Trust failed to treat a suspected stroke

What happened

In early 2014, Mrs F was taken ill while away from home. She was unable to stand or to use her right arm properly and a taxi driver took her to the minor injuries unit. The taxi driver, who had known Mrs F for a number of years, told the reception staff that he thought that she had had a stroke. Nursing staff saw Mrs F. They recorded she was feeling unwell, left a message for her GP to contact her at home and then discharged her. Mrs F was alone at home until her GP contacted her about two hours later. By this time, her condition had worsened and her GP identified that she was suffering from a stroke and called an ambulance. Mrs F was admitted to hospital where staff confirmed that she had had a stroke.

What we found

Minor unit injuries staff did not properly check Mrs F for the possibility of a stroke. Front line staff, even those in a minor injuries unit, should recognise the possibility of a stroke and complete an appropriate diagnostic assessment. That did not happen in Mrs F's case. Staff also did not refer her to another practitioner, which would have been appropriate. The Trust said that reception staff cannot pass on suspected diagnoses from members of the public to nurses, however, it is reasonable to expect reception staff to alert clinical staff when a potentially serious case presents.

The taxi driver knew Mrs F and could have given useful information about any change in her normal function or behaviour. Time is critical when treating stroke, but as a result of the failings, Mrs F had to wait longer for her condition to be identified. That caused her additional worry and meant her symptoms worsened. The Trust also put Mrs F at risk of further health problems because of the delay in diagnosis.

Putting it right

The Trust apologised for the failings we identified and explained what it had done to make sure it had learnt the lessons from the failings so that they are not repeated.