Cases: Failure to diagnose haemorrhage leading to death

Clin Risk 2008;14:120-122
doi:10.1258/cr.2008.080008
© 2008 Royal Society of Medicine

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Cases: Failure to diagnose haemorrhage leading to death

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The Estate of S v Dr C (1) and Dr R (2)


Simon Elliman, Claimant’s Solicitor and
Withy King Solicitors, Claimant’s Solicitor


Bath


MDU Services Limited


London





Background

Top

Background
Claimant’s case

Breach of duty

Causation

Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

S, a 14-year-old girl at the time, initially attended her GPsurgery on 30 November 1998 with a four-day history of headaches,which seemed to worsen in the mornings, together with dizzyspells upon standing. She was also noted to have inflammationof the throat and cervical lymph nodes. Neurological examinationwas normal.

S returned to the surgery on 16 October 2000 with a two-weekhistory of headaches, which again appeared worse in the mornings,improving towards the early evening. On this occasion, she wasseen by Dr C who noted that she had a rare type of migraine,but instigated no further investigations.

On 11 January 2001, S was reviewed by Dr C who noted occasionalvisual disturbance and dizziness, associated with the persistentheadaches. Dr C prescribed Propranolol Hydrochloride 10 mg.

On 19 February 2001, S returned to the surgery after still wakingearly with the headaches and experiencing dizzy spells. Shewas seen by Dr R, who considered the possibility of posturalhypotension. S explained that she had passed out on three occasionsand that the headaches had failed to improve despite the medication.Dr R noted the absence of epilepsy in the family and advisedS to see Dr C on her next visit.

On 26 February 2001, S was reviewed by Dr C as planned and reportedthat her headaches had become less frequent and less severe,although the dizzy spells persisted. She also described a particulardizzy episode the previous week when she had passed out andstarted nodding her head involuntarily. Dr C considered thatthis was suggestive of faints, with possibly suffering a fitsecondary to fainting. S was to return in four weeks’ time fora review and to report any further blackouts or faints.

On 19 March 2001, S was reviewed by Dr C as scheduled and wasprescribed Ibuprofen 200 mg as the headaches continued.

S did not seek further medical advice until 11 November 2002,at which stage she was continuing to experience headaches, andattended her GP as a result of a five-day history of pain inher forehead. She was reported as being otherwise well. Shehad no neck stiffness, although was noted to have swollen tonsilsand mild cervical adenopathy. She was also tender over the ethmoidand frontal sinuses. She was prescribed a further course ofIbuprofen 200 mg and advised to return to the GP in the eventof deterioration.

S returned on 18 November 2002, her headaches having failedto improve. She advised that analgesia failed to help. It wasnoted that the optic discs were clear and the headaches wereconsidered to be stress related. She was advised to use a relaxationtape and to return in 10 days for review. It was noted thatshould there be no improvement, a paediatric referral shouldbe considered.

On 28 November 2002, S returned and stated that the relaxationtape had been of little help. She was advised to take paracetamolas well as her regular dose of brufen and return the followingweek.

On 2 December 2002, the Claimant (S’s mother) telephoned thesurgery and reported that S had been unwell over the weekend.She had also experienced an occasional buzzing in her rightear associated with the headaches, together with occasionalblurring of vision. S was then referred to the paediatric teamat the Royal United Hospital, Bath, noting a four-week historyof almost continuous headaches.

On 3 February 2003, S was assessed by a consultant paediatrician.The consultant paediatrician noted that she had actually beentroubled with these headaches for the past three years, eachepisode running for around 3–4 weeks at a time. He notedthat she also experienced blurred vision and flashing lightsupon moving her head. On examination, the consultant could findno evidence to suggest raised intracranial pressure or any othersignificant pathology. S was advised to modify her diet andreturn in six weeks for review.

On 17 March 2003, S was reviewed by a senior SHO to the consultantpaediatrician, who noted that she continued to have these headachesdespite modifying her diet as advised. On examination, she seemedwell and comfortable. Neurological examination confirmed noabnormalities and fundoscopy showed normal discs, and as themodified diet seemed to have had little effect, she was prescribedPizotifen 1.5 mg nocte. The diagnosis was a migraine and S wasto return to be reviewed in 4–6 weeks’ time.

On 21 April 2003, S became suddenly unwell. She was admittedto the Royal United Hospital but emergency attempts to resuscitateher failed, and tragically she died.

The postmortem examination on 25 April 2003 concluded the causeof death to have been by way of a haemorrhage into a vascularmalformation of the cerebellum.





Claimant’s case

Top

Background

Claimant’s case
Breach of duty

Causation

Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

A letter of claim was sent to the MDU on behalf of the Defendantson 17 March 2004.





Breach of duty

Top

Background

Claimant’s case

Breach of duty
Causation

Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

It was the Claimant’s case on breach of duty that S had received negligent treatment. The principal allegations of negligence were that the Defendants had:

  • failed to investigate properly S’s symptoms between October 2000 and December 2002;
  • failed to refer S to the hospital on 19 February 2001 following a history of persistent severe headaches and three episodes of loss of consciousness;
  • failed to refer S to a paediatrician on 26 February 2001 following a fourth consultation and at least four episodes of passing out and two possible fits;
  • failed to review S and again refer her on 19 March 2001 and failure to request a computerized tomography (CT) scan or other investigation within a reasonable time.

 





Causation

Top

Background

Claimant’s case

Breach of duty

Causation
Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

It was the Claimant’s case on causation that as a result ofthe above negligence S was deprived of hospital treatment thatwould have led to the diagnosis of her vascular malformationand would have resulted in treatment, which would have preventeda haemorrhage occurring. It is likely that earlier prognosisand treatment would have prevented S’s death.





Defendant’s case

Top

Background

Claimant’s case

Breach of duty

Causation

Defendant’s case
Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

In the Defendants’ letters of response dated 9 July 2004, theMDU stated that they were not prepared to admit there had beena breach of duty, and indicated that they wished to obtain theirown expert evidence. In a letter dated 22 March 2005, the Defendantsargued that the treatment and diagnosis received by S was notunreasonable and that given there was no change in her signsand symptoms, there was no reason for a referral to the hospitalor to a paediatrician.

The Defendants admitted that many paediatricians would haverequested a CT scan in March 2002, but stated that in the ‘absenceof signs of raised intracranial pressure, this would not havebeen arranged urgently and in most (if not all centres) thiswould not have been performed prior to her sad death’.





Claimant’s expert opinion

Top

Background

Claimant’s case

Breach of duty

Causation

Defendant’s case

Claimant’s expert opinion
Defendants’ expert opinion

Settlement


Dr Nicholas Kearsley—GP and expert witness

Dr Kearsley identified two incidents which, in his opinion,constituted a level of care which fell below an acceptable andreasonable standard. He considered that a referral should havebeen made on 19 February 2001 when S presented to Dr R witha history of three episodes of loss of consciousness, togetherwith a history of frequent and persistent headaches.

A further consultation on 26 February 2001 following a similarepisode was also considered by Dr Kearsley to amount to negligence.


Dr Ben Lloyd—Consultant Paediatrician

Dr Lloyd was of the view that had S been referred to the hospitalwhen she should have been by the GP that she would, after someinvestigation, have been referred to a neurosurgeon.


Mr Peter Richards—Consultant Neurosurgeon

Mr Richards expressed the opinion that the lesion would haveshown as an abnormality if a CT scan had been taken. The abnormalCT scan would have led to a referral to a neurosurgeon and anyneurosurgeon would have treated the referral with urgency. Themost probable treatment of choice would have been embolizationof anterial feeders and protection against haemorrhage wouldthereby have been achieved.





Defendants’ expert opinion

Top

Background

Claimant’s case

Breach of duty

Causation

Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion
Settlement

 

The Defendants’ experts could see no reason for an earlier referraland considered that the diagnosis of postural hypotension causedby propranolol was not unreasonable. Furthermore, they did notconsider that the delay between the consultation on the 18 November2002 and the referral letter written on 9 December was a significantdelay.

The Defendants’ experts concluded that management was reasonableand although it was admitted that most paediatricians wouldhave requested a CT scan on 17 March 2002, they argued thatin the absence of raised intracranial pressure this would nothave been arranged urgently and it was not likely to have beenperformed prior to S’s death.





Settlement

Top

Background

Claimant’s case

Breach of duty

Causation

Defendant’s case

Claimant’s expert opinion

Defendants’ expert opinion

Settlement

 

On 24 April 2006, the Defendant made a Part 36 Offer in fulland final settlement of the claim in the sum of £10,000plus reasonable funeral expenses. This offer was subsequentlyaccepted by the Claimant on 14 June 2006. The funeral expensesbeing £1866.15 and interest of £352.17, the totaloffer was accepted as £12,218.32. Dr C and Dr R did providea joint personal letter of apology to S’s family as requestedby the Claimant.

Total damages: £12,218.32; June 2006; Total Award: £12,218.32

Failure to diagnose haemorrhage into a vascular malformationof the cerebellum leading to the death of a 14-year-old girl.

Cases: Failure to diagnose haemorrhage leading to death
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Cases: Failure to diagnose haemorrhage leading to death

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Cases: Failure to diagnose haemorrhage leading to death
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Cases: Failure to diagnose haemorrhage leading to death
Cases: Failure to diagnose haemorrhage leading to death

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