Pulmonary Embolisms: Diagnosis

Helen Hayes Excerpts

Wednesday 30th November 2022 Commons Chamber

[Helen Hayes (Dulwich and West Norwood) (Lab)]

I am grateful for the opportunity to bring to the House the issue of the diagnosis of pulmonary embolism. Given the content of this debate, I put on the record that my husband is employed by the NHS.

I applied for the debate on behalf of my constituent Tim Edwards, who is watching the debate from the Public Gallery. Tim’s mother, Jenny, taught for 27 years in Lewes, East Sussex, before retiring in 2012. Jenny sadly lost her life to pulmonary embolism in February 2022. My speech is about the experience of Jenny and her family, and the research that Tim has undertaken in the aftermath of his mother’s death, which points to a significant issue with preventable deaths occurring as a consequence of misdiagnosed pulmonary embolism.

First, I want to put on the record my sincere condolences to Tim and his family on the loss of his beloved mother. I understand that in the weeks immediately prior to her death, Jenny had been enjoying time with her first grandchild. I am sure that, as Tim and his wife watch their daughter grow, they are constantly reminded of the relationship that she will now not be able to enjoy with her grandmother. Tim is motivated by his loss to seek to ensure that positive learning is derived from his mother’s case and many similar cases, so that diagnosis and the prompt treatment of pulmonary embolism is improved.

Globally, venous thromboembolism, which presents clinically as either deep vein thrombosis or pulmonary embolism, is the third most frequent acute cardiovascular syndrome behind heart attack and stroke. Pulmonary embolism is a blood clot in the vein passing to the lung and causing heart failure. The disease is serious but eminently survivable—if it is promptly diagnosed and treated, the death rate is 8%. Unfortunately, many pulmonary embolisms are misdiagnosed and attributed to other acute cardiovascular conditions because of the overlap of symptoms and the greater ease in identifying heart attacks and strokes.

My constituent has undertaken considerable research since his mother’s death, working with the charity Patient Safety Learning. He has estimated that there was a minimum of 400 excess pulmonary embolism deaths across England from April 2021 to March 2022, and that that excess figure is attributable to cases that were missed. He also looked at the age-adjusted mortality rates for pulmonary embolism across counties in England and Wales. There are some regions where the number of fatalities from the condition is almost three times the national average. The Minister may want to inquire as to what drives that discrepancy.

Let me give a sense of what can and does go wrong. In early February 2022, despite exhibiting risk factors and sudden symptoms, including fainting and collapse, my constituent’s mother, Jenny, was wrongly misdiagnosed in the care of an emergency department as having had a heart attack. She was then needlessly fitted with a stent. Upon her discharge from hospital, Jenny’s condition got worse again at home. She was dying. Yet she was reassured by a cardiac nurse who, over the phone, missed the clinical signs that indicate pulmonary embolism: shortness of breath, chest pain in the centre of the chest and fainting. The nurse advised that if these symptoms continued, Jenny should call her GP, and she did so, but she never made her GP appointment. My constituent does not want this to happen to other family’s loved ones, because it was entirely avoidable.

Jenny was waiting in accident and emergency for more than 12 hours, and there were nine independent decision-making points, at any one of which pulmonary embolism could and should have been diagnosed, but the condition was only discovered in an autopsy. My constituent has subsequently been motivated to write a report about what went wrong, given the mistakes that Jenny experienced and his sense that the NHS trust involved was unable to learn from what happened. His background is in the financial services sector, working in reinsurance, and he has a strong understanding of risk management. From a review of Jenny’s case and a report released by the Healthcare Safety Investigation Branch on this topic, part of the problem contributing to misdiagnosis appears to be that many emergency departments are frequently under-resourced and over-reliant on junior staff who may be ill-equipped to reliably suspect, assess and then treat pulmonary embolism, which is a relatively complex condition. That is supported by information provided by the Royal College of Radiologists, which commented on the lack of workforce sufficiency and a shortage of equipment.

Clinical staff in these settings have commented that either they do not have time or, astonishingly, do not feel that they need to follow clinical guidelines on how best to diagnose pulmonary embolism. On that last point, my constituent observes that there appears sometimes to be a culture of excessive leeway for clinicians to make their own decisions and a reluctance to follow clinical best practice. This is a source of concern.

My constituent has also discovered by interviewing a leading European professor in this area that the British clinical guidelines for diagnosing pulmonary embolism are out of step with those adopted across Europe and appear to exacerbate the risk of misdiagnosis, because the guidelines are thought of as subjective. He welcomes the news that these clinical guidelines are currently being reviewed. My constituent is also concerned that prior covid-19 infection has complicated the process of diagnosis in recent years, because some symptoms may be dismissed as linked to covid. However, this is inexcusable, as covid-19 was first established as an additional risk factor for pulmonary embolism by studies across Europe and the US in 2022. Prior covid-19 infection should give rise to greater, not lesser suspicion for patients presenting with symptoms.

In Jenny’s case, well-documented symptoms of pulmonary embolism were discounted because of her prior covid-19 infection, although it had been asymptomatic and she had made a full recovery. My constituent reports that it seemed that clinicians were assuming that covid-19 had been beneficial to Jenny’s health. Upon my constituent’s complaint to the NHS trust responsible for Jenny’s care, a serious incident report was commissioned and an inquest took place. However, in my constituent’s opinion, the NHS trust appears to have exhibited what he describes as a “shrug of the shoulders, these things happen” conclusion, inhibiting sufficient learning.

My constituent demonstrates in his report that the clinicians who treated his mother are at odds with academic literature on the symptoms of pulmonary embolism when they discuss the rationale behind their decisions. That is deeply troubling, given the alarming rise in pulmonary embolism fatalities across the country. The trust used the lowest level of investigation to contribute to its serious incident report, meaning that the subject matter experts chosen to contribute to the report were all involved in Jenny’s original care. The report’s conclusion was that a pulmonary embolism could not have been detected, even though Jenny displayed symptoms consistent with 90% of pulmonary embolisms. My constituent disagrees with the report conclusions, and he is concerned that it lacks objectivity and that there is insufficient learning to prevent such misdiagnosis from happening again. A higher level of investigation would have ensured independent contributors to the report, and the lack of that gives rise to concern about how many other cases may have been inadequately reviewed.

The sadness and frustration that my constituent feels at the circumstances of his mother’s death have been compounded by the intransigence he has witnessed in the NHS trust responsible for her treatment and the discovery that Jenny’s case was not alone. My constituent has been working with the charity Patient Safety Learning and his report will be published in December. The report contains nine calls for action. I have read the report and I have also received a response from NHS England to the recommendations in the draft. I share my constituent’s concerns that the response falls back on existing guidelines and current practice. It does not acknowledge my constituent’s finding of around 400 potentially preventable deaths a year due to misdiagnosed pulmonary embolisms. It makes no commitment to any process of review or change.

The Royal College of Radiologists has also expressed concerns consistent with my constituent’s observation about resourcing issues in emergency departments, and workforce and equipment sufficiency to enable scans to be undertaken. It stated that clinicians do not always have the equipment necessary to provide optimum care. The current vacancy rate in clinical radiology consultants is 8%.

My constituent’s research on this issue following the tragedy that his family has suffered is commendable. It highlights serious problems with excess deaths and misdiagnosis, raises serious questions about a postcode lottery, workforce sufficiency and the availability of equipment, and raises concerns about the culture of learning in the context of misdiagnosis.

I ask the Minister to agree to work with NHS England to commission a review of the data set out in my constituent’s report and the concerns raised by the Royal College of Radiologists, with a view to ensuring that the rate of misdiagnosis of pulmonary embolism is greatly reduced, and fewer families have to suffer the loss that my constituent and his family have suffered.