The Royal Wolverhampton NHS Trust

5. Miss Q complains about the care her mother, Mrs Q received from The Royal Wolverhampton NHS Trust in November 2023. Specifically, she complains:

• on 3 November 2023, the Trust did not send her seven-day referral to the stroke clinic

• on 19 November, a doctor did not assess her properly, did not get specialist input, and discharged her when not medically fit.

6. Miss Q believes her mother had a more severe stroke, and that the stroke might have been avoided altogether had things been done correctly. She says her mother suffered life limiting changes to her mobility and a reduced quality of life before she died. She believes better care would have resulted in a better prognosis.

7. Miss Q wants the Trust to acknowledge what went wrong and make service improvements. She also wants the Trust to apologise to her and pay her financial compensation.

8. On 2 November 2023, Mrs Q began with a headache which by 3 November progressed to weakness and slurred speech. She attended A&E, received aspirin, and a CT scan, which was clear. Her symptoms resolved and she was discharged on a seven-day referral to the TIA clinic, but staff did not send the referral.

9. The Trust did not send the referral to the TIA clinic and on 19 November, Mrs Q attended A&E again with returning symptoms, plus a five-minute period of unconsciousness. She was discharged again after the symptoms resolved, with the same referral to the TIA clinic, which staff this time sent.

10. The TIA clinic saw Mrs Q on 23 November. That morning, she had woken with acute left sided weakness and upon examination the clinic opted to admit her for further investigation.

11. She received a CT scan within one hour of admission. She had a CT angiogram on 24 November, an EEG on 27 November and on 8 December, a routine MRI scan. During this time, staff confirmed evidence Mrs Q had suffered a stroke.

12. She remained an inpatient until she was discharged with a care package on 30 January 2024.

13. Mrs Q has since died.

3 November

18. Miss Q complains that when A&E staff sent her mother home from hospital, they should have sent a referral to the TIA clinic but did not. She says this led to her mother collapsing at home on 19 November with worsening symptoms.

19. The Trust accepted staff did not send the referral and apologised. It said that if staff followed the correct pathway, the TIA clinic would have assessed Mrs Q within the week. In response to this oversight, the Trust said it had reminded A&E staff of the correct pathway and created a poster to remind those staff in real time.

20. Mrs Q had a CT scan of her brain on 3 November. This did not show any signs of a new stroke. However, our neurology adviser explained that a CT scan does not rule out a TIA.

21. Both our physician and neurology advisers directed us to the Royal College of Physicians National Clinical Guideline for Stroke (2023), which sets the timescales for scenario specific patients. This says that patients with symptoms older than seven days should be seen in a TIA clinic within a week. For seven days and under, it directs a TIA assessment within 24 hours.

22. Miss Q told us her mother’s symptoms had begun the day before, prompting a visit to her GP. Staff note a history of similar symptoms between 28 October and 2 November and highlight that in part, some of Mrs Q’s described symptoms had since resolved.

23. The Trust accept that it should have sent Mrs Q to the TIA clinic on a seven-day referral. Mrs Q’s oldest documented symptoms had begun exactly seven days earlier. This means that she was on the threshold but ultimately should have been referred on the shorter pathway and seen within 24 hours.

24. Although the Trust accept that what happened was not in line with what should have happened, its complaint correspondence indicates that the plan in place for Mrs Q still fell outside of national guidance. That plan would still have amounted to a delay of up to six days for assessment. We think this amounts to a significant failing.

Impact

25. If Mrs Q had been sent on a seven-day referral, the TIA clinic would have seen her on or before 10 November. On the correct 24-hour referral, she would be seen no later than the morning of 5 November. Because staff took no action, Mrs Q presented at hospital again on 19 November.

26. She was experiencing repeat symptoms of left sided weakness and facial droop, and new symptoms of slurred speech and an immobile left arm. Mrs Q was also reported to have experienced a period of unconsciousness. This must have been especially worrying for Mrs Q and her family because she had received no follow up from the last time she needed to go to hospital for similar symptoms. The family’s concern that Mrs Q had an undiagnosed and therefore untreated stroke is documented within the records.

27. Our neurology adviser explained that whilst there is good evidence to show prompt attendance at a TIA clinic can prevent TIA’s, or a stroke, there are no guarantees. We therefore cannot say with certainty that a 24-hour, or seven-day referral on 3 November would have prevented the new symptoms she went on to experience. However, our neurology adviser explained that the TIA clinic may have altered her medications or identified an underlying cause. Therefore, it is possible.

28. To consider the impact of this missed opportunity, we need to consider what happened next.

19 November

29. Miss Q says on 19 November, her mother presented with new worsening symptoms. She also visibly deteriorated in the waiting area, but staff took no information from the family who witnessed the event, and she later discovered they had also incorrectly recorded her muscle power score. Whilst staff did submit a TIA referral this time, Miss Q worries these oversights contributed to the incorrect decision to discharge her mother.

30. The Trust said Mrs Q attended with another episode of left sided weakness and facial droop, along with slurred speech. Because she had another CT scan, was already on a full dose of aspirin and her symptoms had again resolved, staff discharged her home, and to the TIA clinic.

31. The records show Mrs Q was conscious and alert and there is nothing to say whether staff spoke to family members. However, the symptoms detailed in the records and on the subsequent TIA referral show left sided weakness, an immobile left arm, facial droop, slurred speech, and a reported period of unconsciousness. These are all very worrying symptoms, and we can appreciate how important communication with clinical staff was to the family here. The symptoms listed are in line with what Miss Q told us, which is reassuring, and means we are satisfied the Trust did have an accurate picture of what was happening.

32. The notes show staff awarded Mrs Q the highest available muscle power score of five. Miss Q has some video footage of her mother taken on this day, but we could not accurately measure power on sight alone. This requires physical examination. We only have the TIA clinic’s scoring system for comparison, but this assessment took place at a later date.

33. Our physician adviser highlighted that Mrs Q’s period of unconsciousness and post episode symptoms of confusion, dysarthria (slow speech) and weakness were not typical of a TIA. This episode on 19 November was the third since 28 October. Our adviser explained that this indicated a high probability of seizures, and A&E physicians would typically be aware that this can also be a rarer presentation of a stroke.

34. Our physician adviser also noted that the NICE Stroke and TIA Clinical Features (September 2021) shows the symptoms listed in the records to be more consistent with a suspected stroke.

35. However, our neurology adviser explained that had Mrs Q been admitted on 19 November, there was very little for neurologists or stroke doctors to act on because she did have another CT scan during this visit, which our adviser again confirmed showed no evidence of a new stroke.

36. The Trust discharged Mrs Q on a seven-day TIA referral. Mrs Q’s symptoms were less than a week old, so in line with the timescales set out in RCP’s National Clinical Guideline for Stroke (2023), this should have been another 24-hour referral.

37. Had Mrs Q been examined by a stroke or neurology specialist, our neurology adviser explained that this would have been the likely outcome. This means that no matter which kind of doctor assessed Mrs Q, we can see a second missed opportunity to appropriately follow the correct pathway for her symptoms. We think that as before, this amounts to a failing.

Impact

38. The TIA clinic saw Mrs Q on 23 November, three days later than it should have on this occasion, and 19 days late overall. The records show this appointment resulted in immediate admission to hospital, due to left sided weakness. Sadly, hospital staff then did confirm Mrs Q had suffered a stroke.

39. Our neurology adviser confirmed that Mrs Q’s CT scan on 19 November was clear, so we know that the stroke occurred after this point. They explained that unfortunately, it was not possible to say whether prompter TIA clinic intervention would have prevented the stroke. They noted Mrs Q was already on the appropriate medications and whilst the clinic may have changed some of these, their doses, or frequency, there is no specific action it could have taken to definitively ensure the stroke would not occur.

40. This means that we cannot say with certainty that Mrs Q’s stroke could have been prevented. Prompter assessment may have prevented a stroke, but it may not have made a difference either. We recognise this is not the clear-cut answer Miss Q was hoping for.

41. With recurring and worsening symptoms, even if the TIA clinic had taken no action, it would have been able to provide Mrs Q with advice and reassurance, and she would hopefully have felt supported by specialists.

42. Miss Q tells us that she was very worried about her mother, particularly that she might deteriorate. The inaction at the time increased this worry and caused her a great deal of concern and stress. We recognise how much this must have increased when Mrs Q was eventually diagnosed with a stroke on 23 November.

43. We have seen evidence of failings because the Trust sent no TIA referral on 3 November when it should have and sent a referral on 19 November on the wrong timescale. Whilst we cannot say sooner intervention would have prevented the stroke, both mistakes meant that Mrs Q certainly did miss opportunities on 3 and 19 November for specialist assessment, possible mitigation, and that much-needed reassurance. We think these missed opportunities are significant enough to partly uphold the complaint.

1. We think the Trust missed two opportunities to refer Miss Q’s mother, Mrs Q, to the TIA clinic at the right time and within the right timeframe, in line with national stroke guidance.

2. Whilst we will never know whether Mrs Q’s stroke could have been prevented, it is our view that Mrs Q may have missed the opportunity for a better clinical outcome, through specialist assessment. This would have alleviated a lot of the distress and worry that Miss Q experienced each time her mother developed new symptoms or had to go back to hospital.

3. The Trust has taken some actions to ensure service improvements, but we do not think these go far enough. Therefore, we will partly uphold the complaint.

4. We make recommendations at the end of this report.

44. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

45. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

46. We have identified failings in relation to Mrs Q’s TIA referrals. We consider that these deprived her of her best chance to prevent the stroke or provide reassurance that she was being looked after at a significantly distressing time. The distress this caused Miss Q as a result, could have been avoided.

47. With that in mind, we recommend the Trust:

• writes to Miss Q within two months to acknowledge the failings we have identified and apologise for the impact

• pays Miss Q £400 within two months in recognition of the missed opportunities for intervention and reassurance because these cannot be put right through service improvements and an apology is not sufficient on its own

• takes steps to ensure A&E staff are aware that symptoms lasting seven days fall into the 24-hour TIA referral criteria and not the seven-day pathway, in line with the RCP’s National Clinical Guideline for Stroke (2023). The Trust will share the steps it has taken with us, within two months of the date on our final report.

48. We ask the Trust to send us evidence it has completed all the recommendations we make in the final report. We will also ask the Trust to send the evidence to NHS England.