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Misdiagnosis of subdural haematoma as migraine (01HDC11439)

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(01HDC11439, 30 August 2002)

Public hospital ~ Standard of care ~ House officer ~ Casualty officer ~ Registrar ~ Atypical presentation of subdural haematoma ~ Misdiagnosis ~ Right 4(1)

A complaint was made by a woman about the services provided to her by a senior house officer and staff at a public hospital. The complaint was that staff at the Emergency Department (1) failed to diagnose her subdural haematoma; and (2) treated her with chlorpromazine, a treatment for migraine, which was inappropriate given her brain injury.

The Commissioner received independent expert advice from an emergency medicine specialist, who advised that it was reasonable for migraine to be in the differential diagnosis. However, as the presenting symptom was headache, post-traumatic subdural haematoma should have been in the differential diagnosis as well, despite the absence of history of head injury. The advisor said that the house officer went to the trouble of asking the registrar for advice, but noted that in a busy Emergency Department it is often not possible for an individual doctor to confirm history and re-examine every patient discussed by more junior staff.

The Commissioner held that:

(1)  the public hospital did not breach Right 4(1) because
(a)  the examination and history taken was thorough and appropriate; and
(b)  the possibility of head injury was considered, but not found;
(2)  the senior house officer did not breach Right 4(1) because
(a)  he ascertained the patient's history and conducted an examination including a full neurological examination, and discussed the possibility of a CT scan with the registrar;
(b)  although his diagnosis of migrainous headache was incorrect, it was reasonable;
(c)  he did consider the possibility of subdural haematoma, and took reasonable steps to eliminate this from his differential diagnosis; and
(d)  his prescription of anti-migraine medication was not unreasonable, and would not have had any clinically significant effect; and
(3)  the DHB was not vicariously liable because the senior house officer did not breach the Code.

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