Adrian Mark Smith · Prevention of Future Deaths report

On 08/06/15 I commenced an investigation into the death of Adrian Mark Smith. The investigation concluded at the end of the inquest on 14/10/15. The conclusion of the inquest was the deceased died from a complication of heparin treatment which was given for a sagittal sinus thrombosis.

The deceased attended A&E at Good Hope hospital on 31/05/15 having suffered a seizure at home. He was discharged home with antibiotics for a chest infection. He was admitted to Good Hope Hospital on 03/06/15 complaining of a headache, left shoulder pain and a fever. Again a chest infection was suspected as the cause for his symptoms. At 08.00 on 04/06/15 he was found fitting on the floor. A CT scan undertaken at 10.36 confirmed a bilateral frontal haemorrhage of the brain. There was discussion with the Queen Elizabeth Hospital neurosurgical department who recommended a MRI scan with DWI and ADC. The radiologist at Good Hope hospital said this test was not warranted and it was never undertaken. The evidence heard at the inquest from a Professor of Neurosurgery at Queen Elizabeth hospital was that this test was indicated and would have diagnosed the sagittal sinus thrombosis. At 16.41 on 05/06/15 in contrast was undertaken which diagnosed the sagittal sinus thrombosis. There was discussion with the Queen Elizabeth neurology department who advised treatment with heparin. At 04.30 on 06/06/15 the deceased collapsed. A CT scan confirmed a further brain bleed. He was transferred to Queen Elizabeth hospital where a decompression operation was undertaken. He failed to improve and passed away on 08/06/15.

(1) Clear instruction was given by the Queen Elizabeth hospital to undertake an MRI scan to confirm the possible diagnosis. This instruction was not followed by the staff at Good Hope Hospital. Systems need to be put in place to ensure that specialist advice is followed.