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Case Overview:
Our client presented to the emergency department at a hospital complaining of a progressively worsening headache which had been ongoing for in excess of a week.
CT brain imaging was performed which was reported as normal. He was then discharged from the emergency department.
He represented again to the emergency department with persistent symptoms of headaches and left leg weakness. Upon clinical examination, left lower limb weakness, mild ataxia with difficulty performing left heel to shin test, and a left visual defect were noted. He was admitted to hospital for further investigation where he underwent repeat CT brain and CT angiogram of the neck vessels, both of which were unremarkable.
He underwent a lumbar puncture which was recorded in his clinical notes as traumatic, with blood visible in the sample obtained. The procedure was not adequately documented and, in particular, the position of our client when the lumber puncture was being performed, the type and size of the needle used, the spinal segment level at which the cerebrospinal fluid (“CSF”) tap was attempted, and the number of insertions or passes made in order to obtain CSF were not recorded.
In the aftermath of the lumbar puncture, he complained of left leg weakness with an inability to perform heel-toe testing. His condition deteriorated further. In view of his presentation, MRI imaging of the spine was undertaken, to investigate the neurological deficits of which he complained. Subsequent review of the MRI confirmed evidence of substantial spinal haemorrhage with intramedullary signal abnormality.
Unfortunately, owing to the manner in which a lumbar puncture procedure was performed he suffered significant neurological injury with ongoing lower limb paresis and bladder and bowel dysfunction.
This case was fully defended and was mediated a week in advance of the trial date. This case ultimately settled for a significant sum.