to assess the risk of DVT. The GP examined the legs whilst the patient was sitting with her shoes on and trousers rolled up. He only felt the painful calf and informed the court that visual inspection in this position was sufficient to determine whether there was difference of more than 3cm (a threshold for the Wells test) or whether there was ankle oedema.

The GP expert gave an opinion that this was an inadequate examination and that the patient should be lying on the couch with trousers off and both legs examined on both sides under a light. Expert advice of a GP consultant that the threshold for referral was possible risk of DVT and that was met here and she should have been referred. Expert opinion evidence from an A&E consultant, Dr Metcalfe, confirmed that death would have been prevented if referred on 3rd as the patient would have been anticoagulated.

(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.

(2). Taking as a whole the evidence of the consulting GP, Dr Adlakha, it cannot be said that the public can be assured that he understands and accepts normative standards of practice with respect to history and examination and that he has made or will make changes in order to reduce risks of harm to patients.