Sudden stroke

BACKGROUND: Mr S is a 48-year-old hospital porter and heavy smoker. He contacts an NHS helpline on a Sunday complaining of vomiting and severe dizziness on and off for the last two days, as well as pain and numbness in his right arm. A nurse adviser refers him to an out-of-hours GP clinic and he is seen by Dr T.

The GP confirms a history of vertigo and vomiting with no abdominal or chest pain but a slight headache. There is no mention in the notes of the arm complaint. Vitals are within range and the GP checks the fundi and pupil reactivity to light, which are also normal and she notes “no other neurological symptoms”. The working diagnosis is labyrinthitis and she prescribes prochlorperazine for symptomatic relief.

Two days later Mr S attends his regular GP surgery complaining again of a sore right forearm and hand. He is seen by Dr A, who notes the OOH attendance and the working diagnosis of labyrinthitis. He records “hand pale/cool; some volar tenderness/redness but no clear sign of infection”. The patient is sent home with advice to contact the practice if no improvement or if symptoms worsen.

Later that day Mr S collapses at home and is taken by ambulance to A&E with left-side weakness and severe headache. A CT angiogram shows extensive right MCA territory infarction with bilateral cerebellar ischaemia, and he also has an ischaemic right arm due to arterial embolus. Mr S is commenced on heparin but is not considered suitable for thrombolysis treatment. He suffers a prolonged recovery in hospital and is left handicapped and unable to return to work.

A claim for damages is pursued against both GPs alleging clinical negligence in failing to act appropriately when the patient first presented with early signs of stroke.

ANALYSIS/OUTCOME: MDDUS acts for Dr A in the case. Expert reports are commissioned from a GP and a vascular surgeon. Considering notes from the initial consultation with Dr T, the GP expert agrees that labyrinthitis was a reasonable working diagnosis but he questions why there is no comment in regard to the patient’s arm, given the symptoms reported by the triage nurse. Assuming there was no gross abnormality present in the arm at this stage and no clear neurological problems, the expert concludes that failure to address this issue in the notes constitutes a legal vulnerability but no clear breach of duty.

Regarding the consultation with Dr A, the GP expert observes that the notes focus primarily on the arm complaint but no working diagnosis is noted – only the advice that Mr S should return if the symptoms do not improve. There is no indication in the notes of vascular examination, i.e. mention of the quality of the pulses in the left compared to the right arm, nor BP or capillary refill measured in both.

Given that Mr S showed no clear signs of serious illness in the consultation – no headache or sign of left weakness – the expert concludes there can be no breach of duty in the failure to manage this condition as a CVA (cardiovascular accident). But he does suggest a legal vulnerability if it cannot be established that Dr A at least considered the possibility of an acute vascular occlusion in the patient’s arm.

However, the crucial factor in this case is causation (the consequences of any potential failing) and this is addressed by the vascular surgeon in his expert opinion. Examining the practice and hospital notes he concludes that Mr S suffered cerebellar infarcts leading to the reported dizziness and a subclavian artery embolus leading to the right arm/hand symptoms. A middle cerebral artery embolus then caused the stroke suffered in the hours after the consultation by Dr A.

In addressing causation, the expert opines that even if Dr A had diagnosed an arm embolus in the hours before Mr S suffered his stroke this would have made no material difference to the outcome. Hospital notes confirmed that on examining Mr S’s hand the on-call vascular surgeon judged it was not “threatened” and decided not to operate. The neurologist who examined Mr S at the hospital considered thrombolysis but did not proceed with that treatment because of pre-existing contraindications. Mr S was given anticoagulation treatment with heparin as advised by the vascular surgeon at the hospital but this did not relieve his stroke symptoms. Earlier treatment with heparin would not have made any difference to the outcome.

MDDUS denies liability on behalf of Dr A on the grounds of causation and the action is subsequently dropped against both GPs.

KEY POINTS

• Ensure you address the full range of presenting complaints in the notes – even if just a working diagnosis.
• Establishing liability in clinical negligence requires evidence of both breach of duty of care and causation.