A PATIENT who suffered a personality-changing brain injury as a result of a blood clot would have made a "significantly better recovery" if doctors had ordered a crucial brain scan earlier, according to a damning report into his care.
The man, known only as Mr C, has been left with short-term memory problems, seizures, and difficulty retaining information after a haemorrhage led pressure to build up in his brain in 2015. The brain damage also resulted in him becoming confused and prone to unruly outbursts.
A report by the Scottish Public Services Ombudsman (SPSO) said the failure to carry out an urgent CT scan when he first presented at the Victoria Hospital in Kirkcaldy was a "significant and serious failing" by NHS Fife which had caused him a "significant personal injustice". It added: "If the diagnosis and treatment had been made sooner there would in all probability have been a significantly improved prognosis for Mr C."
Mr C's ordeal began when he fell out of bed while on holidaying abroad in August 2015. He struck his head on a chair, table and the floor and lost consciousness for 10 minutes. On arriving home a few days later, Mr C attended A&E at the Victoria Hospital complaining of nausea, light-headedness and a "bursting" headache which had come on suddenly when he attempted to lift a heavy bag of cement.
He told doctors that he had had a persistent headache since falling on holiday and that he was also on the blood thinning drug, clopidogrel. Patients on this medication are at increased rise of bleeding inside the head following a head injury.
However, the doctors diagnosed a minor head injury and discharged him without carrying out a CT scan.
Eleven days later in September 2015, Mr C visited A&E again complaining of a "constant headache". His wife complained to the SPSO that she "had to beg" medics to request a CT scan which revealed a brain haemorrhage. Mr C underwent emergency surgery in Edinburgh to remove the clot.
Independent experts told the SPSO that it was an "unreasonable and significant failing" that no CT scan had been requested when Mr C first visited A&E. A consultant in emergency medicine said that, had a CT scan been performed in August, "the bleed was likely to have been smaller and so may have allowed for treatment earlier".
A consultant neurosurgeon also told the SPSO that the delays put pressure on Mr C's brain as the clot grew bigger, and was the "likely" cause of his subsequent seizures. He added that "in all probability" the prognosis for Mr C would have been "significantly improved" if the haemorrhage had been treated on time.
The report noted that the brain injury led Mr C to exhibit behaviour "which could be difficult to manage". His wife complained that he was "manhandled by nursing staff" at the Victoria Hospital and that one nurse had "unreasonably tried to forcibly sedate him with the use of a syringe". Batteries were also removed from his mobile phone "so he could not use it" and he "suffered a number of falls".
The SPSO said that, overall, the nursing care provided to Mr C was "not reasonable".
NHS Fife Director of Nursing, Helen Wright, said the health board accepted the findings and apologised. She added: “We always work towards providing patients with the best possible care, however, we accept that in this case we fell some way short of providing this.
"Since this event we have put in place measures to prevent such an incident from being repeated in future and will consider whether any further service improvements can be made to improve the care of patients who have suffered head injuries."
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