Patient with bleeding on the brain not treated early enough

What happened

Mr P collapsed at home and was taken to A&E. At the time he was taking warfarin (a blood–thinning medication). The A&E doctor who first assessed him made a provisional diagnosis of syncope (loss of consciousness) possibly due to a cardiac cause and dehydration, and referred him to the on–call medical team for assessment. A second doctor noted that Mr P's blood results showed a high international normalised ratio (INR) level (a test for blood clotting). Just over an hour later, a specialist registrar saw Mr P and requested an urgent CT scan in order to exclude the possibility that he had had an intracerebral bleed. However, the radiology department was not told that this scan was urgent. The scan was eventually scheduled for about two hours later.

Mr P's condition deteriorated and so the scan was delayed. The medical team reviewed him and gave him vitamin K which helps the blood to clot. When the scan was done it showed a large intracerebral bleed. Doctors gave him medicine to reverse the effect of warfarin in order to try to halt the bleeding, and contacted the neurosurgeons. The neurosurgeons considered that surgery would not benefit Mr P. He fell into a coma and, despite treatment, did not regain consciousness. He died the following day.

What we found

We partly upheld this complaint. There were failings in record keeping and in the medical and nursing care Mr P received. In particular there were missed opportunities to providehim with earlier investigations and treatment (the warfarin reversal agent), so that he could have had surgery.

Vital blood results were delayed by approximately an hour because staff had taken inappropriate samples. The second doctor who reviewed Mr P failed to act on his abnormal blood results or escalate his case for further urgent medical attention. This meant a registrar did not review Mr P for over an hour.

When a doctor asked for a CT scan, he did not tell the radiology team that it was urgent. Also, there was enough evidence to warrant giving Mr P the warfarin reversal agent before the CT scan. However, doctors did not give it to him at that time, which meant this was another missed opportunity totreat Mr P sooner.

We were unable to say what would have happened if the failings we found had not happened and Mr P had received earlier treatment. We did, however, find that the Trust had not done enough to address the impact of the failings on Mr P's family, or address the risks for future patients.

Putting it right

The Trust wrote to Mrs G to acknowledge the failings we found and apologised for the impact of these. It also paid her £400 in recognition of the ongoing distress she experienced as a result of the failings in her father's care. This was also to acknowledge the uncertainty about whether his outcome could have been different had the failings not occurred, and the way in which the Trust responded to her complaint.

The Trust prepared an action plan to show what it had done or planned to do to make sure that it had learnt from the failings.