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Case ref:201102074
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Date:September 2013
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Body:Grampian NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C received hospital treatment for a cerebrospinal fluid (CSF - the fluid that surrounds the brain and spinal cord) leak in 2009. As other procedures had been unsuccessful, a shunt (a device inserted to transport excess fluid elsewhere) was inserted, but Mrs C believed this to have been too short, and that this contributed to her subsequent stroke.
She complained that the treatment she received to try to repair the CSF leak was unreasonable, that it took too long to identify that she had suffered a stroke, and that the board unreasonably failed to tell her in advance that there was a risk that the treatment might lead to a stroke.
After taking independent advice from a medical adviser, although we recognised Mrs C's concerns, we did not uphold her complaints. After inspecting Mrs C's medical records, the adviser said that her care and treatment was entirely reasonable, and that the shunt was not too short, but had probably moved, which is a common and recognised complication of that procedure. He was clearly of the opinion that this could not have caused the stroke. He also said that there was no sign of delay in identifying that Mrs C had experienced a stroke, and no identifiable risk that the treatment might lead to one. It was not unreasonable that Mrs C was not warned of this.