Delay in diagnosis of temporal arteritis leads to blindness

Mrs M was 78 when, on 14 October 2013, she attended Queen Mary’s Hospital in Sidcup with loss of vision in her left eye.  She presented with a classic presentation of giant cell arteritis (also known as temporal arteritis) and the notes indicate that the treating ophthalmologist suspected the condition.  Blood tests were arranged which, together with a visual field test, were grossly abnormal.  However, inexplicably, the claimant was discharged home, without a diagnosis, and told that she would receive a clinic appointment.  By the time she was discharged, she had no vision in her left eye.

On 23 October 2013 she returned to Queen Mary’s Hospital with loss of vision in her right eye.  Giant cell arteritis was quickly established and high dose corticosteroids commenced.  However, by this stage it was too late to save her vision and, on 27 October 2013, she had suffered complete blindness.

We were instructed and achieved an out of court settlement of £760,000 which has secured Mrs M’s financial future.

Prior to October 2013, despite her age, Mrs M was generally fit and well. She was Type II diabetic, but that was well controlled by diet only, and she had lived an active and entirely independent life since she had been widowed seven years previously.

On Saturday, 12 October 2013, Mrs M noted a dark line in the upper part of her vision of her left eye.  Over the course of the weekend it gradually crept down.  By 8.30 am on Monday, 14 October 2013, the claimant contacted her GP who was concerned that she had suffered a retinal detachment and arranged for an ambulance to collect her from her home to take her to Queen Mary’s Hospital in Sidcup.

The ophthalmology services at the hospital are provided by King’s College Hospital NHS Foundation Trust (the defendant in the case).

On admission her visual acuity in her left eye was abnormal.  She was noted to have had a two day history of a line across the top of her vision in her left eye.  She now had a cloud over the superior aspect of her vision with central flashing lights and headaches.  A Humphrey visual field test was undertaken.  The right visual field test appeared to be normal, but the left visual field plot was grossly abnormal with the superior and central visual field lost.

Mrs M was examined by an ophthalmologist at 11.30 am and it was documented that there was an “old history of migraines” and the claimant experienced “pain on chewing”.  Swelling of the inferior portion of the left optic nerve was observed with haemorrhage and was drawn in the notes.  The working diagnosis was stated to be left ischaemic optic neuropathy.    Urgent CRP and ESR blood tests were requested which subsequently indicated CRP was significantly elevated and her platelet count was also high.  All symptoms were consistent with giant cell arteritis.

There was nothing in the records to suggest that the urgently requested blood results were considered by staff and there were no further ophthalmology notes available for Mrs M’s visit that day.  There was no discharge letter or communication sent to the GP.

Mrs M recalled that she was seen by a young female doctor who advised that she could go home and she would receive an appointment to attend a clinic in two weeks.  She was given no treatment or medication.

During the course of the day, the vision in her left eye gradually deteriorated.  By the time she was sent home, she was unable to see anything through her left eye other than cloudiness.  The doctor told Mrs M that the vision might come back in six months and offered no advice regarding the right eye.

On Saturday, 19 October 2013, Mrs M noticed that she had a few black spots in the vision in her right eye.  She consulted her GP on Tuesday, 22 October 2013 and, the following morning, returned to Queen Mary’s Hospital.  Left sided ischaemic optic neuropathy with disc haemorrhage was noted.  Giant cell arteritis was suspected.  A temporal biopsy was scheduled for Friday, 25 October 2013, and Mrs M was transferred to the Princess Royal University Hospital at 2.46 pm where she saw a consultant rheumatologist.  Intravenous corticosteroids were prescribed and commenced later that day.

The temporal biopsy undertaken on Friday, 25 October 2013 was positive for giant cell arteritis.  Mrs M was discharged home on Saturday, 26 October 2013.  When she arrived home, the vision in her right eye was poor, but she could, for example, make out her feet.  By the evening of Sunday, 27 October 2013, she no longer had vision in her right eye.

We were instructed by Mrs M to investigate her potential claim.  We obtained her medical records and instructed a consultant ophthalmic surgeon to report on the standard of care she had received.  He advised that Mrs M’s care on 14 October 2013 fell below an acceptable standard in several respects including:

1. Failing to immediately prescribe high dose steroids when giant cell arteritis was suspected; and

2. Failing to make any record of the discussion with the claimant on the afternoon of 14 October 2013 when she was inexplicably told that she could go home notwithstanding abnormal visual field tests and blood results.

The expert advised that had it not been for the aforementioned errors, the claimant would have retained her right vision in full, about 50% of her left vision and thereby avoided deterioration to a state of complete blindness by about 27 October 2013.

A letter of claim was served and the defendant trust made a number of significant admissions in relation to both breach of duty and the causative impact of those breaches.  The defendant promptly made a Part 36 offer to settle the claim in the sum of £275,000 which was rejected.  The claimant was keen for her case to settle, but followed our advice that the offer was a gross under valuation.

With limitation due to expire, court proceedings were issued and served.  Judgment was entered in the claimant’s favour and the defendant made a further offer of £350,000.  An interim payment was obtained in the sum of £150,000, which enabled the claimant to start to utilise professional carers.

Whilst the issue of liability had been agreed between the parties promptly (and resulted in the chief executive of the defendant trust writing a letter of apology to Mrs M), there was a significant difference in the parties’ valuation of the case.  Additional expert reports were obtained in relation to the claimant’s care and accommodation needs together with life expectancy.

The case was unusual in that, notwithstanding Mrs M suffering total blindness when she was elderly, she retained some independence and, for the first four years, relied exclusively on her family for care and assistance.  The defendant’s early offers indicated that the defendant robustly challenged the claimant’s financial losses.

Although the working relationship between the parties was generally cordial and constructive, the defendant’s two early offers were woefully inadequate.  We invited the defendant to attend an early joint settlement meeting, which was declined, and the defendant did not negotiate further for a further 15 months. Once both parties had served their medical evidence, the defendant made an offer of £700,000 and we thereafter negotiated a settlement of £760,000. The settlement reflected the claimant’s wish that a trial be avoided and, given her age, she wanted to move on with her life.

The final settlement reached was £485,000 more than the defendant’s initial offer.

Oliver Chapman specialises in ophthalmology cases. If you would like to discuss an ophthalmology case, or any clinical negligence case, please contact him at Thomson Snell & Passmore LLP on 01892 701234.