Insufficient examination
15. Mr T says when he visited A&E on 19 August 2022, he was not examined sufficiently for a diagnosis, and he wasn’t given the appropriate treatment.
16. Mr T says he asked the registrar if they could help him. Mr T says the doctor gave him the briefest of examinations and he feels the doctor could not have assessed him properly. He says the registrar ‘wiped his finger across {his} head’ and said, ‘I have examined you’. Mr T says the registrar said he could go get a leaflet, but the registrar felt Mr T would already be familiar with it. Mr T says he felt laughed at and not taken seriously. Mr T says he felt upset when he read in the Trust’s complaint response, he had refused advice and reassurance. He says his impression of the Registrars consultation was that it was over before he had to leave due to anxiety about the police.
17. Mr T agreed the doctor told him the symptoms he described sometime happened with a head injury and may take months to clear.
18. The Trust complaint response reflects the timeline of events above. It says the registrar regrets Mr T feeling not listened to during the consultation. It says the registrar was not able to offer all the guidance they would have liked as the consultation ended due to the police presence and Mr Stokers anxiety.
19. Mr T’s medical records show he attended the Trust emergency department at 3pm on 19 August 2022 following a referral from NHS 111. Mr T told the clinician he had fainted at home roughly 7 weeks early. He said he had banged his head and lost consciousness. Since then, he had been suffering with headaches not helped by over-the-counter painkillers and was vomiting most days including that day. He had been taking painkillers to little effect. He said he had also been using magic mushrooms and cannabis to help with the pain and had bought some fentanyl. The clinician advised him against using the fentanyl. Mr T has told he us he disputes admitting buying fentanyl but had told the clinician he had considered it.
20. Mr T told us he expected some in depth investigation with x-rays or CT scans followed by a prescription for pain relief.
21. The ED clinician took notes of the recent history leading to Mr Stokers ED visit. The ED GP recorded his initial observations of Mr T having slight swelling over a third of the left eyebrow with tenderness. The ED GP noted Mr Stoker’s forehead initially appeared to have reduced wrinkling, but he could raise both eyebrows equally.
22. The ED GP recommended to Mr T the A&E team review him as he may require imaging, generally X-ray, CT scan or MRI. Mr T was reluctant and anxious as he had bad experiences in A&E in the past. The ED GP discussed the situation with an A&E registrar who agreed to see Mr T under ‘urgent care’ to decide on further management.
23. Mr T told the registrar since the head injury occurred, he had symptoms of short temper, a struggle to focus, visual disturbances, and feeling anxious. Mr T told the registrar he had vomited a few times although not for a few weeks. He also told the registrar he had spoken to several health professionals including the paramedics who had attended him on the day of his accident. They all told him to attend the emergency department. Mr T told the registrar he was wary of A&E and the police.
24. The registrar noted Mr Stoker’s prior medical history of autism, depression, and anxiety. The registrar’s note of the examination says there was no tenderness over the left front area with nothing to see. Mr Stoker’s neurological function seemed intact with a Glasgow Coma Score (GCS)of 15. CGS is a practical tool for assessing levels of consciousness. 15 is the best result and indicates Mr T was fully responsive and unimpaired, with no loss of function.
25. The registrar noted Mr T refused an information leaflet. The registrar recorded Mr T ended the consultation when police arrived for another incident. Mr T says his impression was the consultation had finished as the registrar had wrapped up what they wanted to say. We think the assessment had finished as the registrar’s notes indicate their plan was to reassure, educate, and advise about the diagnosis of post-concussion syndrome.
26. The GMC guidance, Paragraph 7 says in providing clinical care a doctor must: • adequately assess a patient’s condition(s), taking account of their history, including • symptoms • relevant psychological, spiritual, social, economic, and cultural factors • the patient’s views, needs, and values • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation, or treatment where necessary • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • propose, provide or prescribe effective treatment based on the best available evidence • follow our more detailed guidance on professional standards, ‘Good practice in prescribing and managing medicines and devices’, if you prescribe • consult colleagues or seek advice from your supervising clinician, where appropriate • refer a patient to another suitably qualified practitioner when this serves their needs.
27. In the NICE guidance recommends a CT head scan should be considered within one hour of the below risk factors being identified: • a GCS score of 12 or less on initial assessment in the emergency department • a GCS score of less than 15 at 2 hours after the injury on assessment in the emergency department • suspected open or depressed skull fracture • any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign) • post-traumatic seizure • focal neurological deficit • more than 1 episode of vomiting.
28. For a patient who lost consciousness as a result of the head injury a CT head scan should be given within eight hours of the injury. If more than eight hours after the injury, a CT scan should be done within one hour for someone identified with the following risk factors: • age 65 or over • any current bleeding or clotting disorders • dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of more than 1 m or 5 stairs) •more than 30 minutes' retrograde amnesia of events immediately before the head injury.
29. The NICE guidance says certain actions must be taken if the patient presents with a Glasgow coma score (GCS) below 15. It also says clinicians should manage pain effectively to prevent any rise in intercranial pressure, and to provide reassurance.
30. We can see from the GMC guidance the clinicians should have taken any information and observations they needed to make a diagnosis. As the NICE guidance gives specific indicators for a serious head injury, we would reasonably expect a clinician to consider those factors as part of an examination and assessment. We have seen evidence the clinician considered Mr T’s history, presentation and conducted an assessment of him. Our adviser told us the clinicians appropriately considered these factors which allowed them to make the statements about his neurological condition and his GCS score.
31. Our adviser told us Mr T presented to the ED seven weeks after his injury so any serious repercussions from Mr Stokers head injury would have become apparent before then. NICE guidance states clinicians should decide on whether further investigation would be needed dependent upon their observations and clinical judgement.
32. As Mr T presented to the ED more than eight hours after his injury NICE guidance was relevant to Mr T’s presentation. The NICE guidance says a clinician should consider several risk factors and obtain a head CT if any of the risks apply. The listed risks are: • a GCS score of 12 or less on initial assessment in the emergency department • a GCS score of less than 15 at 2 hours after the injury on assessment in the emergency department • suspected open or depressed skull fracture • any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign) • post-traumatic seizure • focal neurological deficit • more than 1 episode of vomiting.
33. We can see from the records Mr T potentially only had one risk factor in that he may have had more than one episode of vomiting.
34. We can see in the records Mr T told the first clinician he had been vomiting most days including that day. However, Mr T told the second clinician he had vomited a few times although not for a few weeks. Mr T also told the clinicians he had been using magic mushrooms and cannabis.
35. We can see the side effects listed for these drugs from the ‘Talk to Frank’ website. The side effects for these drugs overlap with many of the symptoms of post-concussion syndrome given in the South Tees Trust guidance leaflet. Contrary to Mr Stokers belief, these drugs could have made his post-concussion symptoms worse. As specific side effects for both of these drugs are dizziness or a feeling for a need to vomit it seems likely the clinicians may not have given much weight to this single symptom, especially given Mr Stokers contradictory statements and the length of time since the injury.
36. In line with NICE guidance, we can see there was no requirement for the clinician to consider a CT scan because; the examination was more than eight hours after the injury, Mr T was under 65 years old, did not have any bleeding or clotting disorders, did not have a dangerous mechanism of injury, and did not report any amnesia.
37. While the registrar may not have told Mr T the diagnosis of post-concussion syndrome, the description they gave matches the description of post-concussion syndrome.
38. As we have not identified any indications of failings, we will not consider this complaint for further investigation.
39. We are grateful to Mr T for bringing his complaint to our attention. We hope we have been able to reassure him that no significant failings occurred when the Trust A&E department examined and treated him.