Stroke Medical Negligence Miscommunication Between Medical Staff

Stroke Medical Negligence Miscommunication Between Medical Staff

John Whelan Solicitor with specialist expertise in Stroke Medical Negligence gives a case example of Miscommunication Between Medical Staff contributed to a Patient’s poor outcome.

Case Example: Miscommunication Between Medical Staff

A Patient with a history of hypertension, atrial fibrillation, and chronic kidney disease, presented to the A&E department after experiencing sudden onset confusion, slurred speech, and right sided weakness.   The Patient had been on anticoagulant therapy (warfarin) for atrial fibrillation.

Initial Assessment:

a)       Upon arrival at the A&E, the Patient was evaluated by the emergency physician, who suspected the Patient was having a stroke. A CT scan was ordered to rule out any hemorrhagic stroke.

b)       The CT scan came back negative for hemorrhage, and the team began to treat the Patient as a candidate for ischemic stroke. They planned to administer tPA (tissue plasminogen activator), which is the standard treatment for acute ischemic stroke if the Patient is eligible.

Miscommunication Between Medical Staff:

1. Failure to Communicate Critical Information About Warfarin Use:

a)       The Patient’s medical records indicated that the Patient had been on warfarin therapy, but this critical information was not fully communicated to the stroke team.

b)      The nurse who had reviewed the medication history in the A&E did not relay the information about warfarin use to the stroke team, which would have alerted them to the need for a PT/INR test (a measure of blood clotting time) before administering tPA.

c)       The stroke physician was not aware that the Patient was anticoagulated, as the information was either not entered in the notes or overlooked during handoff. Without this knowledge, they proceeded with tPA administration without considering the anticoagulation status.

1. Lack of Clear Handoff Between A&E and Stroke Team:

a)       The transition of care from the A&E physician to the stroke team lacked a thorough verbal handoff. The A&E physician briefly communicated that the Patient was suspected of having an ischemic stroke, but did not emphasise the anticoagulant use, assuming it was already known by the stroke team.

b)      There was no formal system in place to double check or confirm that all critical information, especially regarding high risk medications like warfarin, was communicated to the stroke team. This created a gap in communication that led to the oversight.

1. Delayed INR Testing:

a)       By the time the Patient received tPA, the Patient’s INR (international normalised ratio) was not tested, and the hospital protocol to check the INR in patients on warfarin before tPA administration was not followed due to the communication breakdown.

b)      After administering tPA, the stroke team discovered that the Patient’s INR was high, indicating an elevated risk for bleeding. This was particularly concerning as tPA can exacerbate bleeding in anticoagulated patients.

1. Failure to Monitor for Hemorrhagic Transformation:

a)       After the administration of tPA, no immediate follow up imaging was conducted to rule out potential hemorrhagic transformation (a common complication when tPA is given to patients with elevated INR).

b)      The lack of a follow up CT scan or MRI after tPA administration allowed the situation to worsen unnoticed.

Outcome of Miscommunication:

a)       12 hours after tPA administration, the Patient developed sudden severe headaches, progressive confusion, and worsening weakness. A follow-up CT scan revealed significant intracranial bleeding (hemorrhagic transformation of the infarct), which was complicated by the use of warfarin.

b)       Despite urgent attempts to reverse the bleeding using prothrombin complex concentrates (PCC) and vitamin K, the damage from the hemorrhagic transformation was severe, and the Patient developed progressive neurological deterioration.

c)       The Patient was transferred to the ICU for intensive care, but unfortunately, the Patient remained in a vegetative state with little recovery, requiring long term care.

Important Points of the Case:

1. Failure to Communicate Anticoagulant Use.

2. Incomplete Handoff Between ED and Stroke Team.

3. Failure to Check INR Before tPA Administration.

4. Lack of Follow Up Imaging to Detect Hemorrhagic Transformation.

For more detailed insights into how Stroke Medical Negligence and Patient Safety impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice Page.