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

Dr Baldwin and Dr Hassan, both experienced stroke physicians, respectively on behalf of Mr Hakmi and the defendants, raise similar points on breach of duty to those made by Mr Zoltie and Dr Campbell-Hewson. They both agree that it is for me to determine whether the history taken and the examination made by Dr MacDonald-Nethercott and Nurse Woodward was carried out to a reasonable standard.

Dr Baldwin observes that there was no assessment documented of the examination of the lower limbs or visual fields. He does not consider that the documented examination is adequate to complete the Stroke Proforma (A), which was relied on by Dr Metcalf. Further he draws attention to the fact that it is not clear from the witness statements whether the examination by Nurse Woodward was undertaken at the same time as Dr MacDonald-Nethercott or separately.

Dr Hassan’s view is that Dr MacDonald-Nethercott and Nurse Woodward’s findings were consistent with a reasonable standard of care because lacunar strokes/capsular warning syndrome can have a very fluctuating presentation. He also relies upon the further assessment done at 0520 before his admission to the stroke unit, which recorded the NIHSS score as 1, with mild sensory loss. His view is that with a non-disabling symptom the risks of thrombolysis would still outweigh the benefits.

As to the use of telemedicine, Dr Baldwin said in his report that it was approved and recommended as an option in the 2016 Royal College of Physicians stroke guidelines. However, it relies on the local examination or directly observed examination by the remote physician. In his opinion, telemedicine without video conferencing is less accurate. Dr Baldwin considers that it was in breach of duty for Dr Metcalf, to begin the shift without knowing whether he could access the network. Dr Metcalf’s role was to determine, first, whether Mr Hakmi had suffered an acute ischaemic stroke, then, second, the neurological impairment was sufficient to indicate the use of thrombolysis. He observes that there is an accepted risk of haemorrhagic transformation and anaphylaxis.

Dr Baldwin explains in his report that the process involves a trained local stroke clinician, usually a specialist stroke nurse, medical registrar and the remote stroke consultant who can see and speak to the patient and is led through an NIHSS examination by the specialist stroke nurse. Then the stroke consultant reviews remotely the imaging. He considers that it was incumbent upon Dr Metcalf to inform Mr Hakmi and his wife, who was, also a physician, that the telemedicine was not working correctly. It was also incumbent upon Dr Metcalf to offer Mr Hakmi urgent alternative care which included urgent review by medical consultant where Mr Hakmi had reported to Dr Metcalf that the examination conducted by Emergency Registrar had been inadequate and inaccurate. The importance lay in the timing of the onset of persistent neurological impairment. Dr Baldwin considers that it was a breach in the duty of care for Dr Metcalf to suggest that a stroke mimic was the most likely diagnosis.

Dr Baldwin considers that the telephone assessment by Dr. Metcalf, at 04.30, occurred 70 minutes after the onset of symptoms at 03.40 am, so was well within the 4½ hour window for thrombolysis, 270 minutes. The standard approach is to accept the onset time to be the time when the patient was last known to be well. He considers that what occurred at midnight was likely to be a TIA which resolved completely followed by a recurrence. He considers that fluctuation of symptoms is common in acute stroke. He believes that Dr Metcalf was wrong to suggest that the fluctuation was atypical. His view is that the NIHSS should have been repeated hourly until the time window for IVT closed at 08.10 and Mr Hakmi should have been kept under regular review by a medical registrar. On the morning ward round on 16 November 2016 Dr Massyn noted persistent neurological impairment. He did not calculate the NIHSS score but in Dr Baldwin’s opinion, it would have been greater than 4.

The stroke physicians agree that the onset and interpretation of symptoms is a matter for this court. Dr Baldwin agreed that the finding of power 5/5 was inconsistent with Mr Hakmi’s account of weakness on his right side. He considered, however, that the direction of travel at the hospital was one of deterioration. He agreed that, if the stroke score was 3 or 4 at 0810, then it would have been less earlier. Dr Hassan considers that the two scores at 0420 and 0520 accurately reflect Mr Hakmi’s neurological condition. They agree that Dr Metcalf should have informed Mr Hakmi that his IT equipment was not working. They disagree that the contact by telephone was inadequate.

Following assessment at 0520, Dr Hassan accepts in the joint statement that there should have been a further assessment at 0620 and at 0720. If Mr Hakmi had deteriorated at these time points, he considered that there was a trigger to re-assess for thrombolysis. The treatment decision would still have been balanced, although a failure of antiplatelet treatment and the deterioration would on the balance of probability have tipped the decision in favour of offering thrombolysis.