Delayed Management of Subarachnoid Haemorrhage: A Recent Case

In a recent decided case, a patient failed to prove that negligent management of her subarachnoid haemorrhage (a kind of stroke) caused harm. Whilst this case failed, the story was familiar to brain injury lawyers. It illustrates some of the common issues in these claims.

You will find an explanation of a few medical terms underneath.

The facts of the case: Arksey v Cambridge University Hospitals NHS Foundation Trust

At 9am on November 3, 2012 a 59-year-old woman became suddenly unwell. She was sick, confused, agitated and complained of neck ache. Her blood pressure was high (216/131) An ambulance was called which took her to hospital.

At 1.40pm she was said to be uncooperative. It was unclear whether her behaviour had a medical cause or was because of a ‘difficult personality’. She was also said to be “back to normal” and sent home.

At home, she rested and went to bed in the late afternoon. The following day, November 4, her son found her collapsed on the bathroom floor. An ambulance was called at 9.51am which arrived at 10.04am.

The crew found her in her chair, conscious and alert but complaining of a strange sensation down her left side. Shortly after they arrived she began to fit. Her blood pressure and heart rate increased, and she became effectively unconscious.

She was taken to hospital where a CT scan showed an extensive subarachnoid haemorrhage (a type of stroke) with early hydrocephalus (see below). The following day, she underwent a procedure to coil the aneurysm. She survived but was left very disabled.

She was eventually discharged to a care home in March 2013. She made some recovery, but was wheelchair bound and had to use a frame to walk. She became easily tired, lost some memory, could not return to work and her ability to think was less than it was.

The details of her medical condition

These events suggested she had suffered a ruptured cerebral aneurysm which bled at about 9am on November 3. She had a further bleed at about 9.30am the following day. What started as a minor bleed became a cascade soon after 10am taking the form of a massive subarachnoid haemorrhage.

Medical terms used here:

(a) Aneurysm

An aneurysm is where the wall of one of the arteries to the brain – the blood vessels supplying it with oxygen – weakens. That part of the wall swells outward into a blister like shape. Because it is weak, it may burst.

(b) Subarachnoid haemorrhage

An aneurysm which bursts will cause bleeding. Bleeding into the part of the brain known as the subarachnoid space is called a subarachnoid haemorrhage. This can be a very serious condition. It can cause weakness down one side, headaches, nausea, neck pain, sensitivity to light, blurred or double vision, confusion, loss of consciousness and seizures.

(c) Hydrocephalus

Hydrocephalus is where a bleed blocks the passage of cerebrospinal fluid (the fluid that circulates around the brain and spinal cord). It causes part of the brain – the ventricles – to swell. Hydrocephalus is treated by lumbar punctures. Some patients need ventriculoperitoneal (VP) shunts – tubes inserted which enable fluid to flow out of the brain.

How is a subarachnoid haemorrhage treated?

Subarachnoid haemorrhage treatment is aimed at lowering blood pressure and stopping further bleeding. This means sealing the aneurysm. Some are done by clipping. Neurosurgeons do this by cutting through part of the skull. More often they are treated by coiling. With coiling, interventional radiologists reach the aneurysm by passing an instrument through an artery lower in the body. They then block the bleeding area with small coils which expand to fill the space. However, not all ruptured aneurysms can be treated.

Negligence: What did the hospital do wrong?

The hospital accepted that its management on November 3, 2012 was negligent. It should have admitted Mrs Arksey rather than discharging her, and should have carried out a CT scan. This would have shown the subarachnoid haemorrhage and let them diagnose her stroke.

The hospital also accepted that, at a later stage, they should have carried out a shunt earlier than they did – but this in fact appears to have caused little harm.

Causation: What harm did the negligence cause?

The hospital accepted that a CT scan on November 3, 2012 would have shown some bleeding into the subarachnoid space. The court heard evidence from the neurosurgeon and interventional radiologist who would have treated Mrs Arksey. It accepted their evidence as to what would have happened next.

According to the two doctors, a CT angiogram would then have been done on the same day. This would have shown an aneurysm in the anterior communicating artery of the brain. Mrs Arksey would have been referred to the neurosurgeons by late afternoon, who would have then spoken to an interventional radiologist.

The interventional radiologist would have agreed to coil the aneurysm and arranged to do so the following morning, November 4. To do so it would have been necessary to assemble a large team of at least seven people including an anaesthetist, assistant anaesthetist, a radiographer, radiology nurse, running nurse and porter.

On November 4 Mrs Arksey would have been fetched at about 9am. Explaining the procedure, obtaining her consent and preparing her would have taken 45-60 minutes. She would have been ready to start the procedure at 10am. It would have taken an hour to reach the aneurysm (at about 11am) and another hour to secure it (at about midday).

Given that her re-bleed started just before 10am, this would have created a difficulty for the interventional radiologist. He would have been faced with a difficult decision as to whether to stop or to continue. On balance, if he had been nowhere near the aneurysm by then, he would have stopped.

This meant that, even with the correct management, the hospital would not have been able to prevent her re-bleed. It had been negligent, but its negligence had not caused her harm.

What happened to her claim?

On the key issue the stroke claim failed. There had been negligence on November 3, 2012 but the negligence had not caused harm.

The claimant in fact succeeded on one minor point: the court found that there had been a delay carrying out a VP shunt for a period of just over four months, from January 31, 2014 to May 14, 2014. This, however, did not affect the long-term outcome. Because this was a trial on liability only, the court did not assess the amount of her damages at this stage. Her damages are likely to be only very modest.

The issues in subarachnoid haemorrhage cases

The claim illustrates some of the issues in subarachnoid haemorrhage negligence cases. A successful claim needs four characteristics:

1. A small bleed followed by a large one. The small bleed must cause some symptoms, but not be catastrophic. It acts as a warning sign which alerts doctors to the need to investigate before the devastating re-bleed.

2. The small bleed must produce enough in the way of signs and symptoms to alert doctors that something serious is happening. A bad headache is not enough. Plenty of people suffer bad headaches – even sudden very strong ones – and migraines are common. Few of these people have a subarachnoid haemorrhage. There needs to be something more. The warning signs are one-sided weakness or facial droop, neck pain or stiffness, sensitivity to light, blurred or double vision, confusion, loss of consciousness and seizures. Not everyone has all of these subarachnoid haemorrhage symptoms but apart from nausea they should all ring alarm bells.

3. The ruptured aneurysm must be in a position where it can be successfully managed, usually by coiling.

4. There must be enough time between the onset of the warning bleed and the catastrophic bleed for treatment to work. The problem in Mrs Arksey’s case is that there was not enough time. In her case she would have needed 26 or 27 hours for treatment to be successful. Some cases will need less though.

These are complex claims which demand the right legal skills. It is important to have the right stroke claim experts and to prepare the expert evidence in the right way. The judge in this case was actually quite critical both of the claimant’s expert and her solicitors for the way in which they handled the expert evidence.

Considering making a stroke or brain injury compensation claim?

If you or someone you love has suffered a subarachnoid haemorrhage, stroke or other brain injury caused through negligence, then you may have a claim for compensation. Get in touch with our experienced brain injury solicitors to discuss your case.