Summary
C complained about an Advanced Nursing Practitioner (ANP) assessment, and failure to correctly diagnose a deep vein thrombosis (DVT) and pulmonary embolism (PE).
We took independent advice from an ANP. We found that the practice's complaint response failed to demonstrate reflective learning, particularly around an apparent failure to adequately consider PE within the differential diagnosis (given C’s reported symptoms and relevant personal and family history) and missed opportunity to refer C to the DVT pathway for further assessment.
Upon notifying the practice of our investigation, and sharing the outcomes C was seeking, they took the opportunity to further reflect on the complaint and they acknowledged and apologised for failings in both the clinical assessment and complaint handling. They outlined a list of learning points that they now proposed to action as a result of the complaint. C was satisfied with this. As both parties agreed to a resolution of the complaint, we discontinued our investigation.
Related reading
View Decision Report 202503622 as a PDF (24.33 KB) Updated: September 23, 2026