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Sudden, first and worst, again

01 May 2008

Miss H was 25, had hardly ever been to her GP and was not taking any medication. She was a keen salsa dancer and lived in a flat with two friends.

Miss H had just started working as a qualified accountant. One afternoon, she left work early and went to her GP practice because of a severe headache. She saw Dr S and explained that she was worried because she did not normally get headaches. Dr S established that Miss H did not have any other symptoms and reassured her that this was probably a tension headache. He prescribed paracetamol and advised Miss H to get a good night’s sleep.

Miss H missed her dance class that evening and felt too ill to work the following day. She went back to her GP practice, but Dr S had no free appointments so she saw Dr A instead. When Dr A heard that Miss H was now vomiting, he suspected that she was having a migraine. He advised her to go home and rest. Dr A explained to Miss H that her symptoms would probably improve over the next few hours. If not, he advised her to come back to the surgery or go to A&E.

Miss H went home, but didn’t manage to sleep. She wasn’t feeling any better by early evening, so she went to her local A&E department. She explained to Dr W, a junior doctor, that she’d already seen two different GPs, but still had a headache. Dr W decided to see how Miss H progressed after more paracetamol and an anti-emetic. By the early hours of the morning, Miss H seemed unchanged. She said her headache wasn’t any worse, so Dr W decided to discharge her.

Although she did not feel any better, Miss H struggled downstairs the following morning. She lost consciousness at the breakfast table so her friends rang for an ambulance. At the hospital, a CT scan confirmed that she had had a subarachnoid haemorrhage. Before she could be operated on, she suffered a further haemorrhage.

Miss H was left with neurological disabilities. She began a claim against the GPs (both members of the MPS) and the hospital.

Expert opinion

GP experts were supportive of Dr S’s care. His suggested management was reasonable for a short history of headache in a previously healthy young woman. Dr S did not suspect a subarachnoid haemorrhage and Miss H did not mention that her headache was of sudden onset.

On the whole, GP experts were supportive of Dr A. His assessment showed reasonable judgement. He advised Miss H what she could expect if she was having a migraine and told her what to do if her condition did not improve as he predicted.

However, the experts were concerned that neither GP had made a note of whether the headache was, or was not, of sudden onset, and had not recorded the intensity.

An expert in emergency medicine was critical of the care given to Miss H at the A&E department. Miss H had had a severe headache for over twenty-four hours by the time she went to hospital. Dr W should have ruled out serious causes of headache, such as subarachnoid haemorrhage. From the A&E records it seemed unlikely that Dr W had asked about the onset and severity of the headache.

The claim was settled by the hospital for a high sum, with a small contribution from MPS.

Learning points

  • Subarachnoid haemorrhage crops up frequently in MPS case files. Although it is rare, in cases of headache it is important to consider it before less sinister causes.
  • Patients do not necessarily know what is important about their history, yet most diagnoses are made on history. It is up to the doctor to find out any potentially significant details that a patient does not volunteer. In this case, nobody established whether or not Miss H’s headache was either of sudden onset or its true nature. This should be asked and recorded in cases where subarachnoid haemorrhage is a possibility.
  • When patients present repeatedly over a short period of time with symptoms that are not improving, it is important to reconsider their diagnosis. Do not assume that relevant questions have already been asked. Eliminate serious possibilities first.