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Heading for trouble

01 January 2007

In early 2001,Mr B, a 20-year-old bricklayer, presented to his local A&E department one night, after falling off a wall whilst “larking about” with his friends on a night out. He fell about three metres and hit his head on a bench before hitting the floor. He had not lost consciousness and apart from a nasty headache felt otherwise well. He was fully alert and orientated in space and time with a Glasgow Coma Scale (GCS) of 15/15.

A neurological examination revealed no abnormality. His skull x-ray showed a small, undisplaced left-sided parietal fracture. Mr B was admitted to the A&E department's observation unit and discharged home with a head injury information card, after being seen by the unit’s specialist registrar the following morning.

Over the next five weeks, Mr B attended his GP surgery and saw Dr U on four separate occasions. He complained of headache, blurred vision in his left eye, chronic nausea, dizziness and feeling unsteady on his feet. Dr U noted normal reflexes and equally reactive pupils on each occasion and prescribed co-codamol, metoclopramide, diclofenac and, on one occasion, diazepam, considering that Mr B’s symptoms were largely due to anxiety.

Mr B also went back to the A&E department on two occasions. Each time an absence of neurological signs was documented, with GCS of 15/15. He was discharged both times and advised to see his GP if his symptoms did not resolve.

Five weeks after his initial head injury, Mr B called an ambulance and was taken to hospital. In the A&E department he complained of exruciating, unbearable headache, recurrent vomiting,and drowsiness that had lasted for several days. He saw a doctor three hours after his arrival in the department, when his GCS was noted to be 12/15. An urgent CT of his head was arranged which was completed four hours later. It showed a large subdural haematoma which was compressing the left lateral ventricle.

He was referred and transferred to the regional neurosurgical unit where he underwent craniotomy and evacuation of clot 12 hours after his initial presentation in A&E. Unfortunately, Mr B sustained severe long-term neurological damage, such that he was no longer able to work.

Expert opinion

We asked GP and emergency medicine experts to comment on the case and both found the doctors’ management indefensible. Their most critical comments focused on the following aspects of Mr B’s care:

  • Mr B’s persistent symptoms should have raised serious concerns of an intracranial complication of his skull fracture, and prompted his GP to examine him more thoroughly and consider asking for expert input in his ongoing management.
  • Those who saw him in the A&E department on his first re-attendance should have been similarly concerned and arranged a CT scan of his head and/or referred him for neurosurgical advice.
  • When he did present acutely, there were unacceptable delays in his initial assessment, in the time it took to arrange a CT scan, and in the speed of his transfer to the neurosurgical unit.
  • The documentation of Mr B's neurological signs, both by his GP and by the A&E department, left a lot to be desired. Most entries consisted simply of the comment: neurological system NAD.

The case was settled for a substantial sum.

Learning points

  • Where a patient has persistent symptoms following a significant head injury, and especially where there has been a skull fracture, there should be a high index of suspicion of an intracranial complication, particularly an extradural or subdural haematoma. Symptoms such as persistent headache, retro-orbital pain, nausea, vomiting, visual disturbance or drowsiness should act as red flags in this situation.
  • Urgent investigations, such as an acute CT scan of the head, should be carried out as quickly as possible. If there are delays in the system that are avoidable they should be addressed and circumvented. It is unlikely that logistical delays in arranging such investigations would be an acceptable defence in the event of an adverse outcome.
  • Where acutely-ill patients need to be transferred between hospitals, an explicit system should be in place to ensure that this happens as quickly as possible, and that the appropriate medical personnel and equipment are available to carry this out. Those responsible for clinical governance and patient safety in A&E departments should examine their procedures and staffing arrangements regularly to prevent avoidable delays.
  • Where patients re-attend a department, it is always a good idea to check over any previous documentation.
  • In the UK, NICE issued guidance in 2003 on the management of patients following head injury. It is available online at www.nice.org.uk.
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