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Undiagnosed spinal injury led to man's death

Family settle medical negligence case after serious concerns raised by the Health Service Ombudsman’s report

MRI of spinal column

25 November 2015

The family of an 84 year old man, known only as D has received compensation after a series of significant medical failures highlighted in the Health Ombudsman report led to his death.

D was represented by medical negligence solicitor Suzanne White.
D had been admitted to hospital with symptoms of dizziness, nausea, abdominal and chest pain and irregular heart beat. D was prescribed various drugs  including anti-coagulants to treat the irregular heart beat.   
Two days after being anti coagulated D complained of pain in his neck and right shoulder,  and had lost all feeling on the right side of his body. An x-ray of his neck was taken but was of poor quality, so a CT scan was recommended by a consultant.
The CT scan was not carried out until  two days later, despite the severity  of D’s symptoms. D remained on anticoagulation medication.
The CT reportedly showed no obvious spinal bleed. D was monitored by junior doctors for the following two nights before showing signs of paralysis in all four limbs, which seemed to be caused by spinal cord compression.
It was decided by that stage that D was unsuitable for surgery and an MRI was too difficult to carry out given D’s confused state. D’s prognosis was poor and he  died two days later.
D’s family were initially advised that he had died from a spontaneous fracture to his spine; probably caused by his pre-existing osteoporosis. However, a post-mortem examination revealed the cause of death as a spinal cord transection (a complete tear to the spinal cord).
D’s family was very concerned about the level of care provided to D and made a formal complaint to the Trust which eventually became the subject of a report by the Health Service Ombudsman.
The Ombudsman report revealed a number of failings in the care D received, most significantly that the doctors did not provide anticoagulation medication according to NICE and BNF guidelines. The cause of D’s death was an embolic stoke due to the anticoagulation medication, which caused bleeding around the cervical spinal cord.
Other failings identified by the report included doctors  not considering all the possible differential diagnoses that fitted with D’s symptoms in line with GMC guidance; and failing to arrange an urgent CT scan in line with NICE guidelines.  The failure of doctors to do so fell significantly below the applicable standards and as such, amounted to a ‘service failure’.
An independent expert advising the Ombudsman suggested that “early review and direction of management by a competent senior decision maker should have saved this man’s life and preserved neurological function”
In addition, the Ombudsman concluded that the Trust’s failure to provide answers to D’s family inflicted a separate injustice upon them and ultimately amounted to maladministration.
Medical negligence specialist Suzanne White was asked by  D’s family to represent them at the  inquest into his death. A settlement was reached between D’s family and the Trust before the inquest took place.
Suzanne White said:
“The Heath Service Ombudsman noted a number of significant failures. The family were extremely distressed by the findings of the Health Ombudsman’s report.
“I hope that the Trust involved in this tragic case will learn from the conclusions of the Health Service Ombudsman’s report.”

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