Penningtons Manches has settled a claim against an NHS trust for a delayed diagnosis of subdural haemorrhage leading to death.

The deceased was a 75 year old man who fell down a flight of stairs at his home. He was taken to hospital by ambulance where it was noted that he had a laceration to his skull, a reduced Glasgow Coma Scale score (GCS) and a suspected brain injury. He was noted to be on warfarin (to thin the blood) for a heart condition.

In light of his head injury he was sent for an urgent CT scan to rule out an intracranial bleed. As the radiologist reported that the scan did not show any intracranial bleeding, no attempt was made to reverse the deceased’s warfarin and increase his clotting factors.

Several hours later, the CT scan was reviewed by a second radiologist who identified a small subdural haemorrhage. Although this information was conveyed to the consultant in charge of the deceased’s care in the A&E department, there was a failure to contact the on-call neurosurgeons for advice or to stop/reverse the warfarin, which represented a significant bleeding risk for the subdural haemorrhage. Instead, the deceased was transferred to the Acute Medical Unit (AMU) which was not aware that the deceased had a brain injury while being on warfarin.

Later that day, the deceased suffered a catastrophic neurological decline while on the AMU. A repeat CT scan showed that the subdural haemorrhage had progressed and had caused midline shift of the deceased’s brain, with almost total compression of the right ventricle. Neurosurgical opinion confirmed that nothing could further be done for the deceased. He was given palliative treatment until he passed away the next day.

The Penningtons Manches clinical negligence team investigated a claim on behalf of the deceased’s widow under the Fatal Accidents Act 1976 and the Law Reform (Miscellaneous Provisions) Act 1934 for her loss of practical and financial dependency on the deceased, bereavement damages, and the expenses of his funeral. His widow was a protected party by virtue of having dementia, so the claim was pursued by the deceased’s executor on her behalf. Where a claim is pursued for a protected party, any proposed settlement requires court approval.

Expert evidence was obtained which confirmed that the trust was negligent for failing to identify the subdural haematoma on the CT scan initially. This led to a failure to stop his warfarin medication. If the on-call neurosurgeon been contacted, the advice would have been to stop the warfarin and reverse its effects using appropriate medication. The expert evidence confirmed that this failing led to the deceased’s subdural haematoma rebleeding or continuing to bleed, resulting in his significant neurological deterioration and death. In the absence of these failures, the deceased would have survived.

A letter of claim was submitted to the NHS trust and the claim was admitted in the letter of response. Part 36 offers were exchanged but the extent of quantum continued to be disputed between the parties. As the widow was a protected party, a settlement at the trust’s level was felt to be an under-settlement which would not gain court approval. Court proceedings were issued and served, together with a further Part 36 offer, and the claim subsequently settled after negotiations with the NHS Litigation Authority prior to service of the defence. The settlement was significantly higher than the pre-issue Part 36 offer made by the NHSLA. The settlement has since received court approval.