Pulmonary Embolisms: Diagnosis

Helen Whately Excerpts

Wednesday 30th November 2022 Commons Chamber

[The Minister of State, Department of Health and Social Care (Helen Whately)]

I commend the hon. Member for Dulwich and West Norwood (Helen Hayes) on securing this debate. She is quite right to bring this issue before the House, as pulmonary embolisms are not widely known about and are extremely challenging to diagnose. When diagnosed and treated, the survival rate is very high, and that makes misdiagnosis all the more tragic.

Let me express my condolences to Tim Edwards and his family for the loss of his mother earlier this year. I thank him for the research that he carried out into deaths from pulmonary embolisms, including the information that he has gathered about the variation in the figures around the country. The hon. Member set out clearly the sad facts of Jenny Edwards’ death, particularly how her pulmonary embolism was not diagnosed and unknown until the autopsy. I recognise the need for better diagnosis and I agree with her about the importance of that. I will talk about what we can and are doing, taking on board the hon. Member’s points. I will also talk about reducing deaths from pulmonary embolism by preventing their occurrence. We can never completely remove the risk of embolism, but we can all take action, especially younger people, to reduce the risk.

The NHS has guidance from the National Institute for Health and Care Excellence about diagnosing and treating pulmonary embolisms effectively, which states that patients with symptoms or signs of pulmonary embolisms who see a clinician should have a full medical history, physical examination and chest X-ray. Where there are signs, a D-dimer blood test and the Wells score should be used to determine the likelihood of pulmonary embolism. The challenge is often for the clinician to see the signs and symptoms in the first place, which is increasingly difficult in older patients or those with co-morbidities such as bronchopneumonia, chronic obstructive pulmonary disease, asthma or covid-19. The hon. Member talked about that a moment ago.

That challenge is very much the focus of the Healthcare Safety Investigation Branch’s national investigation into the timely recognition and treatment of pulmonary embolisms in emergency departments. Its report was published in March this year, and it focuses on clinical decision making and improving diagnoses. HSIB notes that the majority of pulmonary embolisms were correctly identified and treated, but it felt that the risk of serious harm or death warranted further exploration. The report found that recognising pulmonary embolism is particularly challenging for less experienced staff, especially when the signs and symptoms may be non-specific or atypical. The decision to initiate treatment is one that balances risks, and the decision can benefit from expert knowledge and skill. The report also notes that, despite expertise and the available tools to identify patients who may have a pulmonary embolism, a small number may always sadly be missed.

During the investigation, HSIB found that emergency department staff had asked for further guidance on the diagnosis of pulmonary embolism. The fact that staff sought that information is a good thing and the right thing to do. HSIB made three safety recommendations on improving guidance and training for clinical staff. First, it recommended that NICE should review the report in relation to its thrombosis guidance. In response, NICE carried out a review of the guidance and has decided to update it to include recommendations for people with covid-19. NICE currently expects to publish the updated guidance in July.

Secondly, HSIB recommended that the Royal College of Emergency Medicine promotes best practice for diagnostic decision making. The royal college is reviewing its guidance, which will be done by the end of this year. In addition, it is reviewing safety information about pulmonary embolism and has education activities planned, including e-learning.

Finally, HSIB recommended that Health Education England develops a strategy to support the training of clinicians to develop their decision-making skills. Health Education England is working closely with professional bodies and provides them with simulation-based interventions to support improved outcomes in patient safety.

Getting a diagnosis of pulmonary embolism is by far the most critical issue to address, as treatments are effective provided that they are administered quickly. Anticoagulation medicines are the main treatment for suspected and confirmed pulmonary embolism. These medicines reduce the formation of further blood clots. After a diagnosis is confirmed, patients continue treatment with longer-term anticoagulant medicines to prevent the formation of future clots.

The importance of effective diagnosis and treatment for people with pulmonary embolism cannot be overstated. While we are on the topic, however, we can all take steps in our day-to-day lives to avoid an embolism—I am not making these comments in relation to any individual case, including the sad death of Jenny Edwards that the hon. Lady has been talking about, but for wider society.

Smoking raises the risk of unwanted blood clots and makes it more likely that platelets will stick together. Smoking also damages the lining of the blood vessels, which can cause clots to form. Stopping smoking significantly reduces those risks. Sitting or being sedentary for long periods, such on a long-haul flight or working at a desk, increases the risk of clots forming. Because the blood is not flowing as much, the cells and proteins in blood settle out and form clumps. Taking regular breaks and moving around reduces the risk of clot formation. Regular exercise, staying hydrated, eating healthily and maintaining a healthy weight are actions that we can all take to reduce the risk of blood clots, which may lead to a pulmonary embolism.

GPs have an important role to play in helping to identify people at risk. The quality and outcomes framework and the investment and impact fund incentivise GPs to deliver proactive case finding and early intervention for patients at higher risk, as well as the ongoing management of patients with long-term conditions that put them at greater risk of blood clots.

In conclusion, raising awareness of pulmonary embolisms in clinical settings, and the significance of early diagnosis, is important but challenging. These challenges must be overcome, as timely and accurate diagnosis of pulmonary embolisms will save lives. Today’s debate has been an important opportunity to talk about how the healthcare system is working hard to improve on the issue. The hon. Member mentioned some research, and I would be happy for her to send it to me so that I can make sure that it is taken on board in some of the work that is going on in this area. I again pay tribute to her constituent, Mr Edwards, who has turned his personal tragedy into action to prevent future deaths due to pulmonary embolism, and for that he should be proud.

Question put and agreed to.