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Failure to diagnose raised intracranial pressure after fall (01HDC11911)

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(01HDC11911, 30 October 2002)

Rural general practitioner ~ Standard of care ~ Head injury ~ Missed diagnosis ~ Record-keeping ~ Rights 4(1), 4(2)

A complaint was made about the care provided by a rural GP to a 76-year-old woman who had an unobserved fall.

The woman had fallen and struck her head. She contacted her GP the next morning as she had a severe headache and had started vomiting. The GP, a rural GP with a heavy workload, visited the woman that morning and gave her pain relief. There was no neurological deficit. The vomiting continued throughout the day and the headache was continuous and moderately severe. That evening the GP visited the woman again, gave her an anti-emetic injection for nausea and prescribed an antibiotic. There is no record that any examination was carried out at that second visit to exclude neurological abnormalities due to raised intracranial pressure. The next morning another GP arranged for her to be admitted to hospital immediately, where a CT scan showed an acute subdural haematoma. Ten hours later the woman suffered a rapid deterioration in her level of consciousness, and underwent an urgent craniotomy. She suffered left hemiplegia and requires full hospital care.

The Commissioner held that the GP:

1) did not breach Right 4(1) in his initial assessment;
2) breached Right 4(1) in the assessment and management plan at the second visit - he failed to carry out an adequate neurological assessment and made an error in judgement in not suspecting raised intracranial pressure in the presence of significant symptoms, and in continuing to monitor the woman at home (the absence of loss of consciousness and abnormal neurological signs appeared inappropriately to outweigh the significant symptoms of raised intracranial pressure (headache and vomiting)); and
3) breached Right 4(2) in failing to comply with the RNZCGP standards of record-keeping, making it impossible to determine the extent of his physical assessment.

The Commissioner recommended that the Medical Council consider whether a review of the GP's competence was warranted.