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Management of head injury (07HDC10767)

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(07HDC10767, 25 September 2008)

Emergency medicine specialist ~ Senior house officer ~ Public hospital ~ District health board ~ Emergency department ~ Brain injury ~ Headaches ~ Standard of care ~ Rights 4(2), 4(5)

A 67-year-old man was transported by ambulance to an emergency department shortly after being assaulted. He was initially attended to by an emergency medicine specialist, who ordered X-rays of the man's face before his shift ended. A senior house officer examined the X-ray and noted that the man had a fractured nose, cheek and suspected eye socket fracture. She discharged him home with an appointment to return to an outpatient clinic six days later. At the clinic appointment his facial fractures were confirmed by CT scan. A month later, when his headaches had not resolved and he had some hearing loss, his general practitioner referred him back to the clinic for an urgent appointment. He was prescribed decongestant spray for sinusitis, and an ENT appointment was arranged for an assessment of his hearing problem.

The following day, the man returned to the emergency department with his family and was attended by the senior house officer. The man had suffered ongoing headaches since the assault, and was vague with some memory impairment. When his headache responded to analgesia, the senior house officer discharged him into the care of his family and general practitioner. The next day the man returned to the emergency department. A CT scan of his head revealed a subdural haematoma, and he was immediately transferred to another public hospital for burr hole evacuation of the clot.

It was held that the emergency medicine specialist did not meet professional standards of care and documentation in his assessment of the man, and breached Right 4(2); overcrowding and staff shortages did not excuse this.

The senior house officer was held to have provided a standard of care that was appropriate for a doctor of her experience, and thus did not breach the Code.

The manual whiteboard system used for handover in the emergency department at that time was incomplete, and did not ensure accurate and thorough handover of patient care between shifts. It allowed the man to "fall through the cracks", and significantly contributed to the emergency department consultant's failure to hand over the man's care to the senior house officer. In these circumstances, the DHB breached Right 4(5) by failing to ensure continuity of care. The failure of the Radiology and Plastics Departments to have robust processes in place for reporting to GPs also constituted a breach of Right 4(5) by the DHB.

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