Case 5 Bad luck or bad judgement

Daphne Hardcastle is a 52-year-old publican who presents to the Emergency Department following an episode of left-sided weakness and slurred speech. Her symptoms, which lasted for approximately 40 minutes, have fully recovered upon arrival. Mrs Hardcastle’s blood pressure is 168/94. Her pulse is 75 and regular. Mrs Hardcastle is a smoker and drinks approximately 40 units of alcohol per week. She is a driver and lives with her husband and three dogs. She is assessed by Dr Wilde, an FY2 doctor in the Emergency Department.

How should Dr Wilde manage Mrs Hardcastle?

Dr Wilde makes a brief assessment of Mrs Hardcastle and establishes that there is no persisting neurology. Heart sounds are normal, blood pressure measurements remain in the region of 160 mmHg systolic and the cardiac monitor shows a regular rhythm. Capillary blood glucose is normal at 5.4 mmol/l. Dr Wilde draws bloods and sends them for routine measurements and a random total cholesterol. She calculates an ABCD2 score of 4 which places Mrs Hardcastle at moderate risk of stroke in the next 48 hours. Dr Wilde faxes a referral to the TIA clinic and advises Mrs Hardcastle to report at 09.00 am the next day according to the Trust’s protocol. Dr Wilde elects not to actively manage blood pressure, expecting it to be checked and followed up the next morning in clinic. Dr Wilde gives Mrs Hardcastle a single dose of aspirin 300 mg and discharges her with reassurance. She explains that Mrs Hardcastle must not drive for a month following the index event.

Has Dr Wilde’s management been appropriate? Is there anything else that you would have done?

Mrs Hardcastle’s husband is awoken at around 2.30 am by loud grunting noises. Mrs Hardcastle has fallen out of bed and is lying on the floor. She is making some effort to get up but seems unable to move her right-hand side or speak. She does not seem to notice her husband as he approaches from the right to help her and appears to be drifting in and out of full consciousness. He calls an ambulance which attends within minutes. Mrs Hardcastle is blue lighted to the Emergency Department, arriving 20 minutes later.

How should Mrs Hardcastle be managed?

Mrs Hardcastle is seen by Dr Phillips, a registrar, who makes a clinical diagnosis of a left total anterior circulation syndrome. He speaks to the acute stroke team but it is decided that the time of onset is not clear and could have occurred at any time after Mrs Hardcastle had gone to bed that evening. Hence, she is not eligible for thrombolysis. Mrs Hardcastle’s blood pressure is 176/90 and an ECG reveals fast atrial fibrillation. The chest is clear. Following a failed swallow screen, Mrs Hardcastle has a nasogastric tube inserted. She is given low dose metoprolol for rate control and transferred to the stroke unit. Six hours after admission, she has a CT scan of the brain which demonstrates established infarction throughout the entire left MCA territory.

Could Mrs Hardcastle have been managed any differently over this 24-hour period? Are there any further interventions that ought to be considered?

Expert opinion

Mrs Hardcastle’s management by Dr Wilde was generally good. An appropriate assessment was made and an evidence based risk tool was then utilized to determine further management and the urgency of specialist review. Dr Wilde would have expected Mrs Hardcastle to access brain and carotid imaging in the rapid access TIA clinic the next morning. With a blood pressure measurement in ED of 168/94, arguments could be made either way in relation to the urgency of commencing an anti-hypertensive agent. With the safety net of a clinic appointment within 24 hours and the expectation that this would be followed up, most physicians would have acted as Dr Wilde did. With the full resolution of symptoms (and a diagnosis of TIA), it is appropriate to commence aspirin prior to brain imaging. It is important to recognize however that a small proportion of patients presenting clinically with a TIA will have experienced minor intra-cerebral haemorrhage. The only criticism that can be made of Dr Wilde’s management is the lack of a documented electrocardiogram. One wonders whether Mrs Hardcastle might have been in atrial flutter at the time of initial assessment which, in the context of TIA, would have led to immediate anticoagulation. However, commencing warfarin on the first attendance in ED would not conceivably have altered the outcome here.

In relation to ongoing management, Mrs Hardcastle should be urgently assessed by stroke specialists. Given her clinical state and the radiological findings, she is at high risk of malignant MCA syndrome. In this syndrome, oedema causes further damage to other areas of the brain including the ACA territory and the hindbrain. It carries mortality in excess of 50%. Mrs Hardcastle ought to be considered for neurosurgical intervention in the form of hemi-craniectomy.

Legal comment

The criteria for a finding of negligence in English tort law are the existence of a duty of care, a breach of that duty of care and a foreseeable injury occurring as a result of the breach. All three elements must be fulfilled if a patient is to succeed in being entitled to compensation.

In English tort law a doctor is not deemed negligent if he/she acts in accordance with the opinion of a responsible body of medical practitioners, skilled and practised in that art. The ‘Bolam’ test has more recently been adjusted by the requirement that a medical opinion must also be ‘reasonable’ and based on evaluation of the risks and benefits associated with a particular procedure to be capable of withstanding logical analysis.

Where clinical opinion conflicts, a judge reviewing the case must assess the rationality of the two opinions. The courts recognize that professional opinion may be divided in terms of a more conservative or more interventional approach and due consideration must be given to the different modes of medical management which may apply to the same clinical specialty; even if one accepted management course is pursued only by the minority of doctors.

An adverse outcome in the course of medical treatment can be unforeseen. Despite appropriate clinical management of the patient there may be an adverse outcome. Adverse outcome is not necessarily the indication of poor/negligent care.

Where there has been an adverse outcome and there is thought to have been a breach of duty of care, there must be an established causal link with the alleged breach of duty in order to prove negligence. It is necessary to establish that the adverse outcome would not have occurred as a result of the natural progression of the disease, and was not a foreseeable and accepted complication of treatment, despite all appropriate care. When investigating a case one will often find examples of suboptimal practice that do not impact upon outcome but investigation is still important to undertake a root cause analysis for the purpose of organizational learning.

Where injuries are caused by a failure to act, it is necessary to evaluate the likely natural progress of the untreated condition and to establish what, as a fact, would have occurred but for the negligent act. If the adverse outcome was determined before the negligent intervention, or if the adverse outcome was to have been more likely than not in any event; then the claim will fail. However, if there was a greater than 50% chance, on the balance of probability, of a good outcome but for the negligent failure to act, the patient would be successful in obtaining damages.

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