Doctor in senior role beyond her training misdiagnosed rare stroke

A young man diagnosed with inflammation of his inner ear turned out to have suffered a rare type of stroke.

The failure to detect it, despite significant “red flag” symptoms, has left him with ongoing complications, the Health and Disability Commissioner said in a report released today.

The doctor at the hospital in Health NZ’s Te Tai Tokerau Northern Region, who initially diagnosed the 33-year-old with “labyrinthitis”, remained profoundly affected by what happened, the HDC said.

She acknowledged failures in care and no longer worked at the hospital, having raised concerns from the start that she felt unsuited to the senior position to which she was appointed, Commissioner Morag McDowell said.

The HDC acknowledged the impact on the patient, who had endured a difficult recovery.

“I commend them for raising their complaint with HDC to prevent this from happening to anyone else,” McDowall said.

McDowall also acknowledged how deeply affected the doctor was, in finding she and Health NZ had breached the Code of Health and Disability Services Consumers’ Rights.

On the morning of January 20, 2023, the man went to a GP with his partner with symptoms of chronic sinusitis, worsening snoring and sleep apnoea.

He was referred for a CT scan of his sinuses and advised about a sleep study.

Around lunchtime that day he was feeling unwell and had developed further symptoms, including intense head pain, visual disturbance, pressure in his head and a loss of balance to the extent that he was unable to walk properly, McDowall said.

His partner took him to their nearest medical centre, by which time he was vomiting and sweating profusely.

She left him in the car and spoke with reception staff, who were concerned about his potential Covid-19 status and advised the woman to take her partner back to the clinic they had visited earlier.

Because of his deteriorating condition, including continued vomiting and slowed speech, the woman took him to hospital.

He was admitted to the emergency department and seen by the doctor.

The man’s partner explained she thought he had had a stroke, but was also worried about possible food poisoning.

The doctor’s working diagnosis was a likely viral inner ear infection, and she recorded a diagnosis of labyrinthitis, an inflammation of the inner ear, the HDC said.

Stroke ‘unlikely’, alternatives considered

The doctor later said she considered a stroke unlikely because of the absence of facial droop, limb weakness or visual disturbance, although it was noted in the man’s clinical record he was seeing red and orange shapes.

The doctor also thought it unlikely because of his young age and the absence of significant risk factors.

She had considered alternative diagnoses such as a subarachnoid haemorrhage and meningitis but assessed them as unlikely given the man’s history.

He was treated with intravenous fluids, pain relief and medication to stop him vomiting.

McDowall said his gait was not formally assessed.

He was still dizzy when sent home later that afternoon with medication and a plan to return to his GP if needed, or hospital if concerns were significant.

His partner told a nurse she did not feel right “wheel chairing” her partner into hospital, and wheeling him back out.

“Something isn’t right,” she said.

CT scan found ‘rare’ stroke

The man’s condition did not improve and the next day the pair were back in hospital, where a CT scan found the 33-year-old had suffered a “cerebellar infarction” – a rare category of stroke that requires immediate treatment, McDowell said.

The man was airlifted to Auckland Hospital for treatment, where he remained for five days.

He had experienced ongoing complications, McDowall said.

Her investigation revealed the doctor who had incorrectly diagnosed the man’s condition had been reluctant to take on the senior doctor position she held at the time.

She had raised concerns soon after starting in the role at the unnamed hospital, and continued raising them to the point of the misdiagnosis despite assurances she was suited to the role, McDowall said.

The doctor said that if a Senior Medical Officer (SMO) was in the department with her at the time, it was likely that she would have run the case by them to cross-check her diagnosis and management plan.

Health NZ has apologised and conveyed its “deep regret” to the man for the delayed diagnosis and subsequent complications.

It also acknowledged the distress caused by such a debilitating illness at such a young age and the subsequent anguish and stress both he and his partner had endured.

Health NZ also confirmed there was no CT scanner available when the man was first taken to hospital, which highlighted the inevitable impact on timely intervention for stroke patients.

“Health NZ recognised that posterior circulation strokes are significantly more difficult to diagnose and that, on reflection, the appropriate course would have been for [Mr B] to be transferred for a CT scan,” McDowall said.

Health NZ said adverse events like this took a very heavy toll on doctors, and it was sorry the doctor involved had not proceeded with training in rural medicine.

“Health NZ feels that this is a ‘sad loss to the future of rural medicine in [the area] and the health of our population, where we desperately need more doctors to staff our rural hospitals’,” it told the HDC.

There was no CT scanner available when the man was first taken to hospital, which highlighted the impact on timely intervention for stroke patients, Health NZ said. Photo / 123rf

McDowall was critical that the doctor had failed to adequately consider the man’s red-flag symptoms.

She also accepted independent expert opinion that it was not safe to discharge the man when he was sent home.

McDowall considered the potentially mitigating factor that the doctor was practising at a level beyond her capabilities.

The HDC noted the role in which she was employed would normally be filled by either a rural hospital or emergency medicine specialist, or potentially a Medical Officer Special Scale with substantial experience and skills in emergency or rural hospital medicine.

Health NZ ‘contributed to failure’

McDowall concluded that while the doctor’s assessment of the man was inadequate, she considered that Health NZ contributed to the failure by employing the doctor into a role for which she was not sufficiently experienced or trained.

Neither had it reduced her responsibilities in a timely manner when she expressed concerns, including about her level of training and support.

McDowall supported Health NZ Northern Region’s idea for a model of care where remote supervision, advice and assessment could be provided via telehealth.

“I suggest that Health NZ give consideration to whether this model could be replicated in other rural or remote areas.”

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.