Diagnosis 12. Mrs A complains the Trust mis-diagnosed her with a post-coital headache during her admission for headache symptoms in late October to early November 2023. She says she has since received a private diagnosis which shows she has inflammation of the brain lining thought to be due to the covid vaccine.
13. NICE guidance on the diagnosis of headaches, say clinicians should evaluate people who present with a headache and any features such as a sudden-onset headache reaching maximum intensity within five minutes, a headache triggered by exercise, new-onset neurological deficit, new-onset cognitive dysfunction, changes in personality, or impaired level of consciousness and consider the need for further investigations and/ or referral.
14. It also says chronic migraine and chronic tension-type headache commonly overlap and that if there are any features of migraine, diagnose chronic migraine.
15. We have seen evidence in the medical records, Mrs A attended the ED in late October with a sudden onset headache which had started the night before, immediately after sex. The Trust admitted her for further investigations which included a computed tomography (CT) scan and blood tests, which both came back normal. It managed Mrs A’s pain during this admission and discharged her home once her symptoms had settled, safety netting her with anti-inflammatory medication should the headache return.
16. Our consultant adviser explained the term post-coital headache is a descriptive term rather than a diagnosis and Mrs A received acute treatment for migraine during her admission.
17. We therefore consider the Trust acted in line with NICE guidance during Mrs A’s initial attendance for an acute headache. This is because it evaluated her presenting symptoms, arranged further investigations, and admitted her under the care of a consultant. It also discharged her with advice and medication once the headache resolved.
18. We were sorry to hear Mrs A required further medical attention for worsening symptoms relating to her headache and we recognise how frustrating this would have been for her. We hope to reassure her that we have not found the Trust got anything wrong in its actions during her first admission relating to her presenting symptoms and we will therefore take no further action with this part of the complaint.
Privacy 19. Mrs A complains the Trust checked her for bedsores during the same admission. She says this process was both unnecessary and undignified.
20. NICE guidance on the prevention and management of pressure ulcers says clinicians should be aware that all patients are potentially at risk of developing a pressure ulcer and staff should carry out and document an assessment of pressure ulcer risk for all adults admitted. The NMC, the code says nurses should respect, support and document a person’s right to accept or refuse care and treatment.
21. We have seen evidence the Trust checked Mrs A’s skin once, on admission using the waterlow (a pressure ulcer risk assessment tool). This was in line with NICE guidance which says a Trust should complete an assessment when it admits an adult for NHS care.
22. Our nurse adviser explained the Trust noted Mrs A had full capacity and was able to decline or accept a skin check. They went on to explain that consent for skin checks is verbal, and nursing documentation will only show if a person has declined such an intervention. The records do not show that Mrs A declined any nursing care offered to her.
23. We therefore consider the Trust acted in line with relevant guidance when considering the management and prevention of pressure ulcers for Mrs A and gained her consent to do so. We were sorry to hear how this process made Mrs A feel. We hope to reassure her that we have not found the Trust got anything wrong in its actions in relation to this and we will therefore take no further action with this part of the complaint.
Drugs/Medication 24. Mrs A complains that during her ED admission, the Trust incorrectly gave her sumatriptan medication for her headache which she says made her symptoms worse.
25. NICE guidance on sumatriptan says a clinician should use the medication initially to treat an acute migraine with a 50 to 100 mg for one dose, followed by 50 to 100 mg after at least two hours but only if migraine recurs.
26. The records show the Trust gave Mrs A sumatriptan to treat an acute migraine during her ED attendance. Our consultant adviser explained contraindications (when it may be harmful) to this medication include high blood pressure.
27. There were occasions during the admission, where Mrs A had high blood pressure, which we can see the Trust managed by administering amlodipine (a medication to treat high blood pressure). The Trust also administered only one dose of sumatriptan to Mrs A during her admission as it noted her headache subsided following this dose.
28. We therefore consider the Trust acted in line with NICE guidance when it considered administering sumatriptan to Mrs A to treat an acute migraine during her admission. We hope to reassure her that the Trust managed her symptoms during this time. We were pleased to see her pain subsided following this action taken by the Trust and we will therefore take no further action with this part of the complaint.
Discharge 29. Mrs A complains the Trust incorrectly discharged her from the ophthalmology service in January 2024 and the neurology service in April.
30. We have seen evidence Mrs A attended SDEC in November 2023 and following an MRI scan, the Trust referred her to ophthalmology which she attended in early December.
31. Our ophthalmology adviser explained the appointment in ophthalmology was to eliminate the possibility of the presence of papilledema, a term for the swelling of the optic disc in the eye. They went on to explain that the Trust’s clinical examination of Mrs A did not reveal a disc swelling and the optimal coherence tomography (OCT) scan confirmed this.
32. Following this, the Trust made a referral to the neurology service with a plan to organise a visual field test (VFT) and a follow up in two months’ time in the ophthalmology clinic which it scheduled for February 2024.
33. Mrs A attended the VFT but did not attend the follow up appointment, so the Trust discharged her in line with its access policy which says all patients who do not attend (DNA) their follow-up appointment, the clinician will review at the end of clinic and decide on next steps.
34. We therefore consider the Trust’s actions in relation to the ophthalmology discharge was in line with its own policy and we can see that following Mrs A’s missed appointment, the ophthalmologist reviewed her latest investigation results and considered it was in her best clinical interests to discharge het back to her GP.
35. We have gone on to look at the Trust’s decision to discharge Mrs A from the neurology service.
36. As we have mentioned previously, the ophthalmology team completed the referral for a neurology appointment for her which she attended in early April.
37. GMC guidance says a clinician must work in partnership with patients, sharing with them the information they will need to make decisions about their care including: their condition, its likely progression and the options for treatment, including associated risks and uncertainties.
38. We have seen evidence that during the appointment, the Trust discussed Mrs A’s concerns that her symptoms related to her recent covid vaccination. It also reviewed her previous investigations.
39. During the appointment the Trust told Mrs A it is likely that she had an immunological reaction (the body's immune response to harmful foreign bodies) to the covid vaccine which caused some inflammation to the lining of her brain which is consistent with Mrs A’s views on her condition. The Trust explained the amount of time it may take for the symptoms to settle and organised an MRI so it could refer to up to date imaging and arranged for a further appointment to discuss results.
40. The Trust then spoke with Mrs A in late April to discuss the results. During this appointment she advised the Trust she had received a private diagnosis of PPPD which she was on medication for.
41. Our neurology adviser has explained PPPD is a form of functional neurological disorder (FND) where symptoms may arise from a physical trigger such as a migraine.
42. The Trust gave Mrs A lifestyle advice to help with her symptoms and although it did not organise a follow up for her, it did discharge her with safety net information on who to contact should she experience a deterioration in her symptoms which is in line with GMC guidance which says a clinician must work in partnership with patients, sharing with them the information they will need to make decisions about their care
43. We consider the Trust acted in line with relevant guidance when managing both her ophthalmology and neurology appointments and in its actions when discharging her from its service. From what she has told us, it is clear she was frustrated by these discharges so we hope our findings will reassure her. We will therefore take no further action on this part of the complaint.
Conclusion
44. We were sorry to hear of Mrs A’s experience and recognise the difficulty she has, as she continues to experience symptoms relating to PPPD. We hope this will give her reassurance, we have not found the Trust got anything wrong in its actions relating to her headache symptoms and its actions during and following her initial attendance in October 2023 and we will not take any further action on this complaint. We hope this will also restore her faith in the NHS.