Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind.
The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’.
The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot.
He had experienced a stroke and should have been immediately sent to hospital.
But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened.
A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team.
He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier.
Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later.
His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care.
The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided.
Ombudsman Rob Behrens said:
“Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting.
“Mistakes like these need to be recognised and acted upon so that they are not repeated.”
The man’s daughter said:
“We were very lucky that he did get his sight back, but at the time we did not know that was going to happen. We went through all the emotions.
“When you’re looking after someone who’s suffering badly and you find out that they didn’t have to go through that, it makes you really angry.
“The impact on his life has been unreal. He has ‘brain fog’, he doesn’t go out or drive anymore, he feels dizzy a lot and uses a walking stick. It’s heart-breaking to see.”
The GP surgery has apologised for the distress caused by not sending the MRI referral and made improvements to prevent this from happening again.
However, PHSO found the surgery had not addressed the fact that money had been spent on the private scan.
PHSO recommended that the surgery should write to acknowledge their failings and apologise. They should also create an action plan to minimise the chance of it happening in the future.
The Ombudsman also advised the surgery to pay the man £1,200 for the distress and to cover the cost of the private MRI scan. The surgery has complied with all these recommendations.
In 2021, PHSO published a report, Unlocking Solutions In Imaging, which highlighted whole system failings in the way imaging is reported on and followed up within the NHS.
PHSO led a call, alongside NHS England and the Royal College of Radiologists, to urge the Government to prioritise improvements to the way scans and X-rays are carried out and reported on. Work has begun to implement the Ombudsman’s recommendations, but progress has been slow and more still needs to be done.