Elderly woman (74) given blood thinners after radiologist failed to spot brain bleed
A pensioner was given blood thinners after a radiologist failed to spot a small bleed in her brain on a CT scan, an inquest heard.
Dympna Halpin (74) from Killeary, Lobinstown in Navan, Co Meath, subsequently developed a massive bleed on the brain which led to her death at Beaumont Hospital on October 26, 2012.
Dublin Coroner’s Court heard that a CT brain scan carried out when Mrs Halpin presented at Our Lady’s Hospital, Navan, with a history of falls on October 14, 2012, was reported as being normal.
Doctors started treating her with blood thinners for a suspected coronary problem but she deteriorated overnight and a subsequent scan showed she had developed a “massive” subdural haematoma or bleed on the brain.
Returning a verdict of medical misadventure, Dublin coroner Dr Brian Farrell said the blood thinners had “exacerbated” the rate of bleeding.
The inquest heard that the scan was organised by Dr Murat Kirca when Mrs Halpin was admitted to Our Lady’s Hospital, Navan. She had a recent history of weakness and falls. Doctors suspected she had acute coronary syndrome but the scan was ordered to rule out a subdural haematoma.
Giving evidence, consultant radiologist Dr John Hanson said he had reviewed the CT scan on his hospital PC at home and believed that it was “entirely normal”.
When the CT scan was reported as normal, Mrs Halpin was given low doses of the anti-clotting agents Plavix and Clexane. Overnight she began to complain of headaches and was vomiting. The following day her neurological status began to drop and a second CT scan was ordered which showed a significant haematoma. She was transferred to Beaumont Hospital where the bleed was evacuated. She showed some improvement following the operation, however, her condition deteriorated and she subsequently died. Dr Kirca said that had the subdural haematoma been reported it would have changed their management of Mrs Halpin and he would “probably not have given Plavix”.
Dr Hanson told the court that on subsequently reviewing the scan a “very tiny, shallow subdural collection” is evident but he described this as “subtle”. When pressed by counsel for the Halpin family Sara Antoniotti that it was found in an area where one “commonly encounters subdural haematomas”, he said he “did not appreciate it on the day” and told the court: “that is something I have to live with”.
“I just misinterpreted the scan. I felt that the scan was entirely normal when I first looked at it. There was nothing jumped out at me, nothing raised any alarm bells,” he said.
The PC system he used at the time is FDA approved but not as "efficient" as the hospital system, he said. Since February this year, radiologists are now working from the same IT system whether they are in hospital or at home, the court heard.
The inquest also heard from Dr Paul Brennan, consultant neuroradiologist, who was asked to review the scan. He said he has shown the scan to several “general radiologist consultants” and the subdural was “completely missed by them”.
Dr Farrell gave the cause of death as complications of the subdural haematoma exacerbated by Plavix which was administered because doctors felt that acute coronary syndrome was a possibility. Returning a verdict of medical misadventure, he stressed that this has no connotations of malpractice on the part of anyone involved.