Dorota Marta KUKLINSKA · Prevention of Future Deaths report

On 10 September 2023 I commenced an investigation into the death of Dorota Marta KUKLINSKA. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Died from a catastrophic brain bleed caused by a cerebral artery aneurysm due to a misreported CT scan and not referring to specialist neurosurgeons.

Mrs Kuklinska attend the City Hospital on 27/06/23 having woken at 05.00 am with a severe headache 10/10 in severity and radiating down the neck and eyes. The headache was associated with vomiting, fever, chills and light sensitivity. There was concern she had suffered a brain bleed so a CT scan was arranged which was misreported as normal as it was later found to show some subtle signs of cerebral swelling but no brain bleed. Had the CT scan been correctly reported it is likely a referral would have been made through NORSE to specialist neurosurgeons and the condition would have been identified and successfully treated. Clinicians advised that a lumber puncture was necessary to confirm or rule out a brain bleed. This was explained to Mrs Kuklinska who was advised of the risks and benefits of a lumber puncture and given an information leaflet but she declined a lumber puncture and self-discharged against medical advice. She was advised to see her GP about the high blood pressure which was identified at the hospital. Given the strong clinical signs of a brain bleed and refusal of lumber puncture a referral should have been made through NORSE to the specialist neurosurgeons which would on balance have identified the condition and successful treatment would have been provided. She attended her GP on 28/06/23 and was prescribed blood pressure medication. On 07/07/23 she advised the GP her headache had resolved as her blood pressure became normal. She collapsed at home on 20/07/23 and was readmitted to hospital where a CT scan confirmed an unsurvivable brain bleed caused by a right middle cerebral aneurysm. She died at the hospital on 21/07/23.

Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:

1a Spontaneous Intracerebral Bleed

1b Right Middle Cerebral Aneurysm

1c

II

1. The inquest heard evidence from a specialist neurosurgeons at University Hospital Birmingham that there are guidelines to confirm a patient with strong clinical signs of a brain bleed, should be referred through NORSE particularly when they have refused a lumber puncture which is the usual test undertaken in accordance with the NICE guidelines. Clinicians at Sandwell and West Birmingham Hospital City hospital site said they were unaware of those guidelines and didn't consider a referral for Mrs Kuklinska. Consideration needs to be given to establishing clear guidance with acute trusts to ensure patients with strong clinical signs of a brain bleed are referred for specialist neurosurgical advice.