Multiple presentations to ED before stroke diagnosis

Health and Disability Commissioner Anthony Hill today released a report finding Canterbury DHB in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman who was later diagnosed with strokes.

A woman went to the Emergency Department (ED) four times over three days, for worsening neck pain and headache, pulsing noises, vertigo and vomiting. At the first three visits she was diagnosed with a severe ear infection and migraine and discharged. The woman said she felt uneasy leaving the hospital and was in persistent pain.

She was referred to the Ear, Nose and Throat (ENT) service at her second and third visits but it was not until her fourth visit to ED that she was reviewed by a senior doctor or given a CT scan, which revealed she had suffered two strokes.

Anthony Hill said ENT doctors failed to discuss the woman’s presentation with a consultant and failed to show critical thinking and make the necessary active diagnostic enquiries, despite the fact she was re-presenting with concerning unresolved symptoms.

"This case demonstrates the significance of the patient’s voice and the importance of listening to the patient’s experience," Anthony Hill said.

Anthony Hill criticised the care provided by the DHB’s ENT service, saying it had contributed to the delayed diagnosis of the woman’s condition. He considered this demonstrated a pattern of poor care and accordingly found the DHB in breach of the Code.

He recommended that the DHB apologise to the woman. He made a number of other recommendations relating to the oversight and support of junior doctors and guidelines for when a patient returns to ED including when to escalate.

The full report for case 17HDC00725 is available on the HDC website.

ENDS

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