A WOMAN collapsed and died days after doctors mistook "red flag warnings" of a brain haemorrhage for neck pain and sent her home from hospital, an investigation has found.
Medical experts criticised doctors at Perth Royal Infirmary for failing to order a routine CT scan which would have had a "98 per cent chance" of correctly diagnosing the patient's life-threatening aneurysm. Her GP had referred the woman - who had no history of migraines - to the hospital on January 7 2016 after she suffered sudden "severe, overwhelming" pain, with dizziness and blurred vision. Although the GP stressed in his referral letter that the symptoms pointed to a subarachnoid haemorrhage (SAH) - a rare type of stroke caused by bleeding on the surface of the brain - this was wrongly "discounted" by a junior doctor and a consultant physician at PRI.
The patient, known only as Ms C, was diagnosed with a musculoskeletal strain on her neck and discharged the same day. She visited her GP three times during the following two weeks complaining of the same symptoms, but collapsed at home on January 24 2016.
She was admitted to intensive care at PRI but died two days later.
Her family complained to NHS Tayside that "red flag warnings" had been missed, but the health board denied any wrongdoing and insisted that Ms C had been a "very unusual" case as she presented with neck pain rather than a headache and lacked some other symptoms normally associated with SAH.
However, NHS Tayside has now been ordered by the Scottish Public Services Ombudsman to apologise to the family after the watchdog found a catalogue of failures in Ms C's care.
One expert medic who gave evidence as part of the Ombudsman's investigation said it was "unreasonable" that Ms C's symptoms were blamed on musculoskeletal neck pain, adding: "A patient with no previous significant headache history who presents with sudden severe neck and occipital pain should be investigated as a thunderclap headache."
Around a quarter of thunderclap headaches are caused by SAH. The expert told the Ombudsman that a CT scan should have been performed immediately.
A retired consultant physician, who carried out an external review into the case on behalf of NHS Tayside, said the decision to discharge without performing a CT scan was an "error of judgement". He said the scan would have been "quick and relatively inexpensive" with a "98 per cent chance" of correct diagnosis.
Although the physician stressed that "it would be wrong to say that this in itself would have been life-saving", he added that "the opportunity for effective intervention would have been greatly increased".
The SPSO concluded that Ms C's headache was "not reasonably investigated", adding: "Whilst we cannot say that Ms C's life would definitely have been saved if these tests had been carried out, the adviser has stated that it was probable that Ms C's condition was treatable."
NHS Tayside Medical Director Professor Andrew Russell said: “We have been in contact with the family over this tragic event and our thoughts remain with them. We will be writing to them again following today’s Ombudsman’s report.
“We accept the recommendations and have shared them with the appropriate clinical groups to take forward in an action plan.
“As an organisation we take every opportunity to improve and we will ensure we share learning from this across NHS Tayside.”
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