Student Shannon Deakin, 16, limped into the surgery with 'knife-like' pains after her left thigh became swollen and turned red.
Newly-qualified locum general practitioner Dr Karim Mohammed diagnosed an infection and gave her antibiotics and anti-inflammatory drugs at the Care UK walk-in centre.
Shannon, of Hoyland in South Yorkshire, was told to see her own GP within 24 or 48 hours and have an ultrasound scan if she was not any better - but she collapsed and died at home about 12 hours later.
After the Sheffield inquest her parents Bryan, 59, and Sue, 44, said they were considering taking legal action against the GP and Care UK.
Mr Deakin said of their only child: 'We don’t think she was given a chance.'
An expert emergency medical consultant Dr Alan Fletcher told the Sheffield hearing if Shannon had been referred to hospital that day she would likely have shown a high score on tests for DVT.
She would have been given an ultrasound scan which would have led to treatment and her chances of survival would have been greatly improved.
But he could not say Shannon, who had 11 GCSEs and was training to be a midwife, would 'more likely than not have survived if she had reached this point in treatment.'
The GP should also have examined Shannon’s calves where swelling is a tell-tale sign of DVT but it was so rare in someone of her age a GP would think it was the least likely option.
Delivering a narrative verdict, coroner Chris Dorries said he had considered whether there was 'culpable human failure' in Shannon’s death or whether it had been 'contributed to by neglect' but he found the appropriate legal criteria were not met.
The inquest heard Shannon had been prescribed the Dianette pill by her GP which is known to increase the chances of developing blood clots.
She had been taking the pill for a month after complaining of acne affecting her back, chest and face but came off it because of side effects just a month before she died on December 4 last year.
The pill was rated as a 'low risk' factor by experts who gave evidence.
A post mortem showed Shannon died from a pulmonary embolism caused by a blood clot moving from her leg through her heart towards her lungs which pathologist Dr Mudher Al-Adnani said was 'extremely rare' in one so young.
Dr Mohammed, who was on-call at the clinic based in Barnsley Hospital, said she came in complaining of a pain in the left side of her abdomen radiating to her groin.
During a ten-minute consultation he noted a large, warm patch of redness on the front of her left thigh.
Because of her brief period on the pill and a lack of negative family history he did not ask any further questions and excluded DVT from his diagnosis. 'I explained it was highly unlikely that it was a clot and my findings were more of an infection or muscular pain,' he said.
But Shannon’s mother Susan, 43, who accompanied her daughter, told the inquest Dr Mohammed failed to notice her daughter’s swollen left foot and she left 'walking on the back of her pump'. The doctor told her: 'It’s either a blood clot or an infection.'
Shannon even texted her cousin four hours after the consultation with the same message and a later text read 'moving a tiny amount kills'. Just 12 hours later she collapsed on the settee at the family’s home.
GP expert Dr James Gray said the locum’s assessment was 'reasonable' but it may have been prudent for him to arrange an ultrasound scan and he did not pick up on Shannon’s swollen foot which could have raised suspicions of a blood clot in the lower leg.
He remained 'unconvinced' the GP had looked into all the risk factors associated with DVT.
Mr Dorries’ conclusion read: 'Shannon Deakin died in consequence of an undiagnosed DVT.
'Shannon had sought medical assistance at lunchtime the previous day and whilst there are unresolved conflicts of evidence about that consultation it cannot be said, even at its highest, that the examination and assessment amounted to gross failure.
'Furthermore, even if diagnosed at that time it cannot be said that a referral to hospital would more likely than not have saved Shannon’s life.'
After the hearing Mrs Deakin said: 'We took the GP at his word. Things could definitely have been done more differently and Shannon might have stood a chance.
'We haven’t a clue how she got DVT. I kept asking her if she had suffered a fall or a bump but she said not. It is a complete mystery.'
Mr Deakin said: 'She was perfectly fine three days earlier. It just came on so quickly. Since her death it has been a total living nightmare. The day Shannon died we died.'
This article is courtesy of the Daily Mail.
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