Mismanagement of head injuries in A&E – common themes from medical negligence claims

Posted: 04/09/2023

One of the issues that we deal with regularly as a clinical negligence team is management of head injuries and signs of brain injury within emergency departments. The role of the emergency department is essentially to identify those patients with conditions that require urgent attention and ensure a treatment pathway for them. However, far too often we see a failure to recognise signs that someone has suffered a form of brain/neurological injury or dysfunction or may be at risk of such injury. The outcome of these failures is likely to be avoidable permanent and sometimes catastrophic or fatal brain injury.

Some of the cases our clinical negligence team have dealt with include:

an elderly gentleman who fell and hit his head. Despite being on warfarin (an anti-coagulant) and reporting a history of a blow to the head, contrary to NICE guidelines, he did not undergo CT scanning and was discharged home. He suffered a bleed in the brain due to the blow to the head and the fact he was on anti-coagulants meant that the bleed progressed until the damage was such that he collapsed and died a few days later. Had the NICE guidelines been followed, the initial bleed would have been identified, the warfarin reversed and he would have survived;
a young female patient presenting with unusual erratic, behaviour. Despite evidence from her family that this was extremely abnormal and that she had not taken drugs or alcohol, she was assumed to be under the influence of something toxic and discharged when in fact she was developing encephalitis;
a man in his forties who had been out celebrating New Year and fell, hitting his head. He lost consciousness and was not fully mobile or comprehensible after the fall but the attending paramedic assumed this was due to alcohol consumption and simply advised that he went to bed. In fact he had sustained quite a significant head injury and bleeding as a result. Over the course of the night, his condition deteriorated due to the ongoing bleed and swelling and he was admitted as an emergency to hospital the following day. Despite surgery, he was left with significant physical and cognitive deficits due to the extent of damage caused by the time he was operated on. With appropriate care, he would have gone to A&E after the fall for assessment and scanning. Had he done so and undergone surgery earlier, he would have had a significantly better outcome. He is now left dependent on others for much of his daily activity and will never work again;
a patient presenting to an emergency department with ‘the worst headache I have ever had’ which had come on suddenly. She was reassured that she had a migraine and sent home although she had actually suffered a subarachnoid haemorrhage or bleed in the brain. This continued and she subsequently collapsed and died. The description of the type of headache should have prompted consideration of a sub arachnoid haemorrhage and investigation: had that occurred she would have undergone surgery and survived;
a lady in her fifties presenting to paramedics with the early signs of a stroke who was thought to have consumed excess alcohol. By the time she was found by her family, she had suffered a catastrophic stroke. This would have been avoided had she been taken straight to hospital.

The repeated patterns that we see tend to be around either not suspecting a neurological cause for someone’s presentation, a failure to consider the potential consequences of a blow to the head, particularly in an anti-coagulated patient, and assumptions about presentation being due to alcohol or drugs. In fact all of these are clearly covered by the NICE guidelines on managing head injury (head injury: assessment and early management – NICE guideline NG 232, May 2023 (previously the guidance was from 2014)). Many of the claims we have dealt with largely succeeded because it was clear that this guidance was relevant to the situation that occurred but was not followed.

The NICE guideline covers assessment and early management of head injury in babies, children, young people and adults and the aim is ‘to ensure that people have the right care for the severity of their head injury, including direct referral to specialist care if needed’.

There is a section that deals specifically with assessment in emergency departments. Some of the key points that are focused on assessing those at risk include:

only assume a depressed conscious level is due to intoxication after an important traumatic brain injury has been excluded. This is a key point – a patient’s presentation with the effects of significant alcohol consumption can be similar and distinguishing the cause of their condition is vital;
ensure all emergency department clinicians involved in assessing people with a head injury are capable of assessing the presence or absence of the risk factors for CT head imaging listed in the recommendations for undertaking a CT head scan. There are some very clear guidelines for identifying those patients at risk of intracranial bleeding / brain injury and ensuring that they undergo scanning, an example being elderly patients with a head injury who are on warfarin;
patients presenting to the emergency department with impaired consciousness should be assessed immediately by a trained member of staff. In cases where surgical intervention or other management is key to the outcome, early assessment by someone with a good understanding of the signs and complications of head injury is key;
a trained member of staff should assess anyone presenting to an emergency department with a head injury within a maximum of 15 minutes of arrival. Part of this assessment should establish whether they are at high or low risk for clinically important traumatic brain or cervical spine injury;
in those considered to be at high risk for clinically important traumatic brain or cervical spine injury, the assessment should be extended to a full clinical examination to establish if there is any need for CT imaging - again following the criteria for this type of scanning;
anyone triaged to be at low risk for clinically important traumatic brain or cervical spine injury at initial assessment should be re-examined by an emergency department clinician. It is important that a review by an experienced clinician takes place before discharge;
patients who return to an emergency department with any persistent complaint relating to the initial head injury should be discussed with a senior clinician who is experienced in head injuries. Consideration should be given as to whether a CT scan is needed;
the care of anyone with new and surgically significant abnormalities on imaging should be discussed with a neurosurgeon.

Regardless of scan results, a person's care plan should be discussed with a neurosurgeon if they have:

persisting coma (a GCS score of 8 or less) after initial resuscitation;
unexplained confusion that lasts for more than four hours;
deterioration in their GCS score after admission (greater attention should be paid to motor response deterioration);
progressive focal neurological signs
a seizure without full recovery;
a definite or suspected penetrating injury;
a cerebrospinal fluid leak.

While these guidelines were only published earlier this year, much of what is contained in them was covered in the previous 2014 guidance. It is vital that those who are assessing patients in an emergency context are always alert to the signs of head / brain injury and make the appropriate assessments, investigations and referrals. A failure to do so can all too easily lead to someone suffering very serious avoidable injury.

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