GP stroke care: could better management change outcomes?

Suffering a stroke is a devastating event that affects around 240 people each day. Understandably, patients who have experienced a stroke, and had their lives turned upside down, will want to consider what caused the stroke, and whether it could have been avoided.

Often, this starts with considering the treatment that was provided after the stroke occurred, and whether, for example, the ambulance could have arrived sooner, or the doctors could have treated them in a different way, to reduce their symptoms. However, it is also important to look further back in the treatment history, to determine whether the stroke could have been avoided entirely.

In support of Stroke Awareness Month and the Stroke Association’s ‘Make May Purple’ campaign, members of the specialist stroke negligence team at Penningtons Manches Cooper are preparing a series of articles on stroke treatment – from GP and paramedic care to A&E and surgery – explaining where problems can arise and what to look out for. This article considers how negligent GP treatment can lead to a stroke, and outlines the steps that can be taken if there are concerns over care that has been provided.

What is a stroke? 

A stroke happens when there is a disruption in blood supply to the brain which can occur either because a clot blocks the flow of blood (a thrombotic stroke) or when there is a bleed on the brain (a haemorrhagic stroke) that causes damage to brain cells and interrupts normal blood circulation. A mini stroke or transient ischaemic attack (TIA) has similar symptoms to a stroke but resolves quickly. TIAs are often considered a ‘warning sign’ as they can be a precursor to a stroke.

How to recognise a stroke

A stroke is a medical emergency and requires urgent treatment so it is important that people can spot the signs, summarised by the FAST acronym:

Face (drooping)

Arms (weakness)

Speech (slurring)

Time (to call 999)

As well as these familiar symptoms, other signs to look out for include sudden weakness or numbness on one side of the body as well as difficulty finding words or speaking clearly. Some people experience blurred vision or loss of sight in one or both eyes while others may struggle with sudden memory loss or confusion. A stroke can cause dizziness, unsteadiness or an unexpected fall, and in some cases is accompanied by a severe, sudden headache.

For any one of these signs or symptoms, it is important to call 999 straightaway. If the symptoms only last a short amount of time, this could be a TIA. It is still vital to call 999 and get urgent medical attention as a TIA is a medical emergency.

The treatment pathway

Patients who have experienced stroke symptoms will often be transferred to hospital by ambulance, assessed in the emergency department, and then treated by the stroke team, either with medication or, where appropriate, in surgery and/or by interventional neuroradiologists. The type of treatment will depend on whether the stroke is thrombotic or haemorrhagic, and this is usually ascertained through CT imaging once the patient has reached the emergency department.

How can GP treatment reduce the risk of stroke? 

GPs are the frontline of stroke treatment as patients will typically approach their GP first when they have health concerns. It is therefore important that GPs carefully assess patients to ensure they recognise those who are at higher risk of stroke. These patients need to be monitored and appropriately managed to reduce their risk. A GP will be able to determine when treatment is required, and if a referral to a specialist is necessary.

Set out below are some of the most common errors made in GP care, which can lead to an avoidable stroke occurring, or a worse outcome for a patient who is already experiencing a stroke.

Poor management of high blood pressure

It is important for GPs to ensure patients’ blood pressure is checked, monitored and where required, treated, as sustained high blood pressure is a risk factor for stroke.

Negligence may include:

• failure to recognise high blood pressure readings;
• failure to monitor blood pressure appropriately;
• failure to offer treatment, or not providing the right treatment, to patients with high blood pressure.

Poor management of medication

GPs must ensure patients are prescribed appropriate medication, and that the medication is monitored to ensure it is working effectively and is not incorrectly stopped.

Negligence may include:

• failure to prescribe, or incorrectly stopping, anti-hypertensive medication;
• failure to prescribe, or incorrectly, stopping anti-coagulant medication;
• failure to treat diabetes/high cholesterol;
• failure to review and monitor existing prescriptions to ensure they are still effective;
• failure to properly manage medication and drug interactions that cause increased blood pressure;
• failing to stop high-risk medication when a patient reports side effects.

Negligent management of atrial fibrillation

Atrial fibrillation is an irregular and often rapid heart rhythm which can cause blood clots to form in the heart, increasing the risk of stroke. It is therefore imperative that patients suffering from arrythmia are appropriately treated and/or referred to a cardiologist to manage their symptoms.

Negligence may include:

• not using suitable scoring tools to assess the risk of a stroke;
• not prescribing appropriate medication in the correct dosage/strength (anticoagulants, betablockers);
• not arranging a referral to a cardiologist.

Failure to recognise symptoms of stroke / TIA

Although a GP would not routinely treat a stroke, it is important they identify ‘red flag’ symptoms. Failing to recognise mini-strokes and refer for further investigation could mean that crucial preventative treatment, which could prevent a full stroke, is not started.

Negligent management may include:

• misdiagnosing stroke/TIA symptoms as vertigo, migraine, stress or anxiety;
• not recognising weakness/loss of sensation as a symptom of stroke;
• failure to recognise visual disturbance as a red flag symptom, such as repeated episodes of amaurosis fugax (temporary vision loss in one eye);
• failure to recognise confusion/memory loss/speech difficulties as stroke symptoms.

Delays in referral to hospital or TIA clinic

For patients presenting with stroke symptoms, it is important that GPs refer them urgently to hospital or a TIA clinic for further review and, if necessary, treatment. A failure by the GP to make an emergency referral for a patient with stroke symptoms is likely to be considered negligent. In addition to mismanagement by GPs themselves, sometimes referral delays can be caused by administrative errors or problems in arranging specialist appointments.

Not providing adequate ‘safety netting’ advice

When a patient is at higher risk of stroke, or has concerns about symptoms, it is important for GPs to provide clear guidance about what signs to look out for and when to seek further advice from a hospital/TIA clinic. Negligence claims can occur when a GP is dismissive of symptoms, leading to a patient not seeking further advice when symptoms continue, change or deteriorate, and therefore missing the window for effective treatment.

When do patients have a claim for medical negligence?

Patients may have a claim if:

• the medical team acted in a way that no responsible body of clinicians would do in the same circumstances – by either doing something that they should not, or failing to do something they should (the test for negligence);
• that failure caused the stroke to occur and/or made the consequences more severe (the test for causation of damage).

What can stroke patients claim?

Medical negligence claims for substandard stroke care can cover:

• pain and suffering;
• rehabilitation and therapy;
• lost earnings and loss of future income;
• care needs;
• adaptations to housing;
• adapted vehicles;
• medical expenses.

The consequences of a stroke can impact all aspects of a patient’s life and those of their family. If the stroke was avoidable and only occurred due to failings in care, a successful claim can help restore an individual’s quality of life and maximise their recovery.

How we can help

Penningtons Manches Cooper’s medical negligence team includes a specialist group of lawyers with extensive experience in claims involving strokes that should have been avoided and/or better managed with appropriate medical care. We are always happy to talk through your concerns without obligation or cost, and our specialist team will provide clear advice on both the merits of a claim and what would be involved in the claims process.

Please email us at piclinnegstrokeclaims@penningtonslaw.com or call us on 0800 328 9545.

Case study: haemorrhagic stroke caused by delayed diagnosis and treatment of high blood pressure

We settled a claim for a man who suffered a haemorrhagic stroke due to a failure by his GPs to recognise, follow up and treat sustained high blood pressure. As a result of his stroke, our client suffers from left-sided weakness and slurred speech. He has undergone significant rehabilitation, but his mobility remains severely restricted, he requires the use of a wheelchair and has needed substantial adaptations to his home.

In investigating this claim, we obtained expert evidence confirming that if he had undergone a health check upon registration with his GP surgery, or been asked to attend a follow-up appointment after repeated high blood pressure readings, he would have been diagnosed with persistent hypertension and prescribed anti-hypertensive drug therapy. With such treatment, on the balance of probabilities, his haemorrhagic stroke would have been completely avoided.

Despite our supportive expert evidence, the defendant GPs denied negligence, arguing that the patient had failed to attend his new patient health check and there had been a communication breakdown after the high blood pressure readings. They claimed that he had been asked to return for a follow up appointment after blood test results but did not do so. Our client strongly contested this on the basis that, if he had been asked to reattend for further checks, he would have complied. The defendants also argued that, given the lack of testing during the intervening period, it could not be ascertained that high blood pressure had been persistent during the whole period, and that his stroke was caused by longstanding hypertension.

Despite the defendants’ denial of negligence, our medical experts remained supportive of the claim, court proceedings were issued, and, after lengthy negotiations, we were able to reach a settlement.  We secured significant damages for our client and those funds have provided him with financial stability, and the opportunity to improve his independence and quality of life.