Settlement for delayed diagnosis of subdural haematoma in elderly patient after a hospital fall

We have successfully settled a clinical negligence claim for an elderly patient’s family against Royal London NHS Foundation Trust for a failure to perform a CT scan after the patient, who was on blood-thinning medication, suffered a fall during his admission for a fractured hip.

The patient, who was aged 86 at the time of the incident, was admitted to the trust having suffered a fall at home and a fracture to his right hip. He was noted to be on warfarin, a potent blood-thinning medication used to manage an underlying heart condition. He was also noted to have a history of dementia and anxiety.

A CT scan was undertaken on admission to rule out a bleed on the brain due to his increased risk of bleeding and the history of a recent fall. The CT scan confirmed no active bleeding. The patient’s warfarin was ceased to prepare him for hip surgery, and he was instead placed on low-molecular weight heparin combined with aspirin.

He underwent hip surgery the following day and remained in hospital for recovery and rehabilitation. During his recovery, he was noted to suffer fluctuating levels of confusion and anxiety and could not be relied upon to safely mobilise without support. He was deemed to require an enhanced level of supervision by nursing staff and was placed on a close observation bay.

At approximately 8.30pm, ten days post-operatively, the patient was found on the floor by nursing staff having suffered an unwitnessed fall. He was hoisted back onto the bed by staff. A full body check revealed a laceration to the head, and the patient was placed on neurological observations to monitor his recovery. It was noted that he was in a state of confusion and that he was still being medicated with low-molecular weight heparin and aspirin at this time.

The patient remained confused, which staff attributed to his underlying dementia. Three days later he was subsequently stepped down to a rehabilitation ward for discharge planning, at which point he was placed back on warfarin. Sadly, his condition continued to deteriorate. It was considered that he was suffering from delirium secondary to his hip wound re-opening and a chest infection. He was transferred back to the Barnet General Hospital for debridement surgery and secondary wound closure.

Despite the closure of his wound, the patient continued to present as drowsy and confused. Seventeen days after he suffered the fall, a head CT scan was ordered which revealed an acute on chronic subdural haematoma. He was subsequently transferred to a specialist hospital for neurosurgical management including burr-hole evacuation.

Unfortunately, the patient made a poor recovery following burr-hole evacuation, suffering from slurred speech, seizures and myoclonic jerks. He required 24-hour nursing care until he sadly passed away a year following his discharge.

We were instructed by the deceased’s family to investigate the care and treatment provided by the trust. It was their case that despite being identified as a high risk patient, he was not closely monitored. Nursing expert evidence was obtained, which highlighted numerous failures in the monitoring that was provided. It was concluded by the nursing expert that on the balance of probabilities, the unwitnessed fall in hospital could have been avoided had he been monitored appropriately.

Further evidence was obtained from orthopaedic and neurosurgical experts. It was considered that following the fall and noting a head injury, the deceased should have undergone a head CT scan to exclude a bleed on the brain. Whilst the deceased was not on warfarin, he remained anticoagulated on low-molecular weight heparin and aspirin. It was considered that had this been appreciated, his warfarin would not have been recommenced as this further exacerbated the bleed on the brain.

The defendant trust denied liability at the pre-action phase and throughout the duration of the litigation. However, it ultimately conceded that warfarin should not have been recommenced and that the management of the deceased’s hip wound was substandard, but it was disputed that the unwitnessed fall could have been prevented and that a head CT scan was mandated immediately after the fall.

The parties ultimately reached a compromise and agreed a settlement shortly before trial.

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