4. Mrs W complains about the Trust’s treatment on 12 September 2021 when she had stroke-like symptoms. She complains the Trust: • wrongly discharged her despite her symptoms • did not investigate her symptoms properly.
5. Mrs W says her life has been drastically changed by an incorrect diagnosis. She says her speech has been affected and she has had to change her job. She says it caused her a lot of distress.
6. Mrs W wants a financial payment to recognise her pain, distress and inconvenience.
7. Mrs W went to the ED on 12 September 2021 with loss of feeling in her left arm and weakness in her left leg. She entered the hospital in a wheelchair. A junior doctor examined Mrs W. She struggled to walk because of problems with her left leg. The doctor diagnosed her with ‘Saturday night palsy’ or neuropraxia, which is numbing caused by sleeping on a body part in an unusual way. The Trust discharged her home.
8. Mrs W found that her condition had not improved so went back to the ED on 14 September. Staff did a CT scan (to get detailed images of the inside of the body) and found she had basal ganglia bleed and lacunar infract, which is a lack of oxygen to the brain cells. The Trust admitted her to a stroke unit.
9. A consultant physician reviewed Mrs W the next day and found she could walk with a walking stick. She also had some aching in her left arm. Ward staff examined her on 16 September and found she had equal power in all four limbs. They ordered an MRI scan and prescribed her aspirin, clopidogrel and atorvastatin. Aspirin is prescribed to treat strokes, clopidogrel is a medication that prevents blood clots and atorvastatin lowers cholesterol and reduces risk of heart and blood vessel disease.
10. The MRI scan found suggestions of an acute ischaemic infarct. This is a stroke where part of the brain is damaged due to lack of blood or oxygen caused by a blood clot. There was no evidence of a haemorrhage, where a blood vessel ruptures allowing blood to escape and cause a stroke.
11. The Trust discharged Mrs W on 17 September.
15. Mrs W complains the Trust did not investigate her symptoms correctly when she went to the ED on 12 September 2021. She also complains it did not investigate her condition properly and incorrectly discharged her on the same day. Given the fact that she was later diagnosed with a stroke it is understandable that she thinks something must have gone wrong.
16. Mrs W was struggling to walk on her left leg, her left arm felt heavy and she had tingling on the left side of her lip and chin. The examination notes said Mrs W’s symptoms were resolving, meaning they were ongoing but milder. The Trust discharged her with a diagnosis of neuropraxia, which is short term injury to a nerve. The Trust said her symptoms could be due to her sleeping on a makeshift bed which she had told staff about during her assessment.
17. Our physician adviser said based on the symptoms Mrs W had, the ED should have done a FAST assessment. The main symptoms of stroke can be remembered with the word ‘FAST’: • face – the face may have dropped on one side, the person may not be able to smile, or their mouth or eye may have dropped • arms – the person with suspected stroke may not be able to lift both arms and keep them there because of weakness or numbness in one arm • speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what is said to them • time – it is time to dial 999 immediately if you see any of these signs or symptoms.
18. Mrs W had loss of power in her leg and arm, one of the above symptoms. Our physician adviser explained this meant she was ‘FAST positive’. The records noted Mrs W told the Trust she had a lack of feeling in her left arm and leg and also had tingling on the left side of her mouth. These are all signs that she should be considered FAST positive.
19. The ED doctor noted they did a FAST assessment but did not find Mrs W to be FAST positive and instead diagnosed neuropraxia. NICE guidelines for stroke say to suspect a stroke if a patient has one or more from: facial weakness, arm or leg weakness or speech disturbance. Mrs W had two of these symptoms with both facial and leg/arm weakness.
20. This evidence shows us the Trust failed to take the right action and identify the stroke.
21. The National Clinical Guideline for Stroke says patients with suspected stroke should be admitted directly to a hyperacute stroke service and be assessed for emergency stroke treatments by a specialist clinician, without delay.
22. NICE guidance on stroke diagnosis and initial management says:
• to offer aspirin (300 mg daily) to be started immediately • refer immediately for specialist assessment and investigation • to be seen within 24 hours of when the symptoms started • admit everyone with suspected stroke directly to a specialist acute stroke unit after initial assessment for a scan.
23. Our physician adviser said if Mrs W had been considered FAST positive on 12 September she should have been admitted to an acute stroke unit, given 300mg of aspirin and given a CT scan. This would have put Mrs W on the acute stroke pathway. They also said in their experience a diagnosis of neuropraxia should only be made if a stroke has already been eliminated as a potential option. This is because the most serious possibilities should be eliminated first.
24. The Trust did not do this and instead chose to discharge her. From this we can see the Trust failed to properly investigate Mrs W’s symptoms and so incorrectly discharged her. This is a failing. The Trust has admitted this failing in its response to Mrs W’s complaint.
25. To decide on the impact of this failing, we considered what should have happened.
26. The medical records show that when Mrs W returned to the ED on 14 September, she was admitted to a stroke ward, given 300mg of aspirin and the Trust did a CT scan. This followed the guidelines set out above, but this should have been done on Mrs W’s first visit to the ED two days earlier.
27. The CT scan showed there was a ‘lacunar infract on the right basal ganglia’ which is a sign of a stroke. This means there was a blockage in the blood vessels in the right side of Mrs W’s brain.
28. Mrs W told us she believes the Trust’s actions have caused her problems with her speech and her mobility due to long term effects on her left leg.
29. Our physician adviser said that while earlier treatment could have potentially reduced the long term effects on her health, they could not be certain that this would be the case. Unfortunately, it is not possible for us to make a direct link between what the Trust got wrong and Mrs W’s long term health condition.
30. We cannot be certain that if Mrs W had been offered treatment when she first went to the ED, that the long term effects on her speech and mobility would have been avoided. But we can see that Mrs W was denied an opportunity for a better outcome. The Trust has accepted this but has not taken action to address it. Below, we make recommendations to put this right.
1. We are very sorry to hear about Mrs W’s distressing experience when she was an inpatient at George Eliot Hospital NHS Trust (the Trust). We hope our final report will help to explain what happened.
2. We have found the Trust got things wrong when discharging her from the emergency department (ED) and not investigating her symptoms properly. We uphold this complaint.
3. The Trust has not acknowledged these failings. We recommend that the Trust writes to Mrs W to accept these failings, apologises and pays her £750. We also recommend the Trust writes an action plan to show how it will learn and improve.
31. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.
32. We recommend the Trust writes to Mrs W to acknowledge the failings found. It should apologise for the distress this caused her and the possible impact this might have had on her condition.
33. Our Principles say that organisations should put things right and, if possible return the person affected to the position they would have been in the poor service had not happened. If that is not possible, they should compensate them appropriately.
34. To decide on a level of financial payment, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. We recommend that the organisation pays Mrs W £750 in recognition of the fact it caused her undue stress and pain between 12 and 14 September and for the long term distress caused by not knowing if she could have had a better outcome.
35. Our Principles say that organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat mistakes.
36. In line with this, we recommend the Trust writes an action plan to identify how it will learn and improve. It should include who is responsible for the action, the timescale for completing the action and how it will be monitored to make sure there are improvements.
37. We uphold this complaint as we have seen the Trust got Mrs W’s discharge and diagnosis wrong and it has not put this right. We hope that our recommendations go some way to put right what the Trust got wrong. We hope she is reassured by our findings and recommendations and is satisfied that her complaint has been taken seriously and will bring about changes at the Trust for future patients. We wish her well in the future.