“3… on the way there I had a bit of a headache. I do get migraines occasionally, usually about 3 or 4 times a year, if that. I have migraine tablets and when I feel the migraine coming on I take a tablet and this usually “nips it in the bud”
“Pt woke 7am. ® sided weakness. ® sided facial droop. ?TIA. Speech problems. - had headache yesterday – worse than normal – did not clear with tablets * Hx – Pt collapsed 4 weeks ago while shopping after sudden episode of concussion. Investigated @ John Radcliffe Hospital (undiagnosed) admitted 3 days Pt sustained head injury from this previous episode …”
“PC: Slurred speech, ® sided weakness. ? stroke. HPC: Woke up this morning with slurred speech and ® sided weakness. No hx of CVA. No hypertension. Or Cardiac disease Head injury – 4 weeks ago, after the patient collapsed. Investigated, no cause found….” (Dr Ramphele examined but, for the present purposes, that is the relevant part of the note). Or Cardiac disease Investigated, no cause found….”
“CNS: GCS 15 PEARL Sensation: intact upper and lower limbs. ?slurred speech No facial weakness Tone: normal, upper and lower Motor: power: 5/5 Reflexes: normal ∆? Psycho-somatic/? TIA P – bloods √ CT: NAD - ECG: NAD - D/W Dr Tolat - Advised: - get Rapid Response assessment - Stroke team to review again D/W: Medical reg: Advi (H)” (There are two ticks under the words upper and lower. There is also a large bracket which covers the spaces after the words, vertically read “normal, 5/5, normal, /bloods”
“The nurse came to take my observations a second time and I see from the records that this is timed at 09.40hrs. The only reason this was done is because Tim went out to find someone because I had deteriorated. From arriving at the hospital I could feel myself getting gradually worse and when the nurse was there I told the nurse I couldn’t feel my right arm and I also knew my speech was getting worse. I was very upset and crying. Tim kept asking them shouldn’t they be doing a scan because all they seemed to be discussing was getting me home. After I got worse Tim made a big fuss because they still wanted to send me home and it was after this that they sent me for a CT Scan. I now know from the notes that this was not until about 11am, about 1 hour and 20 minutes after I had told the nurse I could no longer feel my right arm and 3 hours after I arrived at the hospital.”
“Stroke team Asked to R/V pt again by A & E as pt presenting with worsening weakness. Husband present who reports symptoms have worsened. Pt c/o headache and photophobia. Vision – NAD Face – some R facial droop present but inconsistent and appears athetoid. Speech – no aphasia Dysarthria present”
“Symptoms appear to have changed although pt inconsistent during multiple assessment. No risk factors present. P/ CT head”
“CT head – normal NB* in CT patient was able to lift bottom up to get onto sliding board and sustain in crook position despite apparent “dense weakness”
“21. It was at this point that I requested an urgent CT scan, based on her current clinical condition, as I was concerned with the sudden deterioration in her symptoms, her apparent lack of stroke risk factors and also in light of her reported recent head injury. I liaised with the CT imaging department who agreed to do the scan urgently. Along with a member of the A & E team I assisted to take her round to the CT scanning department. 22. On assisting her to transfer from the A & E trolley to the CT scanning table I observed that she was able to lift her right leg up into the crook position and then lift her bottom up to “bridge” and held this position whilst a sliding board was placed underneath her to transfer her safely. I again found this very odd seeing as a few minutes earlier she was completely unable to lift her right leg up during an assessment. ……. 24. From my own objective assessment and review of previous assessments by Caroline and Dr Ramphele I did not feel that the presentation was consistent with that of a stroke and actually her presentation was more that of a possible stroke mimic. I did question whether this was a case of functional overlay or conversion disorder or whether she was suffering with a hemiplegic migraine. However I did not make any particular diagnosis as our protocol is that if we believe the patient symptoms are not suggestive of stroke we pass the patient back to A & E to review and they make their own formal diagnosis.”
“4.1 A patient suitable for thrombolysis should be referred for urgent CT scanning and the on-call/consultant bleeped” 61. Albeit under the heading “Patient’s (sic) Presenting as a TIA”, the advice for a patient not a stroke was: “3.2 If the patient is not a stroke and the suitability for admission or the cause of the patient’s condition is unclear or uncertain then the patient is to be handed back to the ED Emergency Department doctor for further assessment and planning of care.”
“At the time of the assessment by Nurse Hannon, with a clinical syndromic diagnosis of acute stroke, the first line diagnostic would have been a CT scan to exclude the possibility of a haemorrhagic stroke and enable the consideration of treatment through thrombolysis or antiplatelet therapy. Depending on the conclusion reached by the clinical team, either thrombolysis or antiplatelet therapy would have been offered at this point.”
“SA’s opinion is that this is a complicated issue. The first issue is the distinction between total basilar artery occlusion and basilar artery stenosis. The digital subtraction angiogram that Mrs Owers finally underwent at KCH showed a distal basilar artery occlusion with collateral circulation. However, given the fact that Mrs Owers clinical state fluctuated considerably – certainly for 8 hours after her deterioration at 7:00 – and her MRI showed basilar artery stenosis as opposed to occlusion, this suggests that during the period of her assessment at Medway and at Darent Valley, Mrs Owers did not necessarily have total basilar artery occlusion. Therefore, application of the evidence associated with basilar artery occlusion needs to be considered carefully. The second issue is that as diagnostic modalities and treatment of stroke have matured, so the complexity of issues determining prognosis following basilar artery occlusion has emerged. For an individual patient, the prognosis will be determined by the precise position of the occlusion, the critical extent of the occlusion and the presence, or not, of collateral circulation. Therefore, in any given patient, the prognosis can vary from a very mild clinical deficit through to catastrophic brain stem infarction. Mrs Owers did not present with a devastating clinical brain stem syndrome. Her imaging appears to reveal a varying degree of occlusion and the presence of a certain amount of collateral circulation. Therefore her prognosis cannot be considered inevitably poor, either with or without treatment.”
“SA refers to his original report in respect of his view concerning aspirin and antiplatelet therapy: “Aspirin would have afforded the opportunity to avoid further deterioration. Antiplatelet therapy reduces micro emboli within 30 minutes of oral administration by 33% - 66%, therefore on the balance of probabilities I conclude that timely administration would have made a contribution to avoiding her stroke progression. Without this further deterioration, based on the severity of her clinical state prior to the deterioration, I would predict she would have achieved an independent, not dependent, final clinical outcome.””
“Aspirin v Avoid Aspirin ….Among aspirin – allocated patients there were non – significantly fewer deaths within 14 days (9.0% vs 9.4%), corresponding to an absolute reduction of 4 (SD4) per 1000 patients… Outcome at 6 months…At 6 months, there were fewer deaths among aspirin allocated patients but the absolute decrease of 10 (SD6) per 1000 was not significant… Sub Group Analyses…Analyses of the effect of aspirin subdivided by the prognostic score indicated greater benefit among good prognosis patients but the trend was not significant….. Aspirin The effects of immediate aspirin use in acute ischaemic stroke on the unadjusted primary outcomes in the IST were not significant…since most patients with acute ischaemic stroke are likely to benefit from long term antiplatelet therapy, the IST and CAST results for the safety (and slight additional benefit) of giving aspirin immediately in acute ischaemic stroke are reassuring… Clinical Implications Because the evidence on aspirin is based on 40,000 randomised patients (IST and CAST), Chinese Acute Stroke Trial it is more reliable than that for heparin. The benefit from the IST and CAST, of about 10 deaths or recurrent strokes avoided per 1,000 patients treated with aspirin in the first few weeks is about the same size as the benefit per year from long term aspirin treatment in stroke survivors…”
“Most studies …have used a modified Rankin Score of 0-1 or 0-2 to define good outcomes. Because of the poor natural history of Basilar Artery Occlusion we used a modified Rankin Score of 0-3 as a measure of independence and good outcome.”
“Our observations underscore the continued absence of a proven treatment modality for patients with an acute BAO and that current clinical practice varies widely. Furthermore, the often held assumption that IAT is superior to IVT in patients with an acute symptomatic BAO is challenged by our observations. Therefore, we believe that a randomised controlled trial to compare IVT with IAT in patients with acute symptomatic BAO is a high priority. In the meantime our results should encourage clinicians to treat patients who have acute symptomatic BAO and a mild to moderate deficit with IVT. In case of subsequent acute worsening, additional IAT can be considered…”
“In my view one cannot draw a distinction between medical negligence cases and others. I would summarise the position in relation to cumulative cause cases as follows. If the evidence demonstrates on a balance of probabilities that the injury would have occurred as a result of the non-tortious cause or causes in any event, the claimant will have failed to establish that the tortious cause contributed. Hotson exemplifies such a situation. If the evidence demonstrates that 'but for' the contribution of the tortious cause the injury would probably not have occurred, the claimant will (obviously) have discharged the burden. In a case where medical science cannot establish the probability that 'but for' an act of negligence the injury would not have happened but can establish that the contribution of the negligent cause was more than negligible, the 'but for' test is modified, and the claimant will succeed.”
“I have been asked to comment on the following scenarios. The likely outcome to Mr Owers if:- Mrs Owers had been diagnosed at the Medway Maritime Hospital with a pontine infarct type stroke. - This was not treatable. - She had continued to develop the same physical complications. In this case Mr Owers would still have been very upset by his wife’s sudden illness, but would not have suffered the trauma of a missed diagnosis, no discussion of any treatment options and a premature discharge in a deteriorating physical condition. In as much as it is possible to say, in retrospect in this scenario he is likely to have developed the lesser diagnosis of an Adjustment Disorder with depressive symptoms, and not PTSD. If she had gone on to develop the same physical disability he would still, on the balance of probabilities, have developed a major depressive episode from the initial adjustment disorder.”
“The necessary element of proximity between plaintiff and defendant is furnished, at least in part, by both physical and temporal propinquity and also by the sudden and direct visual impression on the plaintiff's mind of actually witnessing the event or its immediate aftermath…” 146. At page 401F Lord Ackner said that the element of “shock” involved: “The sudden appreciation by sight or sound of a horrifying event, which violently agitates the mind. It has yet to include psychiatric illness caused by the accumulation over a period of time of more gradual assaults on the nervous system.”
“213…I do not consider that, at the time, the sight of Mrs Sharma had the visual effect on the Claimant which was later described. In the case of Walters, the trial judge and the Court of Appeal laid considerable emphasis on the start of the "event", when the mother awoke to find her baby rigid and choking after a convulsion, with blood pouring out of his mouth. Ward LJ likened that to the "assault upon her senses" the mother would have suffered if she had seen her child bleeding in a seat after a road traffic accident. That sort of "assault upon the senses" is, it seems to me, of a very different order to the scene in the A & E Department at ESH on 12 May. Indeed, even if Mrs Sharma had for a short time been in the state described by the Claimant, I do not consider that the sight would have come within the type of "event" described in Walters and the other relevant authorities. Mrs Sharma's condition was fluctuating; she did not have obvious injuries; she was not – or at least did not appear at that stage to be – in any obvious or immediate danger…” (In paragraphs 216 and 217 Swift J pointed out that during a period of 9 hours overnight at St George’s, the Claimant did not see her sister and was not proximate to the events that were unfolding and it was not until she saw her sister on the life support machine that the reality became clear. That must have been deeply upsetting but was not “a sudden or unexpected shock”) “218… It does not seem to me that what happened in this case can properly be described as a "seamless single horrifying event". There was a series of events over a period of time. The Claimant was proximate to some of those events, during the periods spent in ESH and SGH. However, much of her fear, panic and anxiety were caused by information communicated to her by telephone, or face-to-face by Mr Sharma, when he told her that her sister had "gone". I do not consider that any of the individual events within the series actually witnessed by the Claimant gave rise to the sudden and direct appreciation of a "horrifying event". Even when she witnessed her sister on the life support machine, her perception was informed by the information she had been receiving over the previous 15 hours or so and by her own professional knowledge. Mrs Sharma did not have the type of injuries suffered by the deceased in GalliAtkinson, was not in obvious pain and had not been pronounced dead at that time. In the circumstances, it does not appear to me that the sight of her can be regarded as a "horrifying event"; nor was it sudden or unexpected.”
“That is in my view unsurprising. In hospital one must expect to see patients connected to machines and drips, and…expect to see things that one may not like to see. A visitor to a hospital is necessarily to a certain degree conditioned as to what to expect, and in the ordinary way it is also likely that due warning will be given by medical staff of an impending encounter likely to prove more than ordinarily distressing.”
“35. …It was not, like Walters, “a seamless tale with an obvious beginning and an equally obvious end.”
“(a) Whether the events concerned were of a nature capable of founding a secondary victim case, i.e. were they in the necessary sense "horrifying"; and (b) Whether the sudden appreciation of that event or those events, i.e. shock, caused the Claimant's psychiatric illness.”