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Slipping up

01 January 2009

Mr O, a 70-year-old retired army captain, had atrial fibrillation and was taking warfarin. He fell down his cellar steps after slipping on some spilt oil, badly bruising his face and fracturing his left wrist. He was observed overnight in his local hospital’s A&E department. A neurological examination before he was discharged was normal. INR was measured at 2.8. Five weeks after the accident Mr O visited his GP, Dr A, because he had noticed he was "a bit off form”. He was worried about an episode where he became lost on his way home from the pub, and tried to enter somebody else’s house, thinking it was his own.

Dr A asked Mr O if they had given him a scan while he was in A&E and recorded that Mr O “had CT scan”. This was not actually the case – presumably, Mr O had thought that the x-ray of his wrist was a scan. Dr A was concerned enough to admit Mr O to his local hospital, under the care of Dr D, consultant physician.

On the post-take ward round, Dr D diagnosed confusion secondary to dehydration and urinary tract infection, on the basis of a slight pyrexia, moderate proteinuria and a slightly raised urea levels. Dr D advised intravenous fluids and a course of trimethoprim. In the early hours of the morning after his admission, Mr O’s condition deteriorated and he became confused.

An urgent CT scan revealed bilateral chronic subdural haematomas. Following craniotomy and clot evacuation, Mr O made a poor recovery, requiring long-term 24-hour care in a nursing home. Mr O’s family brought a claim against Drs A and D alleging negligence.

Expert advice

A GP expert was entirely supportive of Dr A’s care and he was subsequently removed from the claim. However, an expert general physician was critical of Dr D’s failure to consider a neurological cause for Mr O’s symptoms, despite Dr A clearly outlining the significant head injury and the use of warfarin on his referral letter.

The expert felt that there was more than enough evidence to point to the possible diagnosis of subdural haematoma, and that an urgent CT scan should have been requested. At the very least, a full neurological examination should have been documented, and neurological observations instituted. The claim was settled for a substantial sum.

Learning points

  • It is imperative that a patient’s past history and medication plays its full part in the formulation of a current diagnosis. The failure to note the significance of the head injury, combined with warfarinisation, was the primary failure here. 
  • Dr A recorded that Mr O had had a CT scan after his fall. While this was incorrect, it was what Mr O had told him and he was correct to record it. It did not reassure Dr A that all was well, and he referred Mr O appropriately.
  • Good communication between primary and secondary care is a crucial patient safety issue. A discharge note from A&E, for example, would have prevented the confusion about whether Mr O had had a scan or not. Moreover, had Dr D paid more attention to the contents of Dr A’s referral letter, the poor outcome for Mr O might have been avoided.
  • Elderly patients on anticoagulants are particularly susceptible to subdural haematomas notwithstanding a therapeutic INR level.

Further reading

Rust T et al, Chronic Subdural Haematomas and Anticoagulation or Antithrombotic Therapy, J Clin Neurosci 13(8):823–7 (2006)