Health and Disability Commissioner
Te Toihau Hauora, Hauatanga
14 October 2011
UPPER XXXX 5018
Dear Mrs XXXXXX
Complaint: HXXX Hospital (XXXX Valley District Health Board)
Our ref: C1IHD0001XX
I write further to XXXXXXX XXXXXXXX letter of 22 August 2011 regarding the progress of your
complaint about XXXX Hospital.
I have now received all the necessary information to complete my assessment of your
complaint. This letter explains the steps taken to address your concerns, my decision, and the
reasons for it.
Around Christmas 2010 your husband started to experience the following symptoms; double
vision, tingling lips, faintness and falling over, photophobia and headaches. Your husband
visited his GP, Dr XXX who prescribed antibiotics for suspected sinusitis. Blood tests were
taken and were normal.
Over the next few weeks your husband continued to experience headaches and visual
problems and returned to his GP's practice, and was seen by Dr QXXXXX. Dr QXXXXX referred
your husband for an MRI and outpatients consult at XXXX Hospital. The MRI was scheduled
for 8 February 2011. Two days following this consultation you and your husband opted to
have a CT scan done privately and the result was normal.
On 27 January 2011 your husband experienced similar symptoms as before, but more severe.
He was taken to the Emergency Department at XXXX Hospital. You advised the doctor you
were afraid that your husband was going to have a stroke, and requested that he have his
scheduled MRI bought forward from 8 February 2011. The doctor informed you that this was only possible if you paid for it. Your husband was prescribed Cafergot and discharged.
Following your husband's discharge you went to the MRI Office and asked if they could
bring your husband's MRI forward , it was brought forward to 31 January 2011.
However, on 30 January 2011 your husband woke with a terrible headache, and ataxic
movements. Your husband was transported to hospital by ambulance. The ambulance
transfer report to the emergency department stated suspected stroke.
On arrival at the emergency department you were informed by doctors that they did not think
your husband was presenting with stroke. Rather, they suspected viral encephalitis, despite
not having an elevated temperature. Lumbar puncture and blood tests later showed that your
husband did not have viral encephalitis. Prior to these tests he was moved to an isolation
room, where he became hemiplegic, dysarthric and only able to speak out of the left side of
his mouth. At one stage a doctor informed you that they were still considering hemiplegic
migraine. Your husband's condition deteriorated and he was rushed to the resuscitation ward.
He was then moved to the intensive care unit in a critical condition where it was identified
that he had suffered a massive brain stem stroke.
You have two main concerns:
1) The doctor that saw your husband in the emergency department on the 27 January
2011did not organise an urgent MRI in light of his symptoms, despite you informing
him that your husband (aged 48) was a smoker, had high cholesterol, and had
suddenly developed problems that were suggestive of some sort of ischaemic process.
2) On 30 January 2011 your husband was seen again at the emergency department with
'`acute collapse" and was not given an urgent MRI, and again not treated for a
suspected stroke despite history and previous events.
You want to know if the treatment your husband received was appropriate and if his stroke
could have been prevented if doctors had made different decisions on his treatment.
You want the medical staff involved to review their assessment and treatment of a patient
with this type of history, and you hope that medical staffs do consider a family member's
suspicions regarding diagnosis.
• Comments and copies of all three ambulance reports from Wellington Free
• A copy of the images and report from your husband's CT scan performed at Pacific
Radiology Limited on 25 January 2011.
• Comments and clinical notes from Dr XXXXXX and Dr XXX.
• Response to your complaint and copy of your husband's clinical notes from XXXX
XXXX Valley DHB's response
On 30 May 2011 this Office received a response to your complaint from XXXX Valley DHB.
The DHB's response includes comments from XXXX Hospital's Clinical Head of the
Emergency Department, Dr XXXXXX XXXXXXX, and Medical Registrar, Dr XXXXXX XXXXX. I
have enclosed a copy of the DHB's response for your information, and therefore will not repeat all the details here.
However, I note that Dr XXXXXXX considers that a proper and appropriate assessment was performed on 27 and 30 January 2011.
Dr XXXXXXX considers the working diagnosis of migraine on 27 January 2011 was reasonable
and notes that an urgent MRI would not be a routine investigation for a patient presenting
with a migraine. Dr XXXXXXX believes there was no reason to advance the MRI that was
already scheduled in light of this diagnosis and the resolution of your husband's symptoms.
Dr XXXXXXX states that the possibility of an ischaemic episode was considered, but advises
that headache is a rather uncommon symptom in ischaemic strokes. Even if the diagnosis
had been transient ischaemia, Dr XXXXXXX considers it likely that your husband would have
been discharged and investigated as an outpatient as his ABCD2' score would have been
below the threshold for admission.
Dr XXXXXXX also discusses the treatment your husband received on 30 January 2011. Dr
XXXXXXX confirms that your husband had developed an encephalopathy, but notes that it was impossible to determine if it was infective or ischaemic on presentation. Dr XXXXXXX advises that the absence of temperature does not exclude a diagnosis of encephalitis.
Dr XXXXXXX supports the decision made to treat the encephalitis as infective in the first
instance, as he notes that failure to act upon an infective cause could have resulted in a
treatable cause getting worse. After disproving the presence of an infective cause, Dr
XXXXXXX states your husband was treated as a stroke patient.
Dr XXXXXXX advises that XXXX Hospital has no on-call facility for MRI after hours, and does
not believe that access to MRI on the Sunday would have altered your husband's management
On 14 July 2011 this Office wrote to neurologist, Dr XXXX XXXX (Christchurch Hospital), and
requested his advice on the standard of care provided to your husband. In addition, a number
of specific questions were asked of him, which were formulated by my in-house clinical
advisor after he conducted a preliminary review of your husband's clinical notes and response
from the DHB.
On 4 August 2011 I received Dr XXXX's advice, and I have enclosed a copy of his report for
Overall, Dr XXXX considers the standard of your husband's care was reasonable despite the
delay in diagnosis and poor outcome, noting that diagnosing stroke can be very difficult.
Clinical management of your husband on 27 January 2011
Your husband was diagnosed with probable migraine on 27 January 2011. Dr XXXX considers this diagnosis to be reasonable based on the information that was available to the emergency department physicians at the time, noting that your husband's symptoms were more
suggestive of migraine than brainstem ischaemia.
Dr XXXX acknowledges that your husband's history of cigarette smoking and
hypercholesterolaemia were not recorded, and notes that recording a patient's smoking
history should be a routine part of most medical assessments. Dr XXXX advises that there was
a degree of diagnostic uncertainty and that the possibility of a cerebrovascular disorder was
being entertained. Dr XXXX acknowledges that full consideration of your husband's history of
hypercholesterolaemia and smoking might have led the registrar to consider a cerebrovascular disorder more seriously. However, he does not believe this information, if considered, should have been expected to have made a difference to the primary diagnosis of migraine. Dr XXXX
considers the decision to continue planned outpatient investigations was appropriate, rather
than admit your husband and request an urgent MRI.
Scoring system developed to help physicians assess the risk of stroke. The acronym ABCD2 stands
for age, blood pressure, clinical symptoms, duration of symptoms and diabetes. When the doctor
calculates the patient's risk of impending stroke, he analyses each of those five factors and assigns a
number between 0 and 2 to each one. A total score of 0 to 3 is considered low risk.
For age, blood pressure, clinical symptoms, duration of symptoms and diabetes.
A total score of 0 to 3 is considered low risk. A score of 4 to 5 is
considered moderate risk. A score of 6 to 7 is considered high risk.
Dr XXXX considers the medical registrar's assessment to be largely appropriate. The registrar
did miss an opportunity to diagnose brainstem ischaemia during his assessment of your
husband. However, Dr XXXX states that the only hard sign of brainstem dysfunction described
on assessment was lower-motor neuron pattern right facial weakness, and notes that some
other more typical signs were absent, making the diagnosis difficult. Dr XXXX notes that the
registrar concluded correctly that the appropriate management plan was to treat as a stroke.
Dr XXXX suggests that had an MRI scan been available on 30 January 201 1 , the diagnosis of
stroke may have been made sooner, but any alternative treatment was unlikely to have
significantly altered the course of events.
Dr XXXX has outlined alternative treatment scenarios in light of the logistics of obtaining an
MRI after hours on a weekend, and has concluded that the hospital's decision to treat
empirically immediately with aspirin alone and defer imaging to the following day was
reasonable in the circumstances.
Dr XXXX also notes that your husband's outcome may have been worse had he been in transit
for his MRI when his condition deteriorated. When your husband's condition did deteriorate,
Dr XXXX considers the ICU team acted appropriately by stabilising him before obtaining a
definitive diagnosis with MRI the next morning.
Dr XXXX considers that the nature of the assessments and management decisions your husband
received at XXXX Hospital are likely to have been similar in many other New Zealand centres.
Dr XXXX states that the same decision to continue with urgent outpatient assessment after your
husband's first presentation on 27 January 2011 might have easily been made at Christchurch
Hospital as well, where there is a specialist acute neurology inpatient service. Furthermore,
Dr XXXX states that there is no guarantee that your husband's outcome would have been any
different if he had been treated at a hospital with an acute specialist neurology inpatient
A potential issue that was unrelated to your initial complaint was identified by Dr XXXX. Dr
XXXX considers that the decision to use ergotamine to treat a basilar-type migraine was
unfortunate and not current standard practice, due to concerns that it can narrow blood
DHB's response to Dr XXXX's assessment
On 22 August 2011 I sought he DHB's response to Dr XXXX's comments. In particular, I sought comment on the following matters:
• The prescribing of ergotamine.
• The failure to record your husband's past history of hypercholesterolaemia and
• The logistics of undertaking an MRI for a patient admitted to XXXX Hospital.
A copy of the DHB's response is enclosed for your information. In short, the DHB
• While Ergotamine is not usually prescribed for migraine at XXXX Valley DHB, the ED
registrar had previously worked in Australia. This drug is still used in other parts of
• It is undeniable that smoking and high cholesterol are risk factors in stroke and other
cardiovascular diseases, and their presence should influence the consideration of
stroke as a diagnosis, but Such action was unlikely to have influenced the final
• The MRI scanner at XXXX Hospital is not available after hours. Numbers of acute
MRI scans transferred to Wellington are less than one per month.
I have now reviewed the information on file relating to your complaint. Based on the
information I hold it appears that the treatment provided to your husband by the Emergency
Department Staff at XXXX Hospital was reasonable in the circumstances.
It seems that your husband's symptoms on
27 January 2011 were more suggestive of migraine. Accordingly, Dr XXXX believes it was appropriate for emergency department staff not to undertake an urgent MRI on 27 January 2011, considering migraine was the primary diagnosis. Whether or not the registrar considered your husband's history of cigarette smoking and hypercholesterolaemia appears to be inconsequential, but I have reminded the DHB that its emergency department staff should ensure a patients' full history is recorded.
While you feel hospital staff disregarded your suspicions regarding your husband's condition,
Dr XXXX (after reviewing your husband's clinical notes) has confirmed that the possibility of
an ischaemic episode was considered on 27 January 2011. The DHB has also outlined its consideration of your husband's symptoms and has discussed its rationale for diagnosing migraine.
It is clear that XXXX Hospital has constraints that inhibit it from undertaking MRI's after hours.
However, it seems unlikely that an earlier MRI scan on 30 January 2011 would have altered
your husband's initial management or his outcome. An opportunity was missed to diagnose
his condition earlier, but a decision was made shortly after to treat your husband's condition
as stroke, and this decision was made prior to his seizures and deterioration.
Therefore, apart from advising the DHB to remind its emergency department staff to
thoroughly assess and record a patient's history, I have made a decision, in accordance with section 38(1) of the Health and Disability Commissioner Act 1994, to take no further action
on your complaint.
I appreciate that this year's events have been distressing for both you and your husband.
However, I hope the information gathered during my assessment of your complaint, and
outlined in this letter and attached correspondence, provides you with some reassurance that your husband received care from the Emergency Department Staff at XXXX Hospital that was
reasonable in the circumstances.
I wish you and your husband all the best for the future.
Thank you for bringing your concerns to my attention.
Deputy Health and Disability Commissioner