17. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something went wrong. We have explained our reasons below.
Damaged nerves
18. Ms A says she feels like the doctor damaged her nerves when doing the lumbar puncture on 19 July, which has led to her experiencing continuing symptoms. She says she complained of electric shock pains during the lumbar puncture, but the clinician continued and said it was normal. After the procedure, she says she experienced severe pain in her head which made her feel like her head ‘was going to explode’.
19. The Trust says there is no evidence anything went wrong during the procedure and the records show there were no complications at the time.
20. Our adviser says there are no nationally endorsed guidelines on lumbar punctures, but the NIH has published some guidance. The NIH guidelines on lumbar punctures say:
• use 25G atraumatic needles • there should be no more than four attempts • allow passive withdrawal of CSF • collection of up to 30ml of CSF is well tolerated and safe • the patient should be in the lateral recumbent position (on their side).
21. The NIH guidance also says some of the risk factors for post-lumbar puncture complications are females under 40 years of age, patients with a history of headache, and people with a fear of post-lumbar puncture complications.
22. The treating doctor completed the consent process with Ms A before the procedure and noted the potential risks. The doctor also noted there was a long discussion with Ms A about the reasons for the lumbar puncture, potential complications and the tests that can be done using CSF. The notes say ‘CSF obtained. clear and colourless’.
23. We can see from the notes that the treating doctor explained the procedure to Ms A, gave appropriate local anaesthetic and dd the procedure uneventfully. Our adviser says although the treating doctor did not record the type of needle, the number of attempts and volume of CSF taken, his notes from that time say there were ‘no complications’ and ‘patient well throughout’. Thirty minutes after the lumbar puncture Ms A's early warning score was recorded as zero, which does not suggest she was physically unwell at this time.
24. We are very sorry to hear Ms A experienced pain during and after her lumbar puncture and we do not discount her version of what happened. Although we cannot be certain if Ms A did report that she was experiencing pain, the records do not suggest that anything went wrong during the procedure causing damage to her nerves. Our adviser says there is no evidence Ms A’s lumbar puncture management was inappropriate and inconsistent with the guidelines. We do not consider there are any signs of maladministration (fault).
Aftercare
25. Ms A says staff allowed her to go home straight away after the lumbar puncture, when they should have told her to lie down for one to two hours. She says the doctor left the room after the procedure and shortly after the nurse said she was free to go. She says she went home and felt very unwell. She says she was vomiting a lot all night and she was holding the back of her head because it felt like she was being electrocuted.
26. The Trust says the treating doctor assessed Ms A 30 minutes after the lumbar puncture and she was clinically stable. It says all of Ms A’s vital signs were in normal range.
27. The notes say Ms A’s early warning score was recorded as zero, 30 minutes after the procedure and ‘patient discharged home’. Early warning scores record measurements such as temperature, heart rate and respiration rate. A score of zero means there is a low clinical risk.
28. The NIH guidelines say bed rest after a lumbar puncture does not affect the likelihood of post-lumbar puncture headache, and there are no specific recommendations on aftercare.
29. As the notes suggest Ms A had no complications from the procedure and her vital signs were in the normal range 30 minutes after, our adviser says allowing her to go home was reasonable, and her aftercare was appropriate. We cannot see any signs something went wrong here.
Admission
30. Ms A says she went to hospital on 22 July 2022 because she continued to experience severe pain and vomiting. She says doctors did not do a blood patch test to investigate if she had a CSF leak. A blood patch test is a medical procedure that is used to close CSF leaks.
31. The Trust says there was no clinical indication to carry out a blood patch. It says it was likely Ms A was experiencing a severe form of post-puncture headache, but there was no clinical evidence of a CSF leak. It says it is unlikely the lumbar puncture resulted in any serious complications, particularly as some of the reported symptoms were there before the procedure. It says its impression is that Ms A is experiencing neuralgia (nerve pain) and the consultant referred Ms A to another hospital at her request.
32. The notes show Ms A went to A&E on 22 July 2022. The clerking doctor noted Ms A reported having developed severe headaches and neck and shoulder pain after the lumbar puncture and she ‘wants to have a blood patch’. Staff admitted Ms A to a ward.
33. The Trust discharged Ms A on 25 July 2022. The discharge summary says there were no complaints of neurology and no neurology found on examination. The recorded diagnosis was post-puncture headache and ‘symptoms more in keeping with a non- organic pathology’. The notes say they discharged Ms A with advice to go back to hospital if her symptoms got worse and they would follow up with the neurologist for review.
34. Our adviser explains lumbar puncture headache is caused by low CSF pressure which usually resolves in a few days. Medical journal article, ‘Post dural puncture headache’, says persistent headache can be a sign of on-going leakage of CSF from the dural puncture site. CSF leakage is characterised by headache, usually associated with nausea which is worse on standing or sitting up and feels better when lying down. In Ms A’s case, she reported a headache associated with nausea but did not report that it worsened when standing or sitting.
35. Headaches associated with low CSF pressure after a lumbar puncture usually resolve within 72 hours. Our adviser says it was reasonable for the treating clinicians to wait and see if the headache got better on its own. There was no sign that persistent leak of CSF was causing the headache or that the headache would respond to a blood patch. Other types of headache can happen coincidentally after a lumbar puncture. By the time Ms A saw the consultant neurologist on 16 August, she reported her headache had changed to shooting pains across her neck, which our adviser explains does not suggest a lumbar puncture headache.
36. Our adviser says Ms A’s associated symptoms of and electric feeling in her spine and genital numbness do not suggest an underlying physical neurological disorder and it was reasonable for the Trust clinicians not to do a blood patch. Our adviser says if a blood patch had been attempted, it would not have helped Ms A’s clinical condition.
37. We are very sorry to hear about what Ms A has experienced. After looking at the available evidence, we do not consider there are any signs the clinicians got something wrong when they declined to do a blood patch test during her admission.