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

The conclusion which I have reached is that the first incident, probably a TIA, occurred around midnight, lasted a few minutes and did resolve completely. I do not consider the differences in times in the documentation materially alters that conclusion. I am also satisfied that, having experienced a stroke on 26 September 2016, Mr Hakmi would not have gone to bed unless the symptoms had resolved.

The position was significantly different after he was woken by his 4-year-old daughter at about 0320. He says that he noticed symptoms of a stroke at about 0340. Again, I am satisfied that he did notice some symptoms which alerted him to the possibility that he had suffered another stroke. I do not believe that he and his wife would have left three children in their house alone and driven to the hospital unless he believed he was experiencing symptoms of a stroke. He was a highly trained consultant orthopaedic surgeon, who would have been aware of the need for diagnosis and treatment. The extent, however, of the symptoms he suffered is more difficult to judge in circumstances in which he and his wife have lived and relived the circumstances of that morning with a grievance against the defendants that he would not have suffered his present disability if he had been treated with thrombolysis.

It is a matter for me to determine the extent to which Mr Hakmi and his wife explained the extent and detail of his symptoms. It remains a matter for doubt but I am satisfied that he explained the material points, namely that the earlier incident had resolved, he had some weakness in his right side. I am not satisfied about the extent to which he went into further detail as to his shoulder and hip, numbness in his right hand and his wife having noticed the right side of his face had dropped. There may have been elements of Mr Hakmi’s description explained but nothing that went beyond what Dr Metcalf recorded. I rely upon Dr Metcalf’s note of what he was told by Dr MacDonald-Nethercott and Mr Hakmi as being the fullest of the contemporaneous records of what Mr Hakmi said, which falls short of the detail given by Mr Hakmi and Dr Abbas. For the reasons set out below, I also have some reservations about Dr Metcalf’s note. As I have said, I do not consider that Mr Hakmi would have been driven to hospital by his wife leaving young children alone at home unless he believed that he was experiencing symptoms of a stroke, which were in fact similar to the stroke he suffered on 26 September 2016.

In my view, the history taken by Dr MacDonald-Nethercott probably concentrated on the onset of symptoms at around midnight and that was why it did not differentiate between the two episodes, one at around midnight and the other at around 0340. I accept that he believed there was a degree of urgency as to whether thrombolysis could take place before the expiry of 4 ½ hours. I accept Dr Campbell-Hewson’s evidence that the stroke team may have regarded the events at 2345 and 0340 as being evidence of a stuttering stroke rather than two entirely discrete events. The records, however, are to be compared unfavourably to the history taken by Dr Pulsakar, stroke physician, on 20 September 2016.

Perhaps a more detailed comparison by the emergency medicine experts at trial of the NIHSS scores obtained on 26 September and 16 November 2016, would, in retrospect have been helpful. Dr Campbell-Hewson, however, records for 20 September 2016: There is a completed NIHSS (National Institute of Health stroke scale / score) chart which records a score of ‘3’ at ‘time’, ‘3’ at time plus 2 hours and ‘3’ at time plus 24 hours. The points were given for minor paralysis of the face, mild - moderate aphasia and mild to moderate dysarthria”.

On a visual inspection they are similar to the NIHSS score on 16 November 2016 except for the scoring for aphasia and dysarthria both scored at 1. Facial palsy is marked as one two hours later. On the first occasion he also had no loss of power marked as 5/5 on both upper and lower limbs. Dr Campbell-Hewson notes in his report that Dr Pusalkar’s record states: The impression was ‘likely lacunar stroke’. The plan was ‘CT head - no evidence of bleed. 2. Not for thrombolysis - minor symptoms, low NIHSS score. On further discussion with patient due to his profession (surgeon) and poor co-ordination, Pt discussed with his wife and agreed to go ahead with thrombolysis. Bloods, x-ray abdomen, ECG’. The risk of bleeding being high with thrombolysis due to a low NIHSS was explained but Mr Hakmi wished to proceed.

To me it is unclear whether Nurse Woodward was present when Dr MacDonald-Nethercott examined Mr Hakmi. Dr MacDonald-Nethercott understandably cannot remember, and Nurse Woodward believes she arrived afterwards. Mr Hakmi was admitted at 0406 and Nurse Woodward’s note is timed at 0410. It is unclear who completed the Stroke Proforma (A). Nurse Woodward’s own note records the NIHSS score as zero but when that was completed is unclear. It is unclear to me whether there were two separate assessments before the telemedicine call with Dr Metcalf. I consider that it is unlikely. Dr MacDonald-Nethercott does state that he asked Nurse Woodward to make a repeat assessment, presumably of the neurology. I do not believe that an assessment was made again, probably by Nurse Woodward until 0520, after Dr MacDonald-Nethercott and Mr Hakmi had spoken to Dr Metcalf. As I have said, Dr MacDonald-Nethercott does not refer in his statement to speaking to Dr Metcalf and has no independent recollection of this consultation.

It is not possible to conclude who completed the Stroke Proforma (A), whether it was Dr MacDonald-Nethercott or Nurse Woodward. The form is unsigned and the fact that the circles for all three examinations look similar should not lead me into concluding they were made by the same person. I suspect that it was Dr MacDonald-Nethercott but I cannot be sure.

Mr Hakmi described Dr MacDonald-Nethercott’s assessment as cursory. In his witness statement he said: “This casualty doctor spent a few minutes with me doing a superficial examination whilst I remained on a trolley, then he said to me that the examination was completely normal. I knew that this was not correct. Performing examinations is part of my everyday job, and I know what kind of neurological examinations should have been carried out for a suspected stroke patient.”

The records shows that the result of the upper limb test was noted but not the lower limb test, again unlike the form for the 26 September 2016. I consider that Mr Hakmi was expecting a full neurological examination which was not the Emergency Registrar’s function. This would explain why he considered that the examination was cursory. It is likely that Dr MacDonald-Nethercott carried out an examination of all four limbs otherwise he would not have recorded power 5/5 throughout. The form also leaves blank the test for visual field and visual acuity. Dr Metcalf, however, records that he was told that the visual field was normal. Dr Campbell-Hewson is not critical of a failure to measure visual acuity. I have, however, reached the conclusion on the basis of the examination made by Dr MacDonald-Nethercott that Mr Hakmi did not disclose sufficient signs of a stroke to merit scoring more than an NIHSS score of zero on the Stroke Proforma (A).

By comparison there is some consistency with what occurred on 26 September 2016, when Mr Hakmi scored points for minor paralysis of the face, mild/moderate aphasia and mild/moderate dysarthria but power was scored for both upper and lower limbs at 5/5. I am satisfied that Nurse Woodward was asked to perform a repeat examination, probably because Mr Hakmi and his wife insisted, but that examination was not performed until 0520 after Dr MacDonald-Nethercott had spoken to Dr Metcalf. She recorded an NIHSS score of zero except for sensory which was recorded at “??? 1”. I accept her evidence that she would not have carried out the examination with Mr Hakmi in a wheelchair and that it would have taken place on a trolley before he was moved to the stroke ward.

The position regarding the telephone call with Dr Metcalf is a little clearer but not ideal. First, Dr Metcalf maintained in his statement that the consultation was between 0430 and 0520, which Mr Kellar established was clearly wrong. The CT scan took place at 0449. It could have occurred before the consultation with the stroke consultant but I cannot be sure. The records are equivocal. Dr MacDonald-Nethercott refers in his note to CT has been done A/W Medical report (Stroke Consultant could not download images). Dr Metcalf in his note says Couldn’t see CT head – as couldn’t get into IEP. He added Get local report on CT head if no haemorrhage, add aspirin to treatment.

In either case, it does not take the matter further, as the purpose of the CT scan was to exclude bleeding. If it did occur before Dr Metcalf’s consultation then that would be consistent with Dr Metcalf’s note giving the time of 0520 when the consultation ended, and with Nurse Woodward’s second examination being timed at 0520. Whether it was before or after the CT scan, Dr Metcalf incorrectly relied in his witness statement upon a period of 50 minutes for the consultation to support his evidence that he had taken particular care with Mr Hakmi because he was a fellow consultant.

It emerged at trial that Dr Metcalf kept handwritten notes of the consultations which were destroyed once he had completed a booklet. The history as shown was, he accepted, a composite account of what Dr MacDonald-Nethercott and Mr Hakmi had told him. In my view, Mr Hakmi probably told him what he had told Dr MacDonald-Nethercott. The precise detail of which is unclear. The record nevertheless probably comes close to what occurred except that he records Mr Hakmi waking at 0300 with “symptoms fluctuating since”. This is an important record because it is relevant as to when the window started for treatment with thrombolysis. Mr Hakmi denies that the symptoms were fluctuating.

The computer supplied to Dr Metcalf malfunctioned and he was unable to use the video communication system to see Mr Hakmi or access his medical records. He accepts that he should have checked that the computer was working before he began his shift and should have informed Mr Hakmi that the situation was suboptimal. He should have raised with Mr Hakmi the possibility of contacting another consultant. Mr Hakmi raised in his statement the alternative of driving to Addenbrookes Hospital, Cambridge but given that time was of the essence, I consider that the length of the journey time made that an unlikely solution.

The diagnosis made by Dr Metcalf depended on the information that Dr MacDonald-Nethercott and Mr Hakmi gave him. Although I find that the documentation was below a reasonable standard, I do not find that either Dr MacDonald-Nethercott or Nurse Woodward’s neurological examinations were inadequate. Dr Metcalf spoke directly to Mr Hakmi, he clearly did not believe that Mr Hakmi was suffering from a stroke although he erred on the side of caution and admitted him to the stroke ward. Albeit that it should not have been relevant, I accept that he took particular care because Mr Hakmi was a fellow consultant.

The alternative explanations for Mr Hakmi’s presenting symptoms were, as both Dr Metcalf and the stroke physicians accepted, unlikely. The CT scan undergone by Mr Hakmi on 26 September 2016 had not shown any evidence of a tumour. He did not suffer from epilepsy. He did not suffer from migraines.

In my view, Dr Metcalf appears to have accepted that the earlier incident had completely resolved, which he acknowledged in his note “?completely resolved”, however, he did not consider that Mr Hakmi had suffered a stroke. If he had done so, the window after Mr Hakmi began to feel unwell at 0340, would still have been open for treatment with thrombolysis. I accept Mr Hakmi’s evidence that there was period of time from when he woke at about 0320 to about 0340 when he was symptom free. Only one to two hours had elapsed of a 4 ½ hour window, which it was agreed was necessary for thrombolysis to be effective.

Dr Metcalf did not consider that thrombolysis was an appropriate recommendation because he did not believe that Mr Hakmi had suffered a stroke. In his letter dated 1 December 2016, he stated that he considered dual platelet therapy was appropriate rather than proceeding with thrombolysis where there was a NIHSS score of zero and a recent stroke. He also referred to the possibility of Mr Hakmi suffering from atherosclerosis, which if he had, would not have been assisted by thrombolysis.

I do not consider that, if a full repeat examination had taken place before the teleconsultation with Dr Metcalf, and the result had been made known to Dr Metcalf, it would have shown a significantly higher NIHSS score than that recorded probably by Dr MacDonald-Nethercott following Mr Hakmi’s admission to hospital. It is of particular significance that the examination at 0520, probably by Nurse Woodward, was also zero except for sensory which was recorded at “??? 1”. It is highly relevant that the final examination at 0810, before Dr Massyn came on duty, recorded 3 with facial palsy 1, right arm drift query 1 and right leg drift query 1, sensory loss 1 making a total of 3, or arguably 4.

The question of whether Dr Metcalf would have recommended thrombolysis had he seen via video link Mr Hakmi, or indeed, subsequently had he been contacted up until the end of his shift at 0800, is more difficult. In my view, the probability is that he would still have considered that Mr Hakmi had not suffered a stroke. The objective signs, as opposed to the symptoms reported by Mr Hakmi, were still too subtle to register a definite NIHSS score on Stroke Proforma (A).

Whilst I have accepted the generality of the account given by Mr Hakmi and his wife, in my view there is a distinction that should be drawn between signs and symptoms. Signs are objective findings made by the physician on examination. Symptoms are subjective experiences reported by the patient. I have concluded that the account given by Mr Hakmi and his wife of the symptoms he suffered on 16 November 2016 has unconsciously become more detailed in their memories over the past 8 or so years, as they have gone over and over again what occurred. I am satisfied that Mr Hakmi would not have had an NIHSS score of 4 at any time between admission and before the examination at 0810, when it was recorded as 3 but may arguably have been 4.

Having said that I observe that Mr Hakmi did persuade Dr Pusalkar to offer thrombolysis with a score of 3 on 26 September 2016. If, however, Dr Metcalf had been able to see Mr Hakmi, with the assistance of Nurse Woodward, it is possible, but in my view unlikely, that Dr Metcalf would have come to a different decision.

I accept that there is, nevertheless, a considerable difference between a telephone call and visual observation, which should in my view have taken place. Once Dr Metcalf became aware that he could not conduct a full video consultation with Mr Hakmi, he should have informed him of the problem, and contacted another consultant to do so. It is a matter of speculation as to whether if Mr Hakmi had been referred to another stroke consultant, the decision to offer thrombolysis would have been different. In my view, it is unlikely, based upon the agreed evidence of the stroke physicians that a NIHSS score of 4 would have been required, before a recommendation for thrombolysis would have been considered. As I have already said, at 0810 when the next assessment of Mr Hakmi was made the NIHSS score was 3 or arguably 4.

Mr Hakmi was admitted to the stroke ward at 0530. I accept Dr Baldwin’s opinion that Mr Hakmi should have been checked regularly, probably hourly, following his admission. He had, after all, suffered a stroke on 26 September 2016. Given that Mr Hakmi later required a wheelchair to take him to the toilet, Dr Metcalf should have been contacted again before his on call shift ended at 0800. There was no evidence from Dr Metcalf as to what he would have done on this hypothesis. If he had been contacted at 0630 or 0730, it is probable that the score would have been less than 3 or 3, the closer it was to 0810. Contrary to Dr Hassan’s opinion expressed in the joint statement that if Mr Hakmi had deteriorated then the balance would have been tipped to thrombolysis, I am not satisfied that would have been the case. The NIHSS score was likely to have still been less than 4.

For completeness, it is clear from Dr Masyn’s evidence that had he seen Mr Hakmi after he came on duty sometime after 0800, or indeed beforehand when he arrived at the hospital, he would not have offered thrombolysis even if the period of 4½ hours had not elapsed. Applying the Lister Hospital protocol, the recent previous stroke within three months was an absolute contra indication for further thrombolysis.