Royal United Hospitals Bath NHS Foundation Trust

4. Mrs C complains the Trust misdiagnosed her stroke for a bad migraine on 21 November 2021 and sent her home. The doctors did not give her thrombolysis medication (medication to dissolve blood clots) before discharge.

5. As a result of these failings Mrs C says: • she has been left with no feeling in her right arm/hand and some of her right side • she has long term fatigue and nerve pain • she has been medically retired, as she was unable to do the job she was in before the stroke.

6. In bringing this complaint to us, Mrs C seeks financial compensation.

7. What follows is our summary of events. We have not included all the full details as those involved are already aware of this information. However, we have included this brief background to put this complaint in context.

8. On 21 November 2021 Mrs C started to feel unwell with left-sided headache, a left-sided facial droop and slurred speech. Her husband called for an ambulance.

9. When the ambulance arrived, Mr C noted Mrs C’s issues had resolved within 15 minutes and he could no longer observe any facial weakness.

10. The ambulance transported Mrs C to the Trust’s Emergency Department (ED) following symptoms of a suspected stroke.

11. On arrival at ED, clinical staff conducted an assessment and carried out a range of tests. Following this, the Trust discharged Mrs C with a follow-up appointment at the TIA clinic for the following day. It did not prescribe any thrombolysis treatment.

12. The following day, the TIA clinic confirmed Mrs C had indeed experienced a left acute cerebral infarction (stroke).

13. Mrs C tells us she has been left with permanent effects as a result of the stroke.

TIA misdiagnosis

17. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

18. Mrs C tells us she started to experience stroke-like symptoms on 21 November 2021, around ten days after she had breast surgery. She and her husband noticed that at 4.30pm she had a left-sided headache, associated with slurred speech and a left-sided facial droop.

19. Mrs C’s husband called the ambulance. When it arrived on scene, he reported her slurred speech had resolved within 15 minutes. He did not notice any more evidence of facial weakness.

20. The ambulance crew’s assessment was also Mrs C’s symptoms had resolved within a few minutes and that it might have been a potential TIA. This is a temporary blockage of blood flow to the brain, often also referred to as a ‘mini stroke.’ It lasts only a few minutes and does not usually cause long-term damage.

21. The Trust’s ED staff ran tests and found Mrs C’s observations were normal. There was no weakness, altered sensation, or lack of coordination. Staff noted she had normal facial movements and normal blood tests. Mrs C had a brain CT (a scan taking detailed images inside the body) which showed no detectable stroke at that time.

22. The Trust’s response explains the differential diagnosis (possible diagnoses doctors were considering) was a migraine or TIA. Staff discharged her with a referral for a follow-up the next day in the TIA clinic.

23. Mrs C says ED was very busy during her attendance and remains of the belief that, also because of this, clinicians did not investigate her properly with further tests, such as a brain MRI (magnetic resonance imaging – a type of more detailed imaging surveillance of the body) or provided her with thrombolysis medication to treat her suspected TIA before discharging her.

24. We note the Trust’s email to her dated 20 September 2022 says that, as her symptoms had resolved in the ambulance and during ED observations, it was not necessary to carry out any further tests or prescribe thrombolysis medication. The Trust said this decision would have also been the case even if the TIA Clinic had seen her on the night of the event.

25. In considering what should have happened we obtained clinical advice and reviewed GMC good medical practice and NICE stroke guidelines.

26. GMC good medical practice (section 15) says doctors must provide a good standard of care. It says this this includes adequately assessing patients’ conditions, promptly providing or arranging suitable advice, investigations or treatment where necessary, and referring to another practitioner when this serves the patients’ needs.

27. NICE stroke guidelines say (section 1.2) says for people who have had a suspected TIA or acute non-disabling stroke:

• do not offer a CT bran scan unless there is a clinical suspicion of an alternative diagnosis a CT could detect • after specialist assessment in the TIA clinic, consider an MRI scan to determine which parts of the brain are affected, or to detect bleeding on the brain or alternative possible diagnoses – it says if MRI is done this should be on the same day as the assessment in the TIA clinic

28. We asked our adviser’s opinion on whether the Trust had taken all appropriate steps in investigating and caring for her symptoms. Based on Mrs C’s history and resolved neurological symptoms, our adviser explained nothing else should have happened and no other investigation or treatment was necessary while Mrs C was in ED.

29. Mrs C’s records document the attending clinician had noted blood tests and arranged a CT scan of the head which showed no abnormality. NICE guidelines do not recommend a CT scan for people with a suspected TIA, so the Trust provided care above the expected standard in carrying out this test in ED.

30. We are satisfied ED carried out all appropriate investigations and followed guidelines in discharging her by also referring her to a TIA Clinic the following day with no additional action required. As set out in NICE stroke guidelines, an MRI scan should only be considered after assessment in a TIA clinic. Given the CT scan did not detect any brain abnormality, an MRI scan was not clinically justified while Mrs C was in ED.

31. We asked our adviser if ED staff were clinically accurate and justified when giving Mrs C a differential diagnosis of either TIA or migraine. Our adviser explained that as Mrs C’s symptoms had resolved it was reasonable to consider she may have had a TIA.

32. Our adviser explained that as Mrs C’s symptoms had resolved, it was appropriate to consider Mrs C may have had a TIA and refer her for follow up in the TIA clinic to investigate this further. NICE stroke guidelines say if a TIA is suspected, clinicians should refer the patient immediately for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.

33. We are satisfied the Trust carried out all recommended investigations, treatment and referrals in a timely manner, considering all of the above reasons, clinical advice received and relevant NICE guidelines.

Lack of thrombolysis prescription

34. Mrs C complains the Trust did not prescribe her thrombolysis when she first attended ED because she suspects she was experiencing a stroke. She firmly remains of this opinion also because the ambulance paramedics marked this as a suspected diagnosis on their records.

35. In its response to Mrs C on 20 September 2022, the Trust explains thrombolysis medication can indeed be administered in the Emergency Department for strokes. However, this type of treatment carries significant, high-risk effects and there is a strict protocol to follow for its safe use.

36. The Trust’s assessment in ED included scoring Mrs C against an internationally and widely used scoring system called the National Institute of Health Stroke Scale (NIHSS). This is a set of criteria quantifying if and how severe stroke symptoms in a patient are and monitor for neurological changes over time.

37. The Trust’s clinical opinion is that, as Mrs C scored low on the NIHSS scale, the benefits of thrombolysis treatment would not have outweighed the significant risks it carries. It therefore decided against prescribing it in her case.

38. NICE stroke guidelines say thrombolysis can be given in the emergency department to patients who have been diagnosed with acute ischaemic stroke (a stroke caused by blood flow to the brain being blocked).

39. Our adviser explained it was appropriate not to include thrombolysis in Mrs C’s medications in ED as her symptoms had resolved while she was there and there was no clinical indication she was experiencing a stroke at that time.

40. Our adviser confirmed thrombolysis carries significant high risks and, if given when not clinically necessary, it may make a patient’s condition considerably worse or be even fatal.

41. Given Mrs C’s symptoms had resolved the evidence suggested she had not had a stroke and was therefore not suitable for thrombolysis and this could have been dangerous.

42. With this in mind, we consider ED clinicians acted in line with all relevant guidance when they did not administer thrombolysis medication.

43. We fully recognise how distressing this experience was for Mrs C, particularly as she experienced considerable pain and worry whilst in ED. It is understandable that this caused confusion and concern about whether the treatment may have contributed to her decline.

44. Based on all the evidence available, we have not seen any indications the Trust got anything wrong. The investigations, clinical assessment and medication given appear to have been appropriate, clinically justified, and in line with recognised care practice.

45. Whilst our decision does not diminish the distressing and worrying events Mrs C experienced, we hope our explanation brings some reassurance the care and treatment the Trust provided her was in line with the relevant standards.

46. We appreciate the time and effort involved in raising these concerns and we thank Mrs C for bringing her complaint to our attention.

1. We have carefully considered Mrs C’s complaint about Royal United Hospitals Bath NHS Foundation Trust (the Trust). We are very sorry to hear of her experience at the Trust and acknowledge the physical challenges she has faced.

2. We appreciate the importance of Mrs C’s concerns about the assessment and treatment of a potential TIA (transient ischaemic attack, a temporary blockage of blood flow to the brain, often referred to as a ‘mini stroke.’) in November 2021. We have carefully considered all her concerns.

3. Having reviewed all available evidence, we have seen no indication that anything went seriously wrong. We have decided to take no further action. We have explained the reasons of our decision in detail below.