4. Mrs X is unhappy that the Trust did not allow her to accompany her husband when he went to A&E on 22 June 2021 and did not discuss his symptoms with her.
5. As a result of the Trust’s treatment of Mr X, it took another 24 hours before it diagnosed him with a stroke. Mrs X said he now has short-term memory loss, weakness in his right side, personality changes and fatigue.
6. Mrs X would like a financial payment.
7. According to the records, Mr X told the Trust during his assessment that his stroke symptoms started on 21 June 2021.
8. On 22 June, Mrs X said Mr X was confused and disorientated. He had slurred and garbled speech and poor balance. She contacted the 111 service and it advised Mr X to go to A&E at the Trust. She took him to the Trust after the call.
9. On arrival, a Trust nurse told Mrs X she could not accompany Mr X into the hospital due to COVID-19 restrictions. Mrs X explained to the nurse that Mr X was confused and would not be able to explain the problems he was experiencing to a doctor. But they still would not allow her to join him. Mrs X reluctantly left Mr X at the hospital. She said the nurse told her Mr X could be waiting two to six hours before he was seen by a doctor. They reassured her that the Trust would contact her by phone after a clinician had seen Mr X.
10. Mr X said he remembers sitting down and waiting for someone at the Trust to see him. He told us he was seen by the Trust’s triage team, who completed a quick physical examination. He then saw a junior doctor who directed him to Dr Y, an emergency department doctor. He said Dr Y interviewed him but did not ask him many questions about his symptoms and did not complete a physical examination. Mr X felt Dr Y wanted to get rid of him.
11. Dr Y said Mr X walked into the emergency department with a one-day history of memory issues, ‘not feeling quite right’ and ‘struggling to get words out’. Dr Y’s triage assessment concluded that Mr X had symptoms of intermittent (on and off) confusion, problems speaking and fatigue. Dr Y did not diagnose Mr X with a stroke, as they felt they had a good conversation with Mr X and were reassured by this.
12. The documented triage record says Mr X had ‘problems with [his] eyesight…blurred vision…people commenting that his speech is different…struggling to say the words out that he means…patient states he feels confused…had weakness yesterday’. Dr Y decided Mr X did not have a stroke.
13. The Trust said it did talk to Mr X about how he was going to get home and he said he would call Mrs X. Neither the Trust nor Mr X called Mrs X before he left. Mr X called Mrs X after he had left and Mrs X found him trying to leave the hospital grounds by himself.
14. On the drive home, Mrs X said Mr X was very confused. She said he was asking about his deceased parents.
15. After the appointment, Mr X was not able tell Mrs X what had happened so she checked with the hospital to see if a doctor had seen him. It told her he had been seen and it had not arranged a follow-up appointment.
16. The next day, Mr X’s health did not improve. His GP called to check on his hospital visit. Mrs X explained what happened and Mr X’s symptoms. The GP advised them to call an ambulance immediately. Mrs X went back to hospital with Mr X. After eight hours and a CT scan, the Trust told them Mr X had suffered a stroke.
22. The events happened during the COVID-19 pandemic, when society and the public were taking precautions to make sure of everyone’s safety. We can appreciate that hospitals were restricting visitors to reduce the chance of staff or patients catching COVID-19.
23. The GMC guidance says if a patient’s family member wishes to support the Trust with the care it gives to a patient, doctors should be considerate of this. There are many ways doctors could allow those close to a patient to support the patient, and this does not mean they have to be physically with the patient. For example, they could communicate with the patient or doctor over the phone.
24. GMC guidance also says doctors have a responsibility to make sure their assessments are of a good standard and that they provide suitable advice or treatment for patients. These findings should then be recorded.
25. In this case, Mr X was having a stroke. A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off. The main symptoms of a stroke are the face dropping on one side, limb weakness and slurred or garbled speech.
26. Strokes are classed as a medical emergency and urgent treatment is essential. The NICE guidance says the sooner a patient has stroke treatment, the less damage is likely to happen.
27. NICE says that when assessing a patient for a suspected stroke, doctors should use FAST (face, arm, speech test) to assess a patient who has a sudden onset of neurological symptoms.
28. Doctors also need to consider if a patient is at high risk of getting a stroke. For example, if a patient has a history of diabetes, this means they are at risk of a stroke. The NLM guidance says diabetes causes various changes to the body’s blood vessels that can result in a stroke.
29. The treatment depends on the type of stroke, including which part of the brain is affected and what caused it. They are usually treated with medicine and, in some cases, can be treated with procedures to remove blood clots.
30. NICE says doctors should consider a patient’s overall clinical status and the extent of dead brain tissue from initial brain scanning to inform whether they should treat a stroke patient with intravenous thrombolysis (IVT).
31. IVT is a form of therapy where a clinician injects a patient with a chemical to dissolve dangerous blood clots in their blood vessels. Clinicians, particularly stroke physicians, are cautious about giving IVT, as it carries a risk of death and does not stop the patient from having another stroke.
32. If a doctor decides IVT treatment is appropriate, they should start the treatment as soon as possible and within four and a half hours of the start of stroke symptoms.
33. The NHS website on strokes says aspirin is another form of stroke treatment, as it is an antiplatelet medication. This means it reduces the chance of another clot forming by thinning the blood. But it is also important to note that it is not immediately effective.
34. NICE says doctors should offer stroke patients aspirin treatment as soon as possible, but certainly within 24 hours. If given within 48 hours of the start of stroke symptoms, aspirin treatment could still improve a patient’s outcome compared to no treatment at all. It can be given either with IVT or as an alternative.
Mrs X’s input into Mr X’s symptoms
35. Mrs X complains the Trust did not allow her to stay with Mr X when he went to hospital. She believes this stopped it from finding he had a stroke and meant he had to live with the stroke for another 24 hours before it was finally diagnosed. She argues that she was better placed to explain what was happening to Mr X because he was too confused to explain this to a doctor.
36. In response to this, the Trust explained that it could not allow Mrs X to stay with Mr X due to national guidance at the time, and visits were at the discretion of the senior sister or charge nurse. It stands by its decision to not let Mrs X enter with Mr X.
37. But the Trust still thinks Dr Y should have spoken to Mrs X to understand the extent of Mr X’s confusion, as this may not have been clear to Dr Y as someone who did not know Mr X well. Looking back, the Trust feels Dr Y would have diagnosed Mr X with a stroke on 22 June 2021 if they had spoken to Mrs X and got more information from her.
38. Our A&E adviser said it was essential for the Trust to speak to Mrs X to understand Mr X’s confusion and to provide ‘safety-netting information’. Safety-netting information is what actions to take if the patient’s condition fails to improve or changes.
39. Mrs X had made it clear to the Trust that Mr X was confused, which would mean any information he communicated to the doctors may not be reliable. Mrs X knew him better than the doctors and was better placed to explain what was different in his behaviour. The Trust could have communicated with Mrs X by phone.
40. We can see the Trust was dealing with symptoms it could not explain and Mrs X was offering to shed some light on this. The Trust lost the opportunity to understand what was happening to Mr X.
41. It was a failing that the Trust did not engage with Mrs X and assess Mr X in line with GMC guidance.
Dr Y’s assessment
42. We have decided to also investigate how the Trust assessed and diagnosed Mr X. This is because our A&E adviser found issues with the assessment itself. Mrs X will not have been aware of this issue when she brought her complaint to us. Also, it is clear she is concerned about the diagnosis.
43. In the Trust’s responses it explained that stroke treatment is time critical and can only be given within a few hours of the start of stroke symptoms. If treatment is given after six hours, it said it is of no benefit and may even cause the patient harm. It said Mr X presented with stroke symptoms one day before he went to A&E on 22 June 2021. It says stroke management was not suitable because too much time had already passed.
44. It apologised for the delay in diagnosing Mr X with a stroke. It explained that Dr Y found Mr X had a one-day history of memory issues. They felt Mr X had no clear deficits and there was no evidence of a stroke. They diagnosed Mr X with intermittent confusion, problem seeking and fatigue. Dr Y told the Trust they felt they had a good conversation with Mr X and were reassured by this.
45. Our A&E adviser felt that Dr Y’s neurological examination of Mr X was limited. The written notes state that Dr Y completed a FAST check and the results were negative for a stroke. While the FAST assessment is correct and in line with NICE guidance, we would expect Dr Y to consider Mr X’s symptoms of slurred or garbled speech and weakness. Considering these symptoms, and the fact that Mr X had a history of diabetes, which made him at high risk of a stroke, we would have expected Dr Y to consider this carefully and either speak to Mrs X or arrange for an examination by a stroke specialist. But there is no mention of Mr X’s history of diabetes in the Trust’s records. We agree with our A&E adviser that the assessment does seem to be limited.
46. Also, the handwritten notes are confusing to read and it seems that Dr Y refers to another patient in Mr X’s medical notes. He writes about Mr X falling over while holding his daughter on a bike and checking him for a head injury. Mrs X was also confused about this and thinks the Trust must have been talking about another patient. This evidence adds to our view that the assessment was not done properly and the notes were not in line with GMC guidance.
47. Our A&E adviser said Dr Y’s assessment did not justify a working diagnosis of ‘not a stroke’. They highlighted how Dr Y did not offer an alternative explanation for Mr X’s symptoms, which is not in line with GMC guidance. Our A&E adviser said Dr Y should have got more information if they did not have enough to make a positive working diagnosis. This did not happen.
48. There are signs of a failing in the way the Trust did Mr X’s assessment. Next, we consider whether this failing caused an impact.
Impact 49. Mrs X says Mr X had another stroke and now has short-term memory loss, weakness in his right side, personality changes and fatigue. She feels the Trust could have prevented these symptoms if it assessed him properly on 22 June 2021.
50. Our A&E adviser said it is clear that Mr X missed the first window for treatment, which is four to six hours after a stroke. This is the window where a Trust can treat a stroke and prevent or reduce the impact. Within this window, hospitals would usually use clot-busting drugs like intravenous thrombolysis, or thrombectomy to dissolve or remove the clot causing the stroke.
51. They said there is a slim chance the stroke-affected part of the brain can survive outside of the treatment window. But this depends on how much blood is getting to the affected part of the brain. They explained that it is possible the Trust could have reduced the risk to Mr X, or reduced the impact, if it had started to give Mr X aspirin on 22 June.
52. It is possible that this could have made no or little difference. But it is also possible that there was an opportunity for a better outcome.
53. We next spoke to our stroke adviser for advice.
54. They agreed with our A&E adviser and said there was a small chance that Mr X had another episode of stroke between 22 and 23 June. The chance of this is increased by the fact that he returned to the Trust with persisting symptoms on 23 June. They said this may have been avoided had the Trust given him stroke-preventative treatment.
55. They said there was not a window for IVT treatment but there was a window for medication, had the Trust investigated his symptoms to assess the future risks. Medical treatments like antiplatelet or statins (a class of medications that can lower your cholesterol and reduce your risk of heart disease and stroke) could have been given. There is no record that the Trust did any of this on 22 June.
56. We can appreciate it would have been distressing for Mr and Mrs X that he had worrying symptoms they felt the Trust had not assessed properly.
57. In conclusion, we cannot say with certainty that the Trust’s failings caused Mr X to have another stroke, or for his stroke symptoms to get worse. But we can say with certainty that the Trust missed an opportunity to reduce Mr X’s stroke symptoms and he lost the opportunity for a better outcome.
1. We partly uphold this complaint because we agree there are failings in the way University Hospitals of North Midlands NHS Trust (the Trust) assessed Mr X for a stroke. But there is not enough evidence to say Mr X’s stroke symptoms could have been completely avoided had the Trust assessed him properly on 22 June 2021.
2. We recommend the Trust pay Mr and Mrs X £950 for the missed opportunity to improve Mr X’s outcome and the distress they both experienced as a result of its poor assessment.
3. We appreciate why this complaint is important to Mr and Mrs X and we explain our decision in detail below.
58. 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.
59. They say that organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.
60. To decide on an amount of financial payment, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. After this review, we recommend that the Trust pays Mr X £950 in recognition of his distress and his loss of opportunity for a better outcome.