Scottish Public Services Ombudsman

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  • Case ref:
  • Date:
    April 2014
  • Body:
    A Medical Practice in the Ayrshire and Arran NHS Board area
  • Sector(s):
  • Subject:
    clinical treatment / diagnosis
  • Outcome:
    Not upheld, no recommendations


Ms C suffers from a blood condition - Factor V Leiden - which increases the risk of blood clots. Ms C complained that her medical practice had not taken sufficient account of this condition, in that they had not monitored her blood on an ongoing basis, they had given her an inappropriate contraceptive injection and when she went to them with a possible blood clot in her calf they had not referred her to hospital.

Ms C's concerns started when she attended the practice suspecting that she had a blood clot in her calf. Her GP referred her to hospital to see whether she had a DVT (deep vein thrombosis). The assessment showed some superficial clots, but no DVT. Ms C later had an contraceptive injection at the practice, which she continued to receive on a quarterly basis for the following year. A year after she first went to the practice with pain in her leg, Ms C went back for the same reason. The GP did not refer her to hospital this time, on the basis that no DVT was found on the previous occasion. However, the next morning Ms C woke with pains in her chest, and subsequent investigations found that Ms C was suffering from pulmonary embolisms (clots in the blood vessel that transports blood from the heart to the lungs).

We took independent advice on this complaint from one of our medical advisers, who is a GP. After considering Ms C's medical records, he explained that her blood condition did not require ongoing monitoring. He also said that her contraceptive injections were the most appropriate for her. Finally, he considered whether Ms C should have been referred to hospital when she presented with pain in her calf on the second occasion. He said that, although this was a finely balanced judgement, the GP had acted reasonably given the evidence he had available to him at the time.

Download case 201302473 as a PDF (11.49 KB)

Updated: April 30, 2014