Failure to Follow Stroke Thrombolysis Checklist Leads to Fatal Error

Failure to Follow Stroke Thrombolysis Checklist Leads to Fatal Error
BSC, LLB (Hons) & LPC Sophia Azam
Case by: BSC, LLB (Hons) & LPC Sophia Azam Updated:

In December 2019, our client, experienced a sudden onset of left-sided weakness, indicating a possible stroke. Emergency services were called, but delays in arrival and subsequent missteps in treatment led to tragic consequences. This case study sheds light on the fatal repercussions of failing to adhere to the stroke thrombolysis checklist.

Our Client’s Background

Our client collapsed at home with left-sided weakness in December, 2019. An ambulance was called promptly, but delays in arrival, prolonged the time before he received medical attention. When medics reached his house the diagnosis of a possible stroke was confirmed with FAST positive test amongst other signs as described. He was assessed at home and subsequently transferred to hospital where he did not arrive until about 2 hours after his stroke onset.

Medical Assessments on Arrival to the Emergency Department

On his arrival to the Emergency Department, he had a prompt assessment and investigation. This included a CT brain scan and blood tests carried out by nursing staff, stroke nurses and medics in the ED. Additionally, he had a detailed neurological assessment using the NIHSS score. This confirmed that he had moderately severe stroke with a score of 16 on the NIHSS.

Thrombolysis Incorrectly Given to Our Client

After the investigations, a decision was made to give thrombolysis treatment with Alteplase after contacting the stroke consultant on-call on a video call. As a result, thrombolysis was given to our client. However, it was given before reviewing the CT scan by the stroke consultant. Instead the medics relied on what the Radiographer told them about the CT scan.  

Failure to Adhere to the Thrombolysis Checklist

​Before thrombolysis treament begins an acute stroke check list for inclusion and exclusion criteria should be followed. In our client’s case it was not followed or completed. In particular, the CT scan should not show a haemorrhage or well established infarct before thrombolysis is given. Furthermore, there should be no history of stroke within the previous 3 months.

We know from the CT scan report that there was evidence of acute subarachnoid haemorrhage and early sign of stroke. Our client also has had multiple embolic infarct when he had lupus (SLE) within the last 3 months. This was documented in the clerking before thrombolysis was given where it stated he had SLE and punctuate brain lesions. It is a basic principle of stroke thrombolysis that the thrombolysis checklist should be completed before thrombolysis given. The stroke consultant should review the CT scan or check the CT scan report before giving authorisation for thrombolysis.

Quote from Our Medical Negligence Team

Our medical negligence solicitors state: “In my opinion, it was a grave mistake and a breach of duty on a part of the consultant and the medical team looking after our client that they did not complete the thrombolysis checklist, not reviewing CT scan before thrombolysis given and relying on the verbal report from the radiographer who is not authorised to provide a report on a CT scan.”

Failure to Follow Stroke Thrombolysis Checklist Leads to Fatal Error

Our client was given Alteplase thrombolysis inappropriately and against the thrombolysis guidelines as he had evidence of acute brain bleed and recent stroke within the last 3 months. As a result of providing inappropriate treatment, he developed a devastating brain bleed within half hour of receiving the treatment. His extensive bilateral brain bleed is un-survivable in this situation and he subsequently died 24 hours after the inappropriate treatment.

Serious incident investigation and root cause analysis report by the hospital acknowledges that he received inappropriate treatment of thrombolysis when there was evidence of acute subarachnoid haemorrhage which subsequently led to his death. 

Comments from Our Medical Expert

When we requested details of the treatment and care that ought to have been given instead of the thrombolysis, our expert stated that:

“From the initial neurological assessment with NIHSS of 16, this indicates a moderately severe stroke even before any treatment provided with background of previous strokes and SLE encephalitis . Treatment would have been a combination of medical conservative treatment with a long period of extensive neuro physiotherapy, occupational therapy, speech therapy, psychotherapy with cognitive and behavioural therapy support. Close observation and continuing treatment of his SLE.

Hypothetical Recovery Path Post-Stroke, If Proper Protocol Had Been Followed

On balance of probability and in our solicitors opinion, if the medical error had not taken place, our client would have stayed in Hospital for 8-12 weeks. At time of discharge from Hospital, he would be left with very mild or no facial weakness. His dysarthria would have significantly improved or returned back to normal. He would still have had significant left arm weakness with spasticity and probably non-functioning left arm and hand.

Additionally he would have mild left leg weakness and significant improvement in his coordination and balance, being able to feed himself with meat cut for him, but he would need day to day help with other activities of daily living such as washing and dressing. He would be able to walk with support or walking aid and would have required several months of regular home and outpatient stroke care and therapy input from Physiotherapy and occupational therapy. Finally, he would be unable to return to work or driving or able to do house chores.  

Settlement of £25,000 for Medical Negligence

With the expert guidance of AWH’s medical negligence solicitors, our client received a settlement of £25,000.

This case illustrates the fatal consequences of medical errors, particularly when essential protocols like the thrombolysis checklist are disregarded. Despite prompt recognition of stroke symptoms, delays and procedural oversights resulted in our client’s untimely death. The failure to adhere to established guidelines led to inappropriate treatment, exacerbating his condition and ultimately proving fatal. Expert opinion suggests that proper care could have significantly improved his prognosis. While our legal efforts secured a settlement, it cannot fully alleviate the profound loss. This tragedy underscores the urgent need for accountability and systemic improvements to safeguard patient safety.