An obese man with hypertension died after multiple visits to a VA Medical Center for treatment of flu-like symptoms as well as cough and congestion. With each visit, the doctors failed to diagnosis an inflammation of his deep veins caused by blood clots. Days after his last doctors’ visit, he was taken to the hospital and was noted to be in full cardiac arrest. The doctors had failed to prescribe anticoagulant medicine which would have averted his death.

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