A medical migraine error that led to death

A 27 year old charity worker Liam Ross went to hospital complaining of severe headache and visual problems such as tunnel vision.

The doctor examined Liam including learning about his mothers migraines. After examination the doctor diagnosed Liam with migraine and sent him home pain killers. He was told that if his symptoms worsened he could return to the hospital or visit his GP.

hospital error

The next day Liam was found dead in his flat by a man who had come to service the premises. After an inquest, it was found that Liam died from the effects of a brain cyst after he was misdiagnosed with migraine.

The inquest also found that a fundoscopy eye examination might have alerted him to the symptoms caused by the cyst.

The doctor appeared to fight back tears as they reflected on what happened that day and offered their deepest condolences to the family.

Other doctors had been divided over whether they would have performed the fundoscopy if they were in a similar situation. Today, one year on from the terrible tragedy and the hospital has concluded it’s investigations into the death and made changes to training and protocol to increase the likelihood for such examinations.

A post mortem examination concluded that Liam suffered from a colloid cyst, which could have caused an obstruction leading to a build up of pressure in the brain.

This story is a tragic and saddening case of misdiagnosis. Many believe migraines are not fatal. But this case shows all too easily how migraines and life threatening conditions can be confused.

In the US, preventable medical errors are the number three killer, third only to heart disease and cancer. It claims the lives of 400,000 people each year. (1)

That’s over a 1,000 people each day killed due to medical errors. Furthermore, there are also 10,000 serious complications cases resulting from medical errors that occur each day according to Joanne Disch, RN and clinical professor at the University of Minnesota School of Nursing. Disch spoke before Senate hearing in 2014 about the issue.

Medical errors cost the US $19.5 billion each year. (2) The same study found that “obviously, quality care is not being delivered consistently throughout US hospitals.”

In hearing the closing questions from the Senate inquiry, subcommittee chair Senator Bernie Sanders remarked:

Why is it when a death happens one at time, silently, it warrants less attention than when deaths happen in groups of five or 10?” he asked. “What these numbers say is that every day, a 747, two of them are crashing. Every two months, 9-11 is occurring…we would not tolerate that degree of preventable harm in any other forum.

Doctor Allen Frances is also a professor emeritus at Duke University as has had to start accompanying a close friend to the hospital to ensure the doctors and nurses there don’t “screw up”. (3)

He notes: “the system is broken, and all the incentives are wrong.” It puts profits before patients and it’s “not likely to be corrected soon.”

For now he counsels the “only protection is a well-informed consumer. Read everything about your condition. Ask lots of questions about the rationale, risks, and benefits of every test and treatment. Expect clear and convincing answers. When in doubt, get second and third opinions.”

Sources:

  1. James, John T. "A new, evidence-based estimate of patient harms associated with hospital care." Journal of patient safety 9.3 (2013): 122-128.
  2. Andel, Charles, et al. "The economics of health care quality and medical errors." Journal of health care finance 39.1 (2012): 39.
  3. Frances, A. Why Are Medical Mistakes Our Third Leading Cause of Death? Huffington Post. Nov 2014. Accessed Jan 2016.