QB-2022-001544 - [2025] EWHC 2597 (KB)

Turning to the expert evidence, Mr Zoltie and Dr Campbell-Hewson, both experienced emergency medicine consultants, instructed respectively on behalf of Mr Hakmi and the defendants, accept that their expert opinion on breach of duty is dependent upon my findings of fact.

As I understand the agreed position, the respective roles of the Emergency Medicine Registrar and the specialist stroke nurse are as follows. The registrar considers the differential diagnosis, carries out a basic neurological examination, organises the CT scan and speaks to the telemedicine stroke consultant before handing over to the specialist stroke nurse. The CT scan informs the decision about thrombolysis in establishing whether there has been any intra-cranial bleeding.

Mr Zoltie’s evidence in his report is straightforward. He considers that a failure by Dr MacDonald-Nethercott to take an accurate history from Mr Hakmi would fall below the requisite standard of care. He draws attention to the history taken by Dr Metcalf superceding the history taken by Dr MacDonald-Nethercott.

Mr Zoltie considers that the history was not in accordance with the standard of care to be expected. The only detail in the history was the time of the onset of the symptoms, later identified as insufficiently accurate. There was no description of any resolution of symptoms, progression of symptoms, change in symptoms, or presence or absence of any other symptoms. The history can be compared with the history taken on the previous attendance.

Mr Zoltie considers that if Mr Hakmi was suffering from weakness, when he was seen by Dr MacDonald-Nethercott and Nurse Woodward, then the failure to identify and report it to Dr Metcalf fell below a reasonable standard. He also considers that if Dr MacDonald-Nethercott failed to examine Mr Hakmi’s lower limbs, visual acuity and visual fields, then that that fell below a reasonable standard. He also considered it to be a breach of duty not to document an examination of the lower limbs and visual fields.

In the body of his report, he draws attention to the fact that it is unclear who completed the Stroke Proforma (A), Dr MacDonald-Nethercott or Nurse Woodward, and to internal inconsistencies of the documentation. It is of note that he considers that if Dr MacDonald-Nethercott did not examine Mr Hakmi fully then any information he gave Dr Metcalf would have been incomplete and below a reasonable standard. He also considers that if Mr Hakmi requested a re-examination which was not undertaken that also fell below an acceptable standard.

Dr Campbell-Hewson considers in his report that there was a prompt and timely response by the Emergency Team and stroke nurse following Mr Hakmi’s attendance at the hospital. He emphasises that the emergency doctor is not taking a full and final complete history but a brief screening history to see if a CT scan is required to exclude thrombolysis. He accepts there was shortfall in the documentation.

He draws attention to the fact that Dr MacDonald-Nethercott’s examination involved both objective and subjective assessments. He contrasts his findings with those of Dr Massyn, consultant in stroke medicine, several hours later recording 4++/5 power in the right upper limb at a later examination, which he describes as the most minimal decrease in right upper limb power. He draws attention to theclinical history on the CT request stating ‘? Stroke, Right-sided weakness’, whichwould be evidence that there was right sided weakness on examination, which is inconsistent with the findings in the clinical records. He states, however, that clinical records are likely to be more accurate than the CT request form.

His opinion, ultimately, depends on whose account is accepted whether it was that of Mr Hakmi or Dr MacDonald-Nethercott. His view is that if Dr MacDonald-Nethercott examination was performed competently then it would have been reasonable to have concluded that there had not been a further stroke. If Mr Hakmi’s account is accepted, then the assessment would not have been of a reasonable standard.

The joint statement of the Emergency Medicine Consultants records their different interpretations of the history taken by Dr MacDonald-Nethercott.

Mr Zoltie states that the information provided by Dr MacDonald-Nethercott should be compared with the previous admission where the NIHSS score was recorded, but the examination was also recorded in full on the stroke proforma. Dr Campbell-Hewson observes that the notes clearly indicate that there was neurological assessment of the lower limbs and visual fields, and that the results of these assessments were recorded and were normal. He believes that that it would be reasonable, and in keeping with standard practice, not to assess visual acuity.

The experts both agree that acceptance of the accounts given by the parties would determine whether the assessment of Mr Hakmi was reasonable. Mr Zoltie draws attention to whether Dr MacDonald-Nethercott did in fact complete the examination as documented on the Stroke Proforma (A). He also states that a failure to arrange a second examination, when requested by Mr Hakmi, was below an acceptable standard. Dr Campbell-Hewson believes it was reasonable to entrust it to the stroke nurse. He relies upon the record of a second NIHSS examination at 0520 with similar findings. Mr Zolitie considers that on the handover to Dr Metcalf, as documented by him on the Stroke Proforma (A), would not have provided a full description of the events. Dr Campbell-Hewson considers that “it would not be usual practice for Emergency Department staff to document an extensive verbatim account of a discussion with a consultant from a specialty team.”

In cross-examination Dr Campbell-Hewson said that the emergency doctor should ask the nature of the symptoms, the location of the symptoms, the first onset and progress of the symptoms over time. He accepted that if Mr Hakmi provided the material information. then the failure to provide that information was in breach of duty. He agreed that symptoms down one side of the body were indicative of a stroke. Likewise, there is urgency in obtaining a CT scan to rule out a haemorrhage. A more detailed history will then be taken by the stroke team. He said that the critical part of the assessment is the NIHSS score. He agreed that the Stroke Proforma (A) does not disclose who completed it. He agreed that Dr MacDonald-Nethercott recorded that the upper limb was normal but the lower limb was left blank. The power, however, was recorded as 5/5 throughout. He agreed that if the visual field was not tested it fell below the required standard. He agreed that Dr Metcalf should have been informed if the lower limbs or visual field had not been examined.

The Emergency Medicine Experts are agreed that if the history given by Mr Hakmi is fully accepted then the NIHSS score would have been expected to be 4.