WOMAN DIED AFTER HEADACHE ERROR
Watchdog orders NHSTayside to apologise
A patient referred to Perth Royal Infirmary died after medical staff failed to give her appropriate treatment.
NHS Tayside has been told to apologise to the widower of the woman after he complained to a watchdog.
The Scottish Public Services Ombudsman decided that while the woman’s life may not have been saved, her condition could have been treatable.
The unnamed woman, called Ms C in the findings, had been referred to experts at PRI by her GP after becoming unwell.
The GP identified one possible cause as a suspected subarachnoid haemorrhage – described as a rare type of stroke caused by bleeding on the surface of the brain.
But, at the Perth hospital on January 7, 2016, she was medically assessed by a specialist trainee doctor and then reviewed by a consultant physician. She was discharged home with the problem felt to be musculoskeletal.
The watchdog said the woman attended her GP on several occasions in the following weeks before collapsing at home.
She was admitted to the intensive care unit showing signs that blood had collected between the skull and the surface of the brain – called acute subdural haematoma.
Further treatment was not deemed appropriate and Ms C died in the hospital two days later.
The SPSO took independent advice from a consultant physician who noted it could have been a thunderclap headache – a sudden onset of severe pain – and that a scan should have been carried out.
If this had shown up nothing a lumbar puncture to test for conditions on the brain, spinal cord or other parts of the nervous system should have been arranged. If this was found to be positive a neurological opinion would have been essential.
The watchdog said: “We found it was unreasonable Ms C had been diagnosed with musculoskeletal neck pain.”
It also decided, based on advice provided, that someone presenting with the symptoms but with no previous significant headache history should be assessed for a thunderclap headache.
“We also found Ms C had not been monitored appropriately in the acute medical unit,” the statement continued. “In view of the fact Ms C’s headache was not reasonably investigated, we upheld Mr C’s complaint the board failed to provide Ms C with appropriate clinical treatment on January 7 2016. Whilst we cannot say Ms C’s life would definitely have been saved if these tests had been carried out, the adviser has stated it was probable Ms C’s condition was treatable.”
The ombudsman also said NHS Tayside had failed to address the complaint in a timely and professional manner, and had not addressed all of points raised.
A more detailed response was necessary after he questioned the failure to take action in line with medical guidance. NHS Tayside’s board also delayed issuing the minutes to Mr C after meeting him.
NHS Tayside has been asked to apologise to Mr C, to prove it is taking steps ensuring patients with headaches are appropriately assessed based on health guidelines, as well as being monitored properly, apologise for the inadequate response to his complaints, and for the consultant involved to have the watchdog report discussed with them during appraisal.