Assessment
18. CG176 guidelines say a CT head scan should be carried out for people aged 16 and over if they score 12 or less on the Glasgow Coma Scale (GCS) and they have had more than one episode of vomiting. The guidelines also say to do a CT scan for people aged 16 and over if they have experienced a dangerous mechanism of injury, which includes a high-speed road traffic accident either as a pedestrian, cyclist or vehicle passenger.
19. The GCS is a scale used to assess the level of consciousness of a patient who has experienced a brain injury. A person's GCS score can range from three (completely unresponsive) to 15 (responsive).
20. Ms V complains she was not properly assessed when she arrived in A&E after her accident and that she was left in A&E bleeding for three hours. Ms V says no neurological observations or assessments were done despite her telling staff she had pain in her head, neck, shoulders and chest, she was nauseous (feeling sick), had a terrible headache and was lightheaded.
21. In response to the complaint the Trust said that on admission to A&E Ms V’s observations were normal but due to the mechanism of her injury, she received an urgent review by one of the A&E consultants. It said the clinical findings of her first examination were reassuring with no concerning features of a significant head injury, fractures or internal bleeding. It also said there was nothing about her initial presentation that would have caused staff to do a CT scan of her head or chest.
22. Ms V attended A&E at 5.48pm and she was triaged at 6.06pm. The records state she had been hit by a push bike at speed and had a left sided head injury with a small three-centimetre laceration (cut) to her forehead. Ms V also had swelling to the left side of her face, her teeth were loose and she had neck pain, left hand pain, left hip pain and she was very pale.
23. The records show Ms V had an urgent review by an A&E consultant at 6.17pm with the assessment recording her as being alert, comfortable and speaking in sentences. Her CGS score was 15, suggesting full consciousness. The plan was to give her pain relief and X-ray her left hand. Ms V’s head laceration was glued and she was discharged at 9.05pm with head injury advice.
24. Ms V was still feeling nauseous the next day, her face had swelled and she had head, neck and shoulder pain. Her parents took her to the minor injuries unit and they referred her immediately to A&E at the general hospital. She arrived at 10.14pm.
25. Medical staff organised a CT scan which showed a left frontal bone fracture which extended into the left frontal sinus and suggested an open fracture. Ms V was prescribed pneumovax and co-amoxiclav (medication to treat infection), advised to rest, take regular pain relief and to follow concussion advice.
26. We got advice from our A&E adviser to better understand Ms V’s clinical situation. They said Ms V’s assessment at the Trust on 7 December fell short of the requirements for assessing a patient with a head injury. They explained the recorded first assessment did not provide enough information to decide whether a CT scan was necessary and it did not include whether she had experienced vomiting or amnesia (memory loss), in line with CG176 guidelines.
27. The records state Ms V did not suffer a loss of consciousness but do not mention vomiting. Ms V told us she did not vomit after the accident but felt very nauseous and she was given a sick bowl when she was triaged. Ms V says she is unsure if she was unconscious and does not remember being knocked out but she remembers finding herself in the road. She thinks she was possibly unconscious but not for long.
28. There are no records in Ms V’s assessment that specifically mention vomiting or amnesia which would have meant a CT scan was necessary. This lack of evidence leads us to say that Ms V did not have an appropriate assessment in line with CG176 guidelines. Because of this we cannot say whether a CT scan should have been done or not.
29. Our A&E adviser said that if a CT scan had been done on 7 December, it would have shown the skull fracture that was found when Ms V went to the general hospital. This would have led to an earlier referral for advice and ongoing management. Our A&E adviser explained that unfortunately, Ms V’s chronic symptoms would have developed even if the CT scan had been done earlier.
30. We understand why Ms V has lost confidence in the Trust. When she went to a different hospital, she had a different assessment that included a CT scan which found her skull fracture. We hope she is reassured by our findings that earlier detection of her skull fracture would not have lessened the symptoms she had.
31. The Trust apologised to Ms V for the delay in her diagnosis and said its clinical team had reflected on her case. Our Principles say when mistakes happen, public organisations should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. We considered whether the Trust had gone far enough in addressing Ms V’s concerns. Ms V got advice from a different hospital within 24 hours of visiting the Trust and had a more detailed assessment there. It is fortunate that although she was assessed as having a skull fracture, she did not need surgery.
32. We are pleased to note the failing did not affect Ms V’s treatment or recovery because she got help at another hospital within 24 hours of the first admission. But, the inconvenience of being discharged only to attend another hospital and the worry this caused could have been avoided.
33. The Trust has apologised to Ms V and acknowledged her injuries were more extensive than they had seemed during her admission to A&E. It apologised for the delay in her definitive diagnosis. It also said the clinical team had reflected on her case.
34. We do not think this goes far enough to address the failing and we are not satisfied that the Trust has taken action to prevent this happening again failings. We go on to make recommendations later in this report to address this.
Safety-netting
35. CG176 guidelines say staff should give verbal and written advice to people with any degree of head injury, when they are discharged from an emergency department or observation ward.
36. The guidelines suggest written discharge advice cards for people 16 and over with a head injury to advise them what to do within the first 24 hours after leaving hospital. The cards should also detail symptoms to be aware of including drowsiness, difficulty understanding or speaking and painful headaches.
37. Ms V complains she was not given enough advice when leaving A&E and she was sent home without understanding the severity of her injuries and what she needed to do next.
38. The Trust’s complaint response says Ms V was discharged with appropriate safety netting and she was given head injury advice verbally to get a further medical review if needed.
39. The records show Ms V was discharged at 9.06pm with a note stating, ‘no follow-up required’ and she was given verbal head injury advice. Ms V was also advised to consult a dentist for her chipped teeth.
40. Our A&E adviser said Ms V should have received written head injury advice when she was discharged, in line with CG176 guidelines. Ms V may not have been in a position to take in verbal information on head injuries even though she had a friend with her. It would have been useful for her to have a written discharge card so she knew what to do if her symptoms got worse.
41. There is no evidence in the records that Ms V was given written advice and the Trust also confirmed she was given verbal advice only.
42. We find there is a failing here in the follow-up advice Ms V was given when discharged from the Trust. We understand it would have been important for Ms V to understand what she needed to do if her symptoms got worse. This caused her worry and uncertainty after what had already been a traumatic time. In line with CG176 guidelines she should have received written advice.