A DISABLED woman died of a brain tumour after medics repeatedly dismissed "red flag" symptoms including persistent headaches, vomiting and a loss of mobility, according to a damning report into NHS Highland.
The health board has been ordered to apologise to the patient's family after experts concluded that there was a 90 per cent chance she would still be alive if the tumour had been detected and operated on in time.
A report into the case by the Scottish Public Services Ombudsman (SPSO) found that her symptoms were initially mistaken for a sinus infection and later, when she began to lose the ability to walk, were wrongly blamed on the side effects of tramadol, a powerful painkiller.
The woman, who has not been named, had various physical disabilities, learning difficulties, autism, chronic fatigue syndrome and asthma, and was cared for at home by her mother.
In December 2013, she began complaining of headaches and underwent surgery in February 2014 to remove a nasal ulcer. In July 2014, she was referred by her GP to an ear, nose and throat (ENT) consultant who requested a CT scan of her sinuses. The scan was found to show "no abnomality", but a subsequent review of the CT scan by the SPSO medical advisers concluded that it did in fact reveal a "cystic abnormality".
They stressed that there was "no doubt that if the tumour had been discovered in July or early August it would have been operable". They added that the tumour in question was "a benign tumour which is curable" and that if she had undergone surgery in time she would have had "a 90 per cent chance of a full recovery".
Within two weeks of the CT scan error, however, the woman - known only as Ms A - visited her GP practice on July 30 2014 complaining of headaches and vomiting. She was back again on August 8 and had a home visit on August 11, suffering from the same symptoms, and on August 13 her GP requested an appointment with a neurologist to assess her "ongoing headache and loss of balance".
Ms A had already been admitted to Raigmore hospital on August 12, however, with abdominal pain. The neurologist diagnosed her with occipital nerve compression and on August 18 she was discharged, although her parents insist that she was still "very unwell".
Over the next 10 days she was seen by GPs from her own practice on three separate occasions with persistent headaches, a shaking episode - dismissed as a faint when SPSO advisers say it should have been identified as a seizure - and walking difficulties which were wrongly blamed on tramadol.
The SPSO said: "A reasonable GP would have investigated and taken action urgently in relation to a 'loss of walking ability' in a patient such as Ms A with headaches and vomiting, rather than assuming it was due to a side effect of tramadol."
An MRI was scheduled for September 10, which SPSO advisers criticised as a routine referral when her symptoms should have triggered an urgent referral. At her mother's request, the appointment was brought forward to September 8, but Ms A died at home on September 2.
A post-mortem found the cause of death to be a haemangioblastoma, a tumour of the central nervous system within the brain.
A spokeswoman for NHS Highland said: "We are truly sorry for the standards in the care and treatment provided to this patient and will be writing to the family offering our sincere apologies.
"We accept the findings of the report and it has been shared with staff and senior managers. We will also be conducting a significant adverse event review which will be chaired by a senior doctor.
"This will involve analysing the clinical care and treatment provided in order to learn and implement improvements in our practice. The family will also be kept up to date on this process."
Why are you making commenting on The Herald only available to subscribers?
It should have been a safe space for informed debate, somewhere for readers to discuss issues around the biggest stories of the day, but all too often the below the line comments on most websites have become bogged down by off-topic discussions and abuse.
heraldscotland.com is tackling this problem by allowing only subscribers to comment.
We are doing this to improve the experience for our loyal readers and we believe it will reduce the ability of trolls and troublemakers, who occasionally find their way onto our site, to abuse our journalists and readers. We also hope it will help the comments section fulfil its promise as a part of Scotland's conversation with itself.
We are lucky at The Herald. We are read by an informed, educated readership who can add their knowledge and insights to our stories.
That is invaluable.
We are making the subscriber-only change to support our valued readers, who tell us they don't want the site cluttered up with irrelevant comments, untruths and abuse.
In the past, the journalist’s job was to collect and distribute information to the audience. Technology means that readers can shape a discussion. We look forward to hearing from you on heraldscotland.com
Comments & Moderation
Readers’ comments: You are personally liable for the content of any comments you upload to this website, so please act responsibly. We do not pre-moderate or monitor readers’ comments appearing on our websites, but we do post-moderate in response to complaints we receive or otherwise when a potential problem comes to our attention. You can make a complaint by using the ‘report this post’ link . We may then apply our discretion under the user terms to amend or delete comments.
Post moderation is undertaken full-time 9am-6pm on weekdays, and on a part-time basis outwith those hours.
Read the rules here