She visited her GP and was attended by paramedics muliple times before her death, a report has found
A woman tragically died from complications of a blood clot more than a month after she first visited her GP with symptoms. Linda Sharp died when the undiagnosed clot in her leg broke away and blocked an artery in her lungs.
The 70-year-old was attended to at her home by Yorkshire Ambulance Service on four separate occasions in the three weeks prior to her death on November 21, 2023. By the time of the final call out, she had suffered a heart attack and could not be resuscitated, the coroner said.
Professor Paul Marks, Senior Coroner for Hull and the East Riding of Yorkshire, said the inquest into Ms Sharp’s death found she would likely not have died if she had been treated with anticoagulants and blood thinners. He has now written to the Royal College of General Practitioners, urging for a review of how deep vein thrombosis and pulmonary embolus are diagnosed.
Ms Sharp visited her GP 35 days before she died, on October 17, complaining of swelling in her right leg. The Wells score, a risk tool for thromboembolic disease was applied without any further testing, such as an ultrasound of the calf blood vessels.
She was “reassured and given safety netting advice”. On November 2, she was attended by paramedics because of shortness of breath and taken to Scarborough General Hospital.
At the hospital, she did not undergo any testing for thromboembolic disease and she was not prescribed anticoagulants. She was discharged later that day.
On November 15, she was seen by an advanced nurse practitioner at her GP surgery. Prof Marks said it was “assumed her moderately low oxygen saturation was due to chronic pulmonary obstructive disease, but no confirmatory tests were carried out”.
The following day, November 16, Ms Sharp was attended by the ambulance service and was noted to have initial low oxygen saturation levels. However, these “rose to normal limits after a second set of observations had been carried out” and she was not taken to hospital.
On November 19, paramedics attended again. Prof Marks said he “accepted evidence from the attending paramedic that if he had known about the previous attendance on the 16th November 2023, he would have conveyed Linda to hospital”.
Mrs Sharp was seen again in her GP surgery the next day, November 20, complaining of breathlessness and coughing up blood. Prof Marks said investigations were commissioned, but pulmonary embolism “was not considered in any differential diagnoses”.
Later that day, at around 11:30pm, Mrs Sharp had a heart attack at her home. Paramedics attended and gave advanced life support, but she died at 12:30am on November 21.
Prof Marks said expert evidence was heard that it is “fundamentally flawed” to conflate a low Wells score with there being no possibility of a deep vein thrombosis (DVT) or a pulmonary embolus (PE). He said the algorithm “needs to be supplemented by other tests”.
The coroner’s report was sent to the Royal College of General Practitioners (RCGP), which has until November 10 to respond. It was also copied to York and Scarborough Teaching Hospitals NHS Foundation Trust and Yorkshire Ambulance Service, who were named as interested persons at the inquest.
An RCGP spokesperson said, “We’d like to express our deepest condolences to the family of Linda Sharp. The College has received the coroner’s report and will respond in due course, we are unable to comment further outside this formal coronial process.”
A spokesperson from York and Scarborough Teaching Hospitals NHS Foundation Trust said: “The Trust would like to convey our sincere condolences to Mrs Sharp’s family. We recognise and share the concerns raised by the HM Coroner.
“We take patient safety very seriously and have already implemented learning around similar scenarios into processes within the Trust, with the aim of improving patient care.” Yorkshire Ambulance Service declined to comment.