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An evolving situation

01 September 2010

Mr M, a retired 61-year-old, sustained a head injury when away on holiday with his wife. He slipped in the bath at their hotel and banged his head on the hard tiled floor. According to his wife, he was “knocked out” for a couple of minutes and appeared disorientated for a while afterwards. They attended the nearest Emergency Department (ED), where he was found to be neurologically intact and was discharged with head injury advice.

They returned home that same day and Mrs M insisted on taking her husband to their own hospital, as he kept complaining of a headache and was struggling to recall that morning’s events. Dr A assessed him and, in view of the increasing pain, amnesia and initial loss of consciousness, Mr M was given a head CT.

The on-call radiologist reported the scan as normal and Mr M was reassured and discharged. This time, he wasn’t given any information to take with him.

Over the next few days, Mr M felt increasingly lethargic and nauseated, and experienced several episodes of vomiting. Three days after the accident, he attended his local ED again, concerned about his persistent symptoms. Dr B, the junior doctor who saw him, was able to access the documentation from his prior attendance and was reassured by the normal CT. He requested some basic blood tests, which were normal, and discharged the patient with a diagnosis of viral gastroenteritis, telling him his symptoms had nothing to do with his head injury.

The following day, Mr M returned to the ED, feeling generally unwell with non-specific symptoms. He failed to mention his head injury to Dr C, presuming that his symptoms were unrelated and that the doctor would automatically read through the case notes from his earlier consultations. Dr C, unaware of the head trauma, ordered an abdominal USS that was also normal and he was advised to follow up with his GP.

Mr M slowly deteriorated over the next couple of weeks but chose not to seek medical attention, since everyone at the hospital had been so reassuring. He attributed his symptoms to a virus. When he finally arranged to see his GP, he was struggling to mobilise due to marked weakness in both legs, together with persistent vomiting. Dr T, his GP, sent him to hospital urgently where an MRI showed bilateral subdural haematomas that required surgical evacuation. The operation was a success and Mr M made a full recovery and was neurologically intact after the procedure.

Mr and Mrs M made a claim against the hospital.

The case experts were critical of the management of all of the doctors involved in the second hospital. Dr A should have given written head injury advice to Mr M on discharge, with clear instructions concerning the signs to look out for and when to return to hospital. Dr B should have repeated the CT, remembering that an intracranial haematoma is a dynamic process, and Dr C had failed to take an appropriate history and look at previous records.

The hospital settled for a moderate sum.

Learning points

  • All clinicians should be aware of the important “red flag” symptoms to screen for in patients with head trauma – which are laid out in national head injury guidelines, eg, in the UK, NICE clinical guidelines.
  • All patients presenting with head injury should be provided with written information to take home, to ensure they are aware of the need to return to hospital. 
  • It is important to take a thorough history and ascertain the information that the patient hasn’t volunteered. Avoid being misled by the outcomes of prior consultations. 
  • Patients often make false assumptions about the working of a hospital and what doctors already know about them. Make use of the resources you have available to you by accessing old notes and result servers. 
  • Don’t be falsely reassured. If a patient re-presents for the third time, think about what you might be missing. Remember that clinical situations may evolve. 
  • A subdural haematoma is a frequently missed diagnosis.
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