Abstract
Facts
On 3 March 2005, EH (born on 27 April 1932) was walking her dog, when she slipped on ice and fell backwards striking her head on the ground. She was taken to the A&E Department at Wycombe Hospital where she was seen by a triage nurse at 09:04. The triage nurse found the Claimant to be alert and have a small laceration to her scalp but there was no active bleeding. The Claimant's blood pressure was measured at 182/85 and a note was made that the Claimant was on warfarin, the significance of which was highlighted by the use of asterisk and by heavy underlining.
An SHO in the A&E Department saw the Claimant at 10:05. It was noted that the Claimant was a 72-year-old woman, who had slipped on ice and fallen on the back of her head. On examination it was found that the Claimant's Glasgow Coma Scale (GCS) was to be 15/15, the pupils were equal and reacted to light, and she detected no abnormality even in the central or peripheral nervous system.
The Claimant was discharged home with an advice sheet for head injuries. On arrival at home, she rested for the remainder of the day. She began to feel worse sometime after 17:00 and subsequently vomited; since vomiting was one of the warning signs listed in the information sheet, her husband immediately called an ambulance at 19:40. She was taken back to the hospital where she arrived at 20:28. The Claimant was seen by a doctor in the A&E Department at 21:05. It was noted that she was complaining of a headache across her forehead which was said to have been present for the last 3 hours, with no change in severity since its onset. The Claimant was very nauseous and had vomited small amounts of bile. On examination, her GCS was 15/15, her blood pressure was 182/85 and her pupils were equal. At 21:30, the Claimant was noted to be complaining of increased nausea and vomiting and, although her GCS was still 15/15, she was increasingly drowsy so that she was taken to the resuscitation area. At 21:35, the Claimant suffered a sudden deterioration in her condition, to such an extent, that the prognosis was thought to be extremely poor and when she was admitted to a ward it was for palliative care only, the decision having been made to implement a do not resuscitate policy. A CT scan was performed at some time between 21:35 and a handwritten note timed at 22:30 hours, when the result of the scan was described in summary. The CT scan noted a large right-sided subdural haematoma.
EH was much improved the following morning and she was, therefore, transferred to the John Radcliffe Hospital in Oxford where she underwent a craniotomy with evacuation of right subdural haematoma.
The Claimant was left with a right-sided hemiparesis which grossly affected her qualify of life and deprived her of a great deal of her independence. The Claimant was originally cared for by her husband but sadly, he passed away during the course of the litigation.
EH's main neurological dysfunction was in relation to her right-sided weakness. She could stand and walk a short distance with a stick but needed a wheelchair at home and help to transfer to the commode and bed. She needed help with some activity for daily living, such as showering and washing although she could dress herself. She could feed herself if the food was cut up. It was noted that she would become increasingly dependent on a wheelchair and help for transfers as she got older.
Allegations
The allegations were that the medical staff were negligent in that they failed to undertake a CT scan, which should have been done at the time of the first attendance at the hospital. It was alleged that EH should not have been discharged home in the absence of a CT scan and should have been scanned before a decision was made whether or not to admit her, or if this was not practicable, she should have been admitted and a scan should have been carried out as soon as possible after admission.
Furthermore, the Defendants were negligent in that they failed to admit the Claimant on the morning of 3 March 2005. This is what would/should have happened if a CT scan had been undertaken before admission, because it would have probably shown a thin rim of subdural blood. Alternatively, if the CT scan was not practicable for any reason, admission should/would have taken place in accordance with paragraph 1.5.1 of the NICE Guidelines.
With regards to causation, the Claimant alleged that if she had been admitted, a scan would/should have been undertaken and the result would have probably led to surgery before the Claimant sustained any long-term damage to her brain. Even if no scan had been undertaken, the Claimant would/should have been subject to frequent neurological observations and would have been in hospital, and her deterioration would have been observed more or less immediately, thus leading to a CT scan as a matter of urgency, and the surgery as soon as practicably after. It was the Claimant's case, that with proper treatment she would have avoided the hemiparesis which was now her main problem although she would not have avoided the need for surgery.
Evidence
Expert evidence was obtained from a neurologist with regards to condition and prognosis, and a consultant neurosurgeon and neuroradiologist with regards to causation. The consultant neurosurgeon confirmed that the delay in performing a CT scan led to her hemiparesis, which was not present prior to the Claimant's deterioration. An earlier diagnosis, in the expert's opinion would not have prevented surgery but might have prevented the hemiparesis.
The neuroradiologist examined the CT scans and concluded that the damage in the cerebral peduncle, is the underlying basis of the residual hemiparesis.
Proceedings
Investigations were undertaken and expert evidence was sought and considered. A Letter of Claim setting out all of the Claimant's case, was sent to the Defendants on 30 April 2007. The Defendants responded on 16 August 2007 and admitted they were in breach of their duty to care for the Claimant, in not admitting her for observation on her initial attendance at the A&E Department on 3 March 2005. The Defendants admitted in a further Response letter dated 25 February 2008, that the Claimant suffered some neurological deficit as a result of their negligence but they contended that even with appropriate treatment, she would have been less moderately disabled. Therefore, causation remained an issue throughout.
The case continued to be investigated on the grounds of quantum, and expert evidence and witness statements were exchanged on this point.
The Defendants made a Part 36 Offer on 21 May 2009, of £900,000 inclusive of CRU at £12,586.75. Prior to the Part 36 Offer being made, the Claimant's Solicitors instructed a financial advisor, in order to provide an opinion as to whether the Claimant should request her damages as a lump sum or a periodical payment, in light of her age at the settlement. The Claimant had a life expectancy of 86 years but was 77 years old at the time of settlement. It was thought that maybe periodical payment would be an appropriate way forward for care, given the increased amount of care that the Claimant would require over the coming years.
On consideration of the Defendant's offer, it was decided that this represented a fair offer for the Claimant, considering that causation still remained in issue. The final settlement was £900,000 inclusive of £12,586.75 of CRU. This was a global settlement and there is no breakdown as to the damages; however, it is estimated that general damages would be in the region of £100,000 and special damages for past and future care, would make up the majority of the claim, around £600,000. It was decided by the Claimant, to have the damages in a lump sum rather than periodical payments.