Fife patient left with nerve damage after failings in DVT care

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NHS Fife have now apologised for failures in the treatment of the patient, known as ‘C’, and been ordered to carry out improvements in care.

‘C’ complained to the Scottish Public Services Ombudsman about the treatment provided between April and May 2021.

They had received Dalteparin injections, a heparin-based treatment, from the Board’s outpatient DVT clinic for a superficial vein thrombophlebitis.

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Around nine days later, C reported to the clinic new symptoms of weakness, numbness and difficulty moving their leg. C was admitted to hospital where they received investigations to rule out either peripheral nerve entrapment or a stroke.

Symptoms continued to worsen including new onset of severe leg pain, and it was later confirmed that C had developed limb ischaemia – inadequate blood supply due to blockage of the blood vessels – due to Heparin Induced Thrombocytopenia (HIT), a serious complication associated with heparin-based products.

Although C was transferred to another health board for emergency vascular surgery which saved their leg, they were left with permanent nerve damage and suffer from chronic pain and reduced mobility.

C complained the delay in treating them for HIT resulted in the permanent harm caused to their leg said the outcome would have been better had the condition been diagnosed and treated earlier.

They also complained that the Board’s handling of their complaint had been unreasonable.

The ombudsman said the DVT clinic appointments were a “key opportunity” to manage C’s condition before harm had happened, particularly as blood results which were available indicating that C’s platelet count had dropped.

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“HIT is a very difficult condition to treat even when treatment is commenced immediately, however, had action been taken earlier, in their view, it may have significantly changed the outcome for C,” they stated.

“It was of significant concern that although junior and general medical staff correctly suspected HIT, they did not then receive appropriate specialist support and advice which meant C was not urgently treated for HIT as they should have been.”

The Ombudsman found that there had been a failure to appropriately review and monitor C’s platelet count at the DVT clinic, a failure to appropriately assess and diagnose C for suspicion of HIT, provide appropriate haematology advice to medical staff and review and document C’s response to pain relief.

It also deemed that the Board’s handling of C’s complaint was unreasonable including their handling of the Local Adverse Event Review.

The Ombudsman ordered NHS Fife to apologise for the identified failings and provide evidence that the findings of the investigation had been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again.

They also ordered the board to provide them with evidence that they have reviewed the DVT clinic’s management and review of patients receiving heparin injections to ensure blood results are timeously reviewed and acted on appropriately.

Responding to the decision, NHS Fife’s Medical Director, Dr Chris McKenna, said: “Healthcare staff in Fife work tirelessly in their efforts to provide patients with the best possible quality of care.

“While the vast majority of the care we provide is of a very high standard, we accept that errors were made in this case, and we have apologised to the patient involved.

“As the Ombudsman acknowledges in their report, Heparin Induced Thrombocytopenia (HIT) is unpredictable, and the symptoms reported in this case occur only infrequently with this condition. While ruling out other serious conditions was initially deemed to be the immediate clinical priority, we accept that opportunities were missed that could have enabled the cause to be identified sooner.

“We also note the acceptance within the report that the condition is difficult to treat even when recognised early and that initiating an alternative treatment sooner may not have fully worked.

“We constantly strive to provide patients with the safest and most effective care possible and recognise the importance of learning from this case.

“A series of actions have already been taken following our own local review to prevent such an incident from being repeated in future. The recommendations of the Ombudsman are also in the process of being implemented in full.”


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