Treatment in the emergency department
15. Mrs A complains Dr L (a doctor who reviewed her husband in the emergency department) did not investigate his health problems appropriately. She believes they missed signs of a stroke. She believes Dr L denied her husband treatment that could have led to a different outcome.
16. The emergency medicine adviser explained how there are specific guidelines for recognising and treating strokes and these are written in the NICE Guideline. But they said the guidelines did not apply while Mr A was in the emergency department. This is because the symptoms he had then were not typical of a stroke. But Dr L should have followed ‘Good medical practice’. This says doctors must carry out adequate assessments of patients and arrange for any investigations, treatments or referrals that are needed.
17. The ambulance service gave a record of the paramedics’ contact with Mr A when they left him at the emergency department at 9.19am. The paramedics explained how Mr A had reacted to sunlight and fallen to the floor. They noted Mr A felt unable to walk and had a left-sided headache. On walking to the ambulance, he leaned to one side. The paramedics gave him paracetamol.
18. A nurse first assessed Mr A and noted he had recently arrived in the country and had collapsed at 7.30am that morning. He had opened the curtains and been affected by the bright light. The nurse documented Mr A had a headache on the left side with a pain score of two (on a scale of zero being no pain and ten being the worst pain ever).
19. The clinical records show Dr L noted Mr A’s history at 10.40am. Dr L recorded that Mr A had been feeling generally unwell, had vomited once, and had low oxygen saturation levels (a measure of the amount of oxygen in the blood). There is no evidence he considered any accounts from the family, the reason for his fall or the nurse’s notes. There is also no evidence the doctor read records from the ambulance service that also referred to Mr A’s headaches and reaction to light. Dr L did not follow ‘Good medical practice’ because his assessment was not thorough.
20. The emergency medicine adviser noted the symptoms Dr L recorded were not specific. The adviser said the symptoms could have been due to several different conditions. They said there is no evidence of any signs that should have alerted doctors to the possibility of a stroke. In most strokes cases, patients complain of one of the so-called FAST features, which includes slurred speech or weakness in the face or limbs. Mr A had a cerebellar stroke (when a blood vessel in the brain becomes blocked or bursts). This is typically difficult for doctors to identify and usually includes symptoms of dizziness and vertigo. It can also cause a persistent or worsening headache.
21. During Mr A’s stay in the emergency department, staff recorded pain scores of zero at 11.20am and 12.10pm, a score of one at 2pm and a score of zero at 3pm. The records do not show any evidence Mr A had a persistent or worsening headache. They do show he had a recent history of breathlessness, a productive cough, low oxygen saturation levels, a raised white blood cell count and changes on a chest X-ray. The emergency medicine adviser said these factors, together with his age and health, justified the doctor in diagnosing a chest infection or pulmonary embolism (when a blood clot blocks a blood vessel in the lung).
22. In its complaint responses, the Trust accepted Dr L’s assessment was not good enough. It confirmed they should have considered the nursing and ambulance records that would have been available. The Trust said if Dr L had done this, a CT scan of Mr A’s head would have been arranged to investigate the clear neurological concerns.
23. We agree with the emergency medicine adviser that the NICE Guideline did not apply in Mr A’s case. We can also see Dr L made an appropriate diagnosis of a chest infection or pulmonary embolism. But we consider Dr L’s assessment was not good enough because he did not review information from Mr A’s family, or records from the ambulance service or the emergency department nurse. We find Dr L’s assessment fell below the standard set out in ‘Good medical practice’.
Impact of the failing in the emergency department
24. We asked the stroke adviser what would have happened if Dr L’s assessment had included a consideration of the information from Mr A’s family, the paramedics and nurse.
25. The stroke adviser told us if Dr L had considered the additional information about the circumstances of Mr A’s collapse, he should then have questioned what had caused a sudden onset of neurological symptoms. He should have arranged a CT scan of Mr A’s head within one hour. So the scan should have been done by 11.40am at the latest. This would have been around four hours and ten minutes after Mr A’s collapse.
26. The stroke adviser told us a CT scan on the morning of admission would have shown definite evidence of Mr A’s stroke. The evidence of stroke would not have been as extensive as the scan done the next day, and would not have shown hydrocephalus, which only developed on the afternoon of the next day. But the doctor reviewing the scan would have immediately identified the stroke and offered treatment.
27. Mr A had a cerebellar stroke at the time of his collapse. The stroke adviser said there are two possible treatments for stroke, which can also be combined. The first is intravenous thrombolysis (IVT) with a drug called alteplase. This is only effective if given within four and a half hours of the stroke. The second is mechanical thrombectomy, which is only effective within six hours of the stroke. This is where there is a surgical attempt to remove a blood clot.
28. The Trust told us it did not have the facilities for mechanical thrombectomy. It transfers patients to a local specialist centre for this procedure. But it does not transfer patients at the weekend. Mr A collapsed and was admitted to the Trust on a Sunday. This means Mr A could not have had mechanical thrombectomy. The only treatment option available for him would have been IVT.
29. We asked the stroke adviser to explain the chances of Mr A having successful IVT. They confirmed Mr A should have had IVT because he was within the four-and-a-half-hour range for treatment. But IVT on its own is not as effective as when combined with mechanical thrombectomy.
30. The stroke adviser told us one way of deciding if IVT would have been successful is to use the DRAGON score. This allocates points for different factors including CT scan changes, evidence of disability before the stroke, the patient’s age, blood glucose level and the time since the stroke happened. The stroke adviser’s opinion is Mr A would have scored six at the time of Dr L’s assessment, based on his reading of the clinical records and a scan that took place the next day.
31. The Rankin Scale is used to measure the degree of disability for people who have experienced a stroke. This has since been amended and the Modified Rankin Scale (mRS) is now widely used in UK hospitals. The scale ranges from zero (no symptoms) to six (death).
32. A DRAGON score of six means 22% of patients having the treatment would have an mRS of between zero and two. At worst, they would have had a slight disability. A score of six would also mean 40% of patients having the treatment would have an mRS of five or six, meaning severe disability or death.
33. The stroke adviser said this meant Mr A had a 60% chance of survival, but probably with significant disability. But the DRAGON score does not take account of Mr A’s other health problems. Investigations showed Mr A had pneumonia and a history of COPD. These would have had an impact on his ability to survive after successful treatment. Our view is this would have reduced his chances of survival further.
34. Our decision is Mr A was denied an opportunity for treatment that could have led to a different outcome. We cannot say his death was avoidable because we do not know how he would have responded to treatment. But Mrs A and her family are now left with uncertainty about what might have happened if the failings in the emergency department had not happened. This is a significant and ongoing injustice for them.
35. We uphold this part of Mrs A’s complaint. She is right to say her husband was not given a better chance of surviving the stroke.
Treatment on the ward
36. Mrs A complains there were delays in doctors identifying her husband’s stroke once they admitted him to the ward (the acute medical unit - AMU).
37. Doctors on the ward should have followed the NICE Guideline. This says doctors should arrange a CT scan of the patient’s head within one hour of suspecting a stroke. They should also have followed ‘Good medical practice’ as explained above. This also says doctors should only prescribe drugs or treatments when they have an adequate knowledge of the patient’s health and are satisfied they meet the patient’s needs. It says clinical records should include who is making the record and when, along with relevant clinical findings.
38. The doctors have also followed the RCP Toolkit. This says a consultant should review all newly admitted patients within 14 hours of their arrival in an AMU.
39. Doctors admitted Mr A to the AMU at 3.35pm on the day of admission. At some point a doctor reviewed Mr A. We do not know the name of this doctor or the time of the assessment because the record has not been completed properly. The doctor’s record of Mr A’s history was incomplete and they did not note all the risk factors, such as a recent long-distance flight and smoking. There was also no medication record or reference to Mr A’s sudden collapse and difficulty walking.
40. The stroke adviser told us the doctor’s record-keeping was poor. The doctor did a brief physical examination. They focused on the respiratory problem and did not take account of all the evidence available at the time. This meant they made no attempt to investigate Mr A’s neurological symptoms. The doctor should, at the very least, have had a discussion with a senior doctor. They could also have arranged a CT scan of the head or asked for an opinion from the stroke team.
41. The unnamed doctor did not follow ‘Good medical practice’. They did not do an adequate assessment or arrange the investigations or referrals needed. They also failed to properly complete the record of the assessment, which also fell below the standards of Good medical practice.
42. At 6.40am on day two of the admission Dr D (a junior doctor) reviewed Mr A. They noted his history and ongoing symptoms of headache, confusion and breathlessness. Their focus was on treating pneumonia, which a chest X-ray confirmed. Dr D had a discussion with a medical registrar who suggested giving Mr A tinzaparin (medication to reduce blood clots). The records show staff gave Mr A a single dose of the medication.
43. The stroke adviser said the medical registrar should have either examined Mr A or asked the junior doctor to assess for a stroke. This was because Mr A’s physiological observations, the level of oxygen in his blood (oxygen saturation) and confusion suggested further investigation was needed. Again, the doctors’ actions fell below ‘Good medical practice’ by not doing an adequate assessment or arranging the necessary investigations.
44. The doctors also failed to act on the stroke symptoms and Mr A’s history as noted in earlier hospital and ambulance records and as described by his family. The NICE Guideline says healthcare professionals should arrange a CT scan within one hour for a suspected stroke. This did not happen.
45. The stroke adviser said tinzaparin is not advised for patients who have had a stroke because it can lead to a haemorrhage. It would have been the correct choice of medication to stop blood clots if Mr A only had pneumonia and the COPD issue. Blood clots are a serious and often fatal complication of a hospital admission. But the doctors should not have prescribed tinzaparin without assessing Mr A for a stroke. Again, they did not follow ‘Good medical practice’ when prescribing tinzaparin.
46. At 9.24am two other doctors reviewed Mr A. They only considered his respiratory symptoms due to COPD and pneumonia. They planned to continue with antibiotics and monitoring. Their assessments were inadequate, for the same reasons we have set out above relating to Dr D, and they did not arrange the necessary investigations. The doctors did not follow ‘Good medical practice’.
47. Dr N (a respiratory consultant) saw Mr A at 11.05am. They suspected a stroke and requested an urgent CT scan of the head. They stopped the tinzaparin and continued antibiotics. The scan took place at 2.17pm and showed a large cerebellar stroke and hydrocephalus. Around this time staff started to record changes in Mr A’s observations, including reduced consciousness.
48. This was the first time a consultant had reviewed Mr A since his admission to the AMU. This was a delay of over 19 hours. This was outside of the 14 hours set out in the RCP Toolkit.
49. Dr A (a consultant stroke physician) reviewed Mr A at 4.35pm. They confirmed the stroke diagnosis. They considered surgical decompression (a procedure to relieve pressure on the nerves in the spine) but decided it was not appropriate for Mr A. They also noted Mr A was at high risk of death and was struggling to stay conscious.
50. Our surgical adviser said the only treatment option was surgical decompression. This would have required a transfer to the regional neurological centre. Because of Mr A’s age, pneumonia and COPD, the chance of him surviving the procedure is likely to have been low. The surgical adviser agreed with Dr A that it was not appropriate for doctors to offer surgical decompression at that stage. Dr A followed ‘Good medical practice’.
51. The stroke adviser told us doctors gave appropriate treatment for Mr A’s pneumonia. They gave him appropriate antibiotics. They also appear to have provided him with appropriate pain relief. In these respects, they followed ‘Good medical practice’.
52. In summary, we find doctors fell below the relevant standards in the following aspects of care and treatment in the AMU:
• inadequate assessment and investigation by various doctors • poor record-keeping by an unnamed doctor • incorrect prescription of tinzaparin • delay in a consultant review after admission.
Impact of failings in the AMU
53. We asked the clinical advisers to explain the impact of the failings we have identified.
54. The stroke adviser explained how the only effective treatments for Mr A’s stroke would have been timely IVT and mechanical thrombectomy. IVT must take place within four and a half hours and mechanical thrombectomy within six hours of the start of stroke symptoms. By the time Mr A had been admitted to the AMU. these timescales had passed.
55. The stroke adviser said if a consultant had reviewed Mr A within 14 hours of admission, they would have arranged a CT scan for the morning of day two of the admission. A CT scan would also have taken place sooner if the different doctors in the AMU did good assessments. They said a CT scan would have confirmed the stroke, but not the hydrocephalus, which was yet to develop.
56. The medical adviser explained the usual treatment for strokes that have happened several hours earlier is to prescribe regular aspirin to try and thin the blood. This is the treatment recommended in the NICE Guideline. The medical adviser said aspirin is very unlikely to have had any positive effect on Mr A’s health because in his opinion, Mr A’s death could not have been avoided if doctors had identified the stroke on day two of the admission.
57. Hydrocephalus is a recognised complication of a stroke. The medical adviser explained how doctors would not have been expected to consider hydrocephalus. They could not have taken any steps that would have changed the outcome for Mr A once the time limit for effective IVT had passed.
58. We asked the stroke adviser how the prescription of tinzaparin affected Mr A. They said the medication would have increased Mr A’s risk of developing haemorrhagic transformation. This happens when there is a leakage of blood into the brain. There is no evidence from the CT scan Mr A had on day two of any haemorrhagic transformation. There is no evidence the tinzaparin had any effect on Mr A’s health.
59. We cannot say poor record-keeping had any direct impact on Mr A. But it has meant there is a gap in our understanding about when events happened.
60. While we have seen potential failings in the treatment doctors gave to Mr A in the AMU, we cannot say they contributed to the decline in his health or his death. We cannot say these failings led to an injustice to Mr or Mrs A. We partly uphold this issue.
Communication
61. Mrs A complains the doctors did not contact her or her family to explain what was happening to her husband. She says a doctor called the family on day two of the admission and asked why Mr A was in hospital. The doctor gave reassurance someone would call the family after the scan but did not suggest any urgent need for them to go to the hospital. She feels if the family had visited, they could have made sure staff were fully aware of when what happened when her husband first became unwell.
62. ‘Good medical practice’ says doctors must be considerate to those close to the patient and be ‘sensitive and responsive’ in giving them information and support.
63. During the Trust’s complaint investigation Dr L remembered speaking to Mr and Mrs A in the emergency department. Although there is no specific record of the discussion, it is clear they could only have got some of the information they recorded from speaking to Mr and Mrs A. There is no evidence Dr L shared any thoughts about diagnosis or treatment with Mr A or his family, but we would not necessarily expect that information to be recorded.
64. Dr N noted he spoke to Mr A’s son at 11.05am on day two. Dr N recorded details of what Mr A’s son said about his history. By that time, doctors had diagnosed pneumonia but not the stroke. There is no evidence Dr N explained his thoughts about possible diagnoses or planned investigations or treatment. But Mr A’s son recalled being told his father had breakfast and had spoken with nurses. He also recalled Dr N saying he would give an update once the results of the CT scan were available.
65. We cannot be critical of Dr L and Dr N’s communication before the CT scan. At that stage Mr A had not developed hydrocephalus and they could not have expected that to happen. It was only after the CT scan that the seriousness of Mr A’s situation and the likelihood he would not survive would have been clear to doctors. There is no record of Dr N saying someone would call the family with the scan results, but we are persuaded by the family’s memory of what happened. Staff did not give this update.
66. There is also no evidence doctors contacted the family to alert them to the sudden deterioration in Mr A’s health around the time of the CT scan. They do not appear to have advised them what the scan showed until some hours later. The clinical records support Mr A’s family’s memory that doctors did not do enough to explain what was happening. We find doctors were not ‘sensitive and responsive’. They did not follow ‘Good medical practice’.
67. Mrs A says she and her family were not told of the urgency of the situation, and this meant they were unable to spend time with her husband when he was still conscious. They did not have an opportunity to say goodbye.
68. We are persuaded by the family’s compelling account about the lack of communication from doctors at the hospital and the impact this had. We uphold this part of the complaint.