The scene

A patient in his 60s presented to an MDU GP member with right ankle pain and swelling, which started during a recent holiday in the Mediterranean. On examination there was a small effusion at the ankle with painful ankle movements. The GP made a note in the clinical record of the patient's history of ankle osteoarthritis (OA) and considered that his symptoms were due to an OA flare-up, likely caused by unaccustomed levels of exercise while on holiday. The GP prescribed naproxen and advised the patient to return if things didn't settle, noting in the records that there were no features of cellulitis or DVT.

One month later the patient presented with a five-day history of the room spinning round when moving his neck, and the GP made a diagnosis of benign paroxysmal positional vertigo, which the patient had suffered on previous occasions. He was given betahistine tablets as treatment, but returned three weeks later because they had not helped his vertigo. Examination was normal and the GP prescribed a trial of cinnarizine, but this was also not helpful, so the GP made a referral to ENT one week later. There was no documentation of any reported ongoing problems with the patient's leg or ankle at any of the consultations.

Three weeks later, the patient collapsed at home and was taken to hospital where he sadly died the next day from a massive pulmonary embolus (PE).

The claim

The patient's wife subsequently brought a claim against the GP, alleging that the history and examination taken at the first consultation were inadequate, that a DVT should have been suspected, and that a Wells score should have been calculated – which would have been at least 1, given the recent onset of unilateral ankle swelling without a clear explanation. It was further alleged that if this had been done, a DVT would have been diagnosed and treated, which would have avoided the later PE and prevented the patient's death.

Responding to the GP's request for assistance in dealing with the claim, the MDU obtained independent expert evidence from a GP, who was fully supportive of the member's management of the patient. The expert considered that the member's history and examination were appropriate, and that the documentation of the findings was in accordance with a reasonable body of competent GPs.

The expert GP's view was that the GP did consider a possible diagnosis of DVT, even though the patient didn't present with typical symptoms, but there was no evidence in the history or examination to support a diagnosis of possible DVT. The expert further noted that the diagnosis of osteoarthritis was a reasonable one to make in the circumstances, giving a clear explanation for the unilateral ankle swelling. A Wells score was not appropriate, as it should only be used in those patients with a provisional diagnosis of a suspected/possible DVT.

The MDU's claims handler also obtained expert evidence on causation from a haematologist, who confirmed that the clinical presentation at the initial consultation was not suggestive of DVT, and that even a haematologist would not have considered DVT as part of the likely differential diagnosis, and would not have performed a Wells score.

Furthermore, on the balance of probabilities, asymptomatic 'silent' calf vein DVT developed at the very earliest one month before the patient's collapse, and this DVT silently extended proximally in the leg, embolising to fatal PE. Therefore DVT was not present almost three months before the patient's death when he first consulted his GP with right ankle pain and swelling.

The outcome

The MDU strongly denied liability in its letter of response, based on the expert's evidence and our member's contemporaneous records, and emphasised that the patient presented with no features suggestive of DVT. The MDU also highlighted that haematology evidence confirmed that the DVT did not develop until seven weeks after the GP member's consultation.

After two months the claimant's solicitors made an offer for the MDU to settle the claim for a small amount. This was far below the valuation of the claim, but given the strength of the expert evidence obtained, the MDU rejected the offer. The claimant's solicitors then wrote to say they were discontinuing the claim against the GP member in light of the MDU's robust response.