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Failure to diagnose subarachnoid haemorrhage (02HDC18871)

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(02HDC18871, 15 December 2003)

General practitioner ~ Standard of care ~ Professional standards ~ Subarachnoid haemorrhage ~ Record-keeping ~ Rights 4(1), 4(2)

A man complained that on two occasions a GP failed to diagnose his 78-year-old mother's brain haemorrhage, despite him querying the possibility on the second occasion.

The woman had suffered a sudden, severe headache, with vomiting and disorientation. Her family reported her symptoms to the GP and asked him to visit. As he was busy in his surgery he sent his practice nurse to assess her. The GP visited that evening and made a provisional diagnosis of a viral illness. He gave her an anti-emetic and pain relief, and advised the family to call if her condition deteriorated. Three days later her son took her to the GP's surgery because she was still unwell, although her headache had diminished. The GP examined her and confirmed his earlier diagnosis. When the woman's son queried the possibility of a brain haemorrhage, the GP reassured him and referred his mother to a geriatrician. Three days later the woman's symptoms were unchanged, and her son took her to a public hospital, where a subarachnoid haemorrhage was diagnosed.

Although subarachnoid haemorrhage is not always easy to diagnose, and occurs in only 25% of patients presenting to general practice with severe sudden headache, the woman had what the Commissioner's expert advisor described as symptoms "so indicative of subarachnoid haemorrhage that the diagnosis should immediately be considered by every doctor hearing it". She did not have any supporting signs of a viral illness and, in the advisor's opinion, the sudden and severe onset of her symptoms should have prompted the GP to consider subarachnoid haemorrhage as a differential diagnosis. It was also noted that the woman had a recent history of a high systolic blood pressure. A minimal examination under these circumstances should comprise checking for mental alertness, neck stiffness, and altered limb tone and reflexes. The GP's notes do not indicate that the patient's blood pressure was checked or a neurological examination performed.

At the follow-up consultation, the GP should have re-evaluated his previous diagnosis of viral illness, and taken a blood pressure reading and carried out a comprehensive neurological examination. When the son raised the possibility of a subarachnoid haemorrhage, it would also have been useful to have discussed with the patient a course of action to follow if she experienced further symptoms that might indicate cerebral bleeding.

It was held that the GP breached Rights 4(1) and 4(2) in failing to perform and appropriately document an adequate examination of the patient, and in not considering a subarachnoid haemorrhage in his differential diagnosis.