Queen’s Hospital failing led to postman’s death.

A man died after doctors at Queen’s hospital missed a fatal blood clot which developed after routine knee surgery, England’s Health Ombudsman has found.

The man’s death has now been ruled as avoidable by the Parliamentary and Health Service Ombudsman (PHSO).

The man, who had been a postman for over 30 years and was a semi-professional footballer in his younger years, died of a pulmonary embolism after doctors failed to test for deep vein thrombosis (DVT), despite noting that it was a risk following the surgery.

A pulmonary embolism happens when a blood clot breaks off and travels to the lungs where it blocks the flow of blood.

The 46-year-old was playing football with colleagues when he damaged his knee. Four days later he went to A&E at Queen’s Hospital in Romford and had surgery that day.

Following the operation, he was struggling to walk and had a lot of pain in his leg. Two weeks after the surgery, he went back to A&E where a doctor questioned whether he might have DVT.

An X-ray and blood tests were carried out but no tests for DVT were done and he was sent home.

Two weeks after that, the man had tightness in his chest and fainted. His family called an ambulance, but his heart stopped while on the way to the hospital. Sadly, despite attempts to revive him, he never came round and died in hospital.

His family complained to the Parliamentary and Health Service Ombudsman about his care.

The Ombudsman found that doctors at Barking, Havering and Redbridge NHS University Hospitals Trust went against national guidance by not carrying out the relevant tests to rule out DVT.

The investigation concluded that if the tests had happened, DVT would have been found and treated, which would have prevented the fatal pulmonary embolism.

Rob Behrens, Parliamentary and Health Service Ombudsman, said, “This is a tragedy that should have been avoided. A fit and healthy man lost his life because doctors failed to carry out the correct tests. That is an injustice to him and his family.

“When mistakes like this are made it is vital that they are learned from so they do not happen again. That’s why it’s important to raise concerns when things go wrong. A well-handled complaint that is embraced by the organisation involved has the power to reveal the truth and even create lasting positive change by driving up standards.”

The man left behind his father, brother and two sisters. His older sister said, “He was such a lovely person, he was my rock. There are not enough superlatives to describe him.

“As a postman, he knew everybody, and he was very well-liked. At his funeral people lined the streets to say goodbye and so many people told us about ways he had helped them while on his rounds. He would help people who couldn’t walk very well or who were poorly, that’s the kind of man he was.

“He was so kind to everybody, and I just miss him so much. I don’t think we will ever get over losing him, especially knowing that it didn’t need to be this way.”

The Ombudsman recommended that the Trust write to the man’s family to acknowledge its failings and apologise. The Trust should also create an action plan to prevent this happening again and give the family £15,000.

Earlier this year, the Ombudsman published a report about the urgent need for trusts to prioritise patient safety to prevent avoidable deaths. The Broken trust report analysed 22 cases of avoidable death over the last three years and set out a series of recommendations to improve patient safety.

The report called on NHS organisations to embed learning cultures that are transparent about mistakes and take accountability for learning from them. It also recommended better support for families affected by harm and getting the right oversight and regulatory structures to prioritise patient safety.

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