Complaint: Trust staff initially failed to involve Dr K in his wife’s care 16. Dr K told us that when he arrived at Hillingdon Hospital, he was not taken to see Mrs L and the doctors did not speak to him. Instead, he was taken to an empty room to wait.
17. The medical records include an entry made at 7.20am of Mrs L’s background history – this is likely to have come from the ED doctor speaking with Dr K about Mrs L. An ED consultant spoke to Dr K twice during the morning. The ED consultant told him that Mrs L was to have a CT scan and after the scan explained it showed a basilar artery thrombus (a blood clot causing a form of stroke that has a high risk of death) with some blood still flowing through the artery. The ED consultant explained they planned to do a head CT angiogram and MRI scan to obtain more information about the extent of brain damage.
18. Mrs L’s medical records show another ED consultant spoke with Dr K at 12.30pm, by telephone, to tell him the outcome of discussions with other specialist doctors.
19. 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’ (Domain 3, paragraph 33). ED doctors spoke to Dr K twice in person and once by telephone.
20. Dr K was understandably concerned and distressed - he felt Trust staff were not involving him in planning his wife’s care and were not taking account of his experience as a hospital doctor. We recognise how distressing it must have been for Dr K to be in a room on his own waiting to find out what was happening to his wife. It is clear he understandably wanted, and would have welcomed, more discussions with the doctors caring for his wife.
21. We took into account the need for ED staff to balance caring for Mrs L and keeping Dr K updated and involving him in care planning. Our ED adviser said staff would prioritise patient care – and we can see the ED doctors had numerous telephone calls with other specialist doctors about Mrs L, both within and outside the Trust.
22. Dr K wanted to be involved in his wife’s care; we recognise the knowledge he had about Mrs L’s medical history. Mrs L’s medical records show an ED doctor took a background history from Dr K. Our ED adviser noted Trust ED doctors ordered relevant tests and imaging to obtain the information they needed and updated Dr K about this. It is clear the doctors were appropriately prioritising Mrs L’s care. From the evidence we have seen, Trust doctors acted in line with Good Medical Practice in relation to updating Dr K about his wife’s care. We have seen no evidence Trust doctors involved him in their contacts with staff from other Trusts – but we would not have expected them to, despite Dr K’s medical experience. We do not uphold this issue of complaint.
Complaint: Poorly interpreted Mrs L’s CT scan and failed to urgently act on the diagnosis 23. CT scans of Mrs L’s head, chest, abdomen and pelvis were done at 5.01am. A consultant radiologist reported on the CT head scan at 6.28am. The report included ‘prominent basilar artery aneurysm [a bulging, weakened area in the wall of the artery] with hyperdense segment ... Further evaluation with intra cerebral angiogram is advised. Neurosurgical opinion would be helpful’.
24. Dr K says the CT head scan radiology report does not make it clear whether the blood clot had caused complete or partial obstruction of blood flow, or whether there was a blood clot. He says it was important to know as this would have influenced Mrs L’s management.
25. A consultant radiologist reported on the CT head scan. The report noted a basilar artery aneurysm – it was unclear whether there was a dissection or blood clot. Our radiology adviser agreed – they said the high density within the artery suggested a blood clot although the dilation of the artery was possibly an underlying dissection. The reporting radiologist therefore advised that a CT angiogram should be done.
26. Trust staff discussed the CT scan results with the neurosurgery and stroke team at Trust B (which has a specialist stroke unit) who agreed with the advice in the radiology report that a CT angiogram should be done, to provide more detail about the damage caused to the brain.
27. Our radiology adviser said it was appropriate to do the CT angiogram and in line with NG128 – which says if thrombectomy might be indicated, CT contrast angiography should be done. The CT angiogram was reported at 7.56am. The consultant radiologist noted ‘… partially thrombosed [where a blood clot has formed and partially blocked blood flow] and calcified aneurysm of the basilar artery. Further input from neurosurgical team or neuroradiologist is recommended’. The ED doctors consulted the neurosurgeons at Trust A for advice, sharing the CT angiogram with them.
28. Our radiology adviser is a specialist – a consultant interventional neuroradiologist. They said the reports of the CT scan and CT angiogram were appropriate for a non-neuroradiologist in an acute setting. It was also appropriate, and in line with The Royal College of Radiologists’ Standards for interpretation and reporting of imaging investigations, that the radiologist reporting on the CT angiogram suggested further input from the neurosurgical team.
29. Our radiology adviser looked at the CT angiogram. It is their view Mrs L’s basilar aneurysm was completely blocked by a blood clot rather than the reported partial blockage.
30. Dr K is concerned inaccurate reporting of the CT angiogram would have affected his wife’s management. Based on what we have seen, this was not the case. While the report said there was a partial blockage, when it was completely blocked, Trust staff consulted neurosurgical staff, as recommended. Our radiology adviser said it was a rare case of a blood clot in what was probably a dissected artery.
31. In summary, and taking account of the advice from the ED and radiology advisers, we think that while staff accurately interpretated Mrs L’s CT head scan, they did not interpret the CT angiogram accurately. However, the reporting radiologist was not a specialist neuroradiologist and our radiology adviser said the CT angiogram was reasonably reported on, under these circumstances. The reporting radiologist appropriately recommended specialist input from neuroradiology or neurosurgery. There was no impact on Mrs L’s management.
32. We now turn to how urgently staff acted when they had the reports of the CT scan and CT angiogram. Good Medical Practice says doctors must ‘consult colleagues where appropriate’ and ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
33. Mrs L’s medical records show ED staff contacted several colleagues for advice and to facilitate Mrs L’s care. These contacts were made promptly, starting with the ED doctors contacting the neurosurgical team at Trust A once the first CT head scan report was available. They were advised to do a CT angiogram, which they promptly arranged. When the CT angiogram report became available at 7.56 am, the ED doctors contacted neurosurgeons at Trust A and then the stroke team at Trust B for advice. Mrs L’s medical records show the ED doctors continued to contact colleagues within and outside the Trust throughout the morning. We have seen no evidence that ED staff did not act appropriately or without sufficient urgency when managing Mrs L’s care.
34. We find Trust doctors acted in line with Good Medical Practice – they contacted relevant colleagues promptly when they had the scan results. Based on this, we do not uphold this issue of complaint.
Complaint: Trust staff lacked knowledge about how to manage an intubated patient for an MRI scan 35. Dr K complains Trust staff did not know Mrs L’s intubation equipment was incompatible with an MRI scanner or how to make alternative arrangements for an MRI scan.
36. Mrs L was under the care of several teams - ED, anaesthetic, intensive care and stroke. It was the stroke team that told the ED doctors that Mrs L should have an MRI scan of her brain to decide if she was a suitable candidate for mechanical thrombectomy.
37. The records show ED doctors did not know the Trust did not have facilities to do MRI scans for intubated patients. Our ED adviser said an ED doctor would not be expected to know this. It would be the anaesthetic team that would know the requirements for anaesthetic and monitoring equipment in an MRI scanner. We can see that the intensive care team did know that the Trust did not have the facilities to do an MRI scan for patients who were intubated.
38. While the intensive care team knew the Trust could not do an MRI scan on an intubated patient, there was no guidance setting out what staff should do in these circumstances. Sadly, the result of this was that Trust staff were unable to arrange an MRI scan to assess whether Mrs L was a suitable candidate for a thrombectomy.
39. The Trust acknowledged ‘Mrs … [L] was deprived of a time critical MRI scan’. It apologised to Dr K and took action to prevent the same failing happening again by establishing facilities to do MRI scans at the Trust and developing a pathway. The Trust said the failing would not have changed the sad outcome for Mrs L. We asked our neurology adviser about this. He said NG128 includes that if the time of onset of a posterior circulation stroke is more than six hours earlier, an MRI is required to check the extent of the brain damage before a thrombectomy is done.
40. Our neurology adviser said, if Mrs L had an MRI scan, been found suitable for thrombectomy and undergone the procedure, there was a chance her death could have been avoided. However, our radiology adviser said a mechanical thrombectomy would have carried a high risk of rupturing the blood vessel. He added that some interventional neuroradiologists would not have offered mechanical thrombectomy under these circumstances. Dr K told us he recognised the risk of a thrombectomy causing a rupture – but that was better than not doing the procedure and his wife having no chance at all of surviving.
41. We have no way of knowing whether an MRI scan would have shown Mrs L was suitable for a mechanical thrombectomy. However, because the Trust could not arrange an MRI scan, Mrs L lost any chance, however small, she had of treatment. This continues to distress Dr K. Because the Trust has not acknowledged the impact this has had on Dr K, we partly uphold this aspect of his complaint.
Complaint: Trust staff lacked knowledge of the protocol for referring a patient to the tertiary neuro centre 42. Dr K says Trust staff should have known that an MRI scan would be needed before referring a patient to the specialist stroke unit at Trust A.
43. Good Medical Practice says doctors should promptly arrange suitable advice, investigations or treatment where necessary, refer a patient to another practitioner when this serves the patient’s needs and consult colleagues where appropriate.
44. Having obtained Mrs L’s CT angiogram report, Trust ED staff sought advice from Trust B’s stroke team, which agreed to look at the CT scans but advised intervention was unlikely. ED staff then promptly contacted Trust A neurosurgeons who said their intervention was not needed.
45. ED staff continued to pursue a possible thrombectomy option for Mrs L and discussed the possibility of treatment with a Trust A stroke doctor. ED staff were advised a head MRI scan was required, to see if Mrs L was a suitable candidate for mechanical thrombectomy. ED staff requested an MRI scan.
46. ED staff sought specialist advice, in line with Good Medical Practice and continued to follow up on treatment options for Mrs L.
47. Although we can see this situation would have been concerning for Dr K, we would not expect Trust ED staff to be aware of the criteria required by the tertiary neuro centre for transfer of patients.
48. We have seen no evidence of any failing in this aspect of Mrs L’s care. We do not uphold this issue of complaint.
Complaint: Trust staff failed to refer Mrs L for interventional radiography 49. The ED adviser said because the Trust did not have a pre-existing pathway for MRI scans of intubated patients, ED staff had to spend a considerable amount of time trying, unsuccessfully, to facilitate appropriate care for Mrs L
50. The medical records show the ED consultant discussed Mrs L’s case with interventional radiology and neurology consultants at Trust A at some stage before 11.45am. The records also show several discussions between ED staff and specialist doctors at the Trust, Trust A and Trust B between 09.40am and 12.30pm, to try and access an MRI scan and interventional radiology (mechanical thrombectomy) for Mrs L.
51. An entry in Mrs L’s medical records at 1pm on 4 June says ‘A+E consultant confirmed following discussions pt[patient] cannot be transferred out for MRI \ [therefore] for medical management’. Based on what we have seen, Trust staff tried to refer Mrs L for a head MRI and consideration of mechanical thrombectomy – but were unsuccessful. We do not uphold this issue of complaint.
Complaint: Mrs L’s care lacked consultant input and Trust staff failed to involve Dr K in communications with Trust A 52. Dr K is concerned there was a lack of consultant-level input into his wife’s care. We considered the level of seniority of the doctors involved.
53. The ED adviser said there is no national standard or guideline setting out the level of seniority of medical staff who should be involved in a patient’s care. An ED ST5 doctor (a doctor in their 5th year of what is usually six years specialist training to be a consultant) did an initial assessment of Mrs L. An ITU registrar and medical registrar (and other more junior doctors) also examined Mrs L.
54. Mrs L’s medical records show an ED consultant was involved in later decisions about her potential transfer to Trust A, MRI scan and liaison between all the different specialties involved in Mrs L’s assessment and care.
55. Good Medical Practice says doctors must promptly provide or arrange suitable advice. Mrs L’s medical records show several consultants, from different specialisms, were involved in Mrs L’s care on 4 June: Trust radiology consultants, the neurosurgical consultant at Trust A, the stroke consultants at both Trust B and Trust A, the Neurology consultants at Trust A and Trust B, the Interventional Radiology Consultant at Trust A, the Anaesthetic and Intensive Care Consultants at the Trust.
56. Dr K complains Trust doctors failed to involve him in their communications with Trust A. We have been advised the records show ED doctors told Dr K about the results of multiple discussions with other specialities and this was appropriate.
57. We have seen no lack of senior doctor input, or a failure in communication relating to contact with other trust’s doctors. We find no failings in this aspect of Mrs L’s care. We hope this reassures Dr K that his wife was assessed by, and received care from, appropriately experienced doctors.