CT scan, investigations, and MRI
16. Miss L says the Trust did not investigate her symptoms further after reporting a CT scan as normal at the beginning of March 2021. She told us she attended the ED on four occasions after the CT scan and the Trust did not perform an MRI until mid-August.
17. The Trust said the care provided in the ED was appropriate for the symptoms Miss L was exhibiting. It said the CT scan was reported as normal in March and an MRI scan was performed mid-August when Miss L’s symptoms developed further.
18. The Trust explained arachnoid cysts are sacs filled with fluid that are found between the brain or spinal cord and the arachnoid membrane. It explained these cysts commonly have no symptoms and any symptoms are dependent on the size and location of the cyst.
19. A headache following COVID-19 vaccination is well recognised and our neurology advisor explained this headache may be severe. They explained migraine is the most common cause of this severe headache and it is not unusual for patients with severe migraine to attend an ED.
20. GMC Good Medical Practice says doctors must provide a good standard of care. If they assess or diagnose patients, they must adequately assess the patient’s condition, taking account of their history and presenting symptoms, and promptly provide or arrange suitable investigations were necessary.
21. Miss L attended the ED in early March 2021 and the Trust considered whether she had a subarachnoid haemorrhage due to her sudden acute headaches. A subarachnoid haemorrhage is a type of stroke caused by bleeding in the space below the protective layers of the brain. To investigate this the Trust organised a CT scan and referred Miss L to the medical team for further management.
22. Our ED advisor explained this was the appropriate investigation to have undertaken based on Miss L’s symptoms. A CT scan done within six hours of headache onset may be accurate enough to find all cases of subarachnoid haemorrhage.
23. The NICE headaches guidance explains the features clinicians should consider when diagnosing types of headaches or migraines. The guidance distinguishes the features of migraines, cluster headaches, and tension type headaches.
24. The guidance states pain from a tension-type headache can be bilateral, non-pulsating, mild to moderate in intensity and not aggravated by routine activities. It says the headaches can be continuous.
25. Miss L’s records show she attended the ED twice - in March, and early May. The Trust noted her headaches were intermittent, mostly frontal, and she was experiencing occasional nausea and episodes of vomiting. The pain was not aggravated by routine activities like chewing or combing her hair. The Trust gave her a provisional diagnosis of tension headaches. We can see the Trust referred to the CT scan in March on these attendances.
26. Our ED advisor noted Mis L’s symptoms were fluctuating and instantly responded to treatment and medication from her second visit to the ED.
27. The symptoms Miss L presented with over this period more closely aligned with a tension-type headache. We therefore think the Trust acted in line with the NICE headaches guidance when reaching a diagnosis of tension headaches.
28. GMC Good Medical Practice guidance says clinicians should recognise and work within the limits of their competence. It also says clinicians should arrange suitable investigations where necessary and refer patients to other practitioners when this serves their needs.
29. Miss L had a CT scan early in the course of her illness which was reported as normal. We have considered the content of this report further in the next section. Our neurology advisor explained it was reasonable for ED physicians to regard the report of a normal CT scan as consistent with migraine and to treat Miss L on that basis.
30. It is not the expected expertise of an ED clinician even up to consultant level to interpret a CT scan. Our ED advisor explained there was no reason for anyone in the ED to rescan Miss L as it had been reported as normal by a radiologist. From June, the ED physicians were also aware Miss L had been diagnosed with migraines by a neurologist. Our neurology advisor said further investigations were reasonable after a period if Miss L’s headaches persisted.
31. A neurologist diagnosed Miss L with migraine with aura in early June. The Trust also made a referral for an outpatient MRI in early August. Miss L attended the ED in mid-August and reported worsening headache symptoms. Symptoms included photophobia (sensitivity to light), pain in her abdomen, and that her headache symptoms worsened when she leant forward. She also reported recent episodes where vision in her left eye had changed, known as transient visual obscuration. The Trust performed the MRI during this attendance.
32. The Trust investigated Miss L’s symptoms in line with the GMC’s Good Medical Practice between March and August 2021.
33. The Trust was acting in line with the GMC’s Good Medical Practice when it used the CT scan report when treating Miss L over this period. The Trust also referred Miss L for an MRI in line with this guidance given the CT scan.
34. We acknowledge how difficult this period was for Miss L. She told us she missed work and stopped going outside due to the headaches, and we recognise how difficult this was for her. We have not found any failings in the Trust’s actions here.
Misdiagnosis
35. Miss L complains the Trust misdiagnosed her after incorrectly reporting a CT scan as normal in March 2021. She says she was incorrectly diagnosed until August 2021.
36. The GMC’s Good Medical Practice says doctors must provide a good standard of practice and care. It says documents doctors make to formally record their work must be clear and accurate. It goes on to say clinical records should include relevant clinical findings.
37. The CT report fails to identify Miss L has numerous features of obstructive hydrocephalus. Obstructive hydrocephalus is where a blockage prevents the flow of cerebrospinal fluid (CSF), causing a build-up of fluid, which puts pressure on the brain. Our radiology advisor explained the content of the report in March 2021 is substantially incorrect.
38. A CT scan of the brain can show changes caused by obstructive hydrocephalus. These changes include a build-up of CSF fluid and an increase in pressure, which results in visual changes to the brain. Our radiology advisor told us these findings are immediately evident in Miss L’s original CT scan, and it is markedly abnormal.
39. We have found the Trust failed to act in line with the GMC’s Good Medical Practice. It failed to identify and record that Miss L had features of hydrocephalus on the CT scan in March 2021. We have gone on to consider the impact of this failing.
40. Miss L told us she experienced unnecessary pain before she eventually received treatment. She says is still being impacted now and had to have two more surgeries in February 2024 when her VP Shunt malfunctioned.
41. We sought advice from a neurosurgeon to consider what would have happened if the failing had not occurred, and the impact of this not happening.
42. NHS Hydrocephalus guidance says CT and MRI scans are often used in combination to confirm a diagnosis of hydrocephalus. If the CT scan had been reported correctly in March, we think the Trust would have arranged an urgent MRI. This MRI would have led to the diagnosis of the arachnoid cyst.
43. Once Miss L had been correctly diagnosed, we think she would have had the required surgery by mid-March 2021. Our neurosurgery advisor told us hydrocephalus requires urgent investigation and treatment. If Miss L’s CT scan was correctly reported in March she would have been admitted to the neurosurgical unit for further management.
44. An MRI would then have been performed to confirm Miss L’s diagnosis and Miss L would have remained in hospital until her surgery was performed. Our neurosurgery advisor told us Miss L would have been managed with the same level of urgency in March as she was in August, had she been diagnosed then.
45. When the Trust diagnosed the cyst in August Miss L was urgently transferred to the neurosurgical team at another Trust. She was transferred, treated, and discharged within four days.
46. On the balance of probabilities, we think it is likely that if the failing in reporting the CT scan had not occurred, Miss L would have undergone treatment in March. We have therefore considered the impact of the delay in surgery going ahead between March, when we think the operation should have occurred, and August, when the operation did occur.
47. Miss L told us she had always been active prior to her symptoms starting. She told us she experienced so much pain and nausea after her symptoms started she would sometimes be bed bound for two days.
48. When they occurred, symptoms also started randomly, so Miss L avoided going out which completely stopped her life between March and August. She told us she had to take a lot of time off work due to her symptoms.
49. We think Miss L experienced pain for longer than necessary, between March until she was diagnosed and treated in August. We think this could have been avoided if the failing had not occurred, and Miss L had surgery sooner.
50. Miss L was reporting worsening symptoms when she attended the Trust between March and August. Our neurosurgery advisor told us it appears Miss L’s hydrocephalus was worsening over this period, given her worsening clinical presentation. We therefore think the pain Miss L experienced got worse during this time, and again, this could have been avoided if the failing had not occurred.
51. Miss L told us she had very little time to prepare herself from when the cyst was found and she had surgery. This was happening during the COVID-19 pandemic and she was alone with everything moving so quickly. We acknowledge how distressing this would have been. Miss L feels she would have had more time to prepare for treatment if the cyst had been identified earlier.
52. We cannot say Miss L would have had a different experience if her cyst was identified in March. The pandemic was happening at this time and surgical intervention would still have been required. This would always have been managed on an urgent basis and Miss L may not have had more time to prepare for surgery or had the option of having a someone present.
53. Our neurosurgery advisor explained the treatment options available to Miss L did not change between March and August. As the treatment options were unchanged, we are satisfied that the failing did not impact on the clinical options available for Miss L.
54. We have reviewed Miss L’s records from the Trust that performed her surgery to consider if the delay in treatment impacted her recovery, or had a long term impact on her. The records show she was discharged shortly after her surgery and the notes do not suggest anything abnormal in her recovery following the operation.
55. We are therefore satisfied that the failing did not have a long term impact on Miss L. We recognise Miss L is concerned she continues to be impacted now and had to have two more surgeries in February 2024 when her VP shunt malfunctioned. We understand why Miss L would be worried about this. We have not been able to link this to the failing that we have provisionally found.
56. Miss L told us she experienced anxiety between March and August but was focussed on her symptoms until her surgery. She says doctors told her she may have died or become brain damaged if they had not performed the MRI when they did. She told us she has struggled to process this and has experienced problems with her mental health, including a fear of going out, since her surgery. Miss L told us it all comes back to her some days, and she will have a strong emotional reaction.
57. Miss L told us she believes she has PTSD and confirmed she has sought counselling to address the anxiety she experiences.
58. Internal communications from the Trust acknowledge the misreported scan could have been potentially fatal. We accept Miss L’s account that she was told at the time that she could have died or become brain damaged if the MRI scan had not been undertaken, and her condition remained undiagnosed.
59. We understand this would have been incredibly difficult for Miss L to process and that it has contributed towards the mental health difficulties she experienced due to the misdiagnosis.
60. We cannot say the ongoing impact to Miss L’s mental health is solely due to the Trust’s failure to diagnose her in March. Miss L has described how she was impacted by her experiences around the surgery, its urgent nature, and the restrictions in place due to the pandemic.
61. We do not doubt the impact this must have had on her. We have not considered Miss L’s VP shunt surgery and cannot consider this part of her experience when determining impact. We can say the impact Miss L experienced to her mental health lasted longer than the five months it took to be diagnosed correctly.
62. We can say the failure to report the CT scan correctly in March means Miss L was misdiagnosed for five months. Our neurology advisor confirmed her symptoms could easily have necessitated time off work and we have seen references to time off work in both her GP and Trust records. We think Miss L experienced unnecessary pain and other symptoms for longer than she should have done if she had been correctly diagnosed and treated in March 2021.
63. We have gone on to consider whether the Trust has recognised this failing. We have also considered whether it has taken action to remedy the injustice we have identified above.
64. The NHS Complaint Standards say organisations should use complaints as an opportunity to improve. Organisations should also give honest and accountable responses that explain if mistakes were made and ensure learning is identified and used to improve services.
65. The CT scan from March 2021 was reported as no acute intracranial abnormality by an external reporting company, meaning no urgent issues were identified. An internal communication from the Trust in February 2022 says the original CT scan is very abnormal and described it as ‘yet another reporting error.’ The Trust added an addendum to Miss L’s records in March 2022 after reviewing the original scan which says there is generalised moderate hydrocephalus.
66. It is concerning to note that the Trust’s complaint response dated June 2022 does not reflect this. The Trust confirmed the CT scan was reported as normal and said the care it provided to Miss L was appropriate to the symptoms she was exhibiting at the time. The Trust response says an MRI was performed when Miss L’s symptoms developed further, and an obstructing arachnoid cyst was identified.
67. We note the Trust response to Miss L does not acknowledge the CT scan of March 2021 was misreported or that this is what led to her misdiagnosis. Disappointingly, we think the Trust’s response was not honest or accountable.
68. We therefore do not think the Trust has acknowledged this failing, or taken steps to remedy the impact this had on Miss L. We set out our current thinking recommendations to do this in the next section of this report.
69. We have also considered what action the Trust has taken to prevent a similar failing from occurring again.
70. We note an external reporting company produced the report for the March 2021 CT scan. Our ED advisor told us many Trusts may have a policy that outsourced out of hours radiology scans are rereviewed and revalidated by a Trust radiologist.
71. We asked the Trust for any policies that were in place for the period in question around how it verified out of hours radiology reporting. The Trust provided a rota showing periods when reporting is outsourced but did not provide anything showing it rereviewed or revalidated outsourced reports over the period in question.
72. We also asked the Trust if it had put any policies in place around reporting out of hours scans in place following Miss L’s complaint. We also asked whether the Trust raised the misreported CT scan with the external reporting company. The Trust provided no comments in response to these questions.
73. Neither the Trust’s response to Miss L’s complaint, nor the Trust’s communications with us, demonstrate it learned lessons from its failure in Miss L’s care to help avoid a similar incident occurring again. We have set out our recommendations to address this below.