Decision report 201202928

Summary

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke.

We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s complaint.

We did not uphold Mr C's third complaint as our investigation did not find evidence that doctors had ignored reported symptoms of slurred speech. The notes provided clearly detailed the symptoms and signs that Mrs C had when she was assessed at the hospital.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified in Mrs C's care;
• review the processes governing referral to the on-call neurology team when a patient presents with symptoms consistent with hemiplegic migraine, to ensure an appropriate management plan is agreed and documented, with reference to the SIGN guidance; and
• provide evidence that they have reviewed the procedures within the accident and emergency department for the identification of stroke and the appropriate point for involving a stroke physician in light of the failings identified in this complaint.
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