Kerry Danielle Halpin, a young mum-of-two, died after "one of the rarest forms of strokes" was missed by medics on a brain CT scan.
The 35-year-old from Blackpool died at the Royal Preston Hospital on November 1, 2019 after going to A&E.
The mum-of-two had complained of headaches, nausea and neck stiffness as well as sensitivity to light, reports LancsLive..
She went to Blackpool Victoria Hospital where she worked at 11.30am, two days earlier.
Describing the pain, she said it was "one of the worst headaches of her life."
A&E doctors suspected she was either suffering from a brain haemorrhage or an infection in the brain such as meningitis or encephalitis.
Miss Halpin, of Lynwood Avenue, was immediately started on broad spectrum antibiotics and was sent for a CT scan.
At an inquest at County Hall in Preston yesterday (February 16) the senior consultant radiologist, Martine Paetzel, said both she and her colleague deemed the scan to be normal and reported this back to ward staff at 3.46pm.
However, the following day a second CT scan revealed that Miss Halpin, of Lynwood Avenue, had a basal artery thrombus, a rare form of blood clot which accounts for just one per cent of strokes.
Senior coroner Dr James Adeley heard that the 2-3mm clot had been visible on the first scan but both radiologists had failed to spot it.
“It was shocking for me when I found out later on,” he said.
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“She was young, only 35, with no prior medical history. To be honest it was at the very bottom of my differential diagnoses."
After a ‘discrepancy meeting’ with a number of radiologists Dr Billington said the clot had been ‘a difficult call which anyone could miss’.
Dr Siddarth Wuppalapoti, a neurosurgical consultant at the Royal Preston Hospital who is ‘highly specialised’ in removing blood clots in the brain, said he only comes across two or three basal artery thrombus cases a year across a population of 1.8 million.
Cassie Newton, a specialist biomedical scientist who works at Blackpool Victoria Hospital, visited her friend Miss Halpin on the afternoon of October 30.
“Kerry was in agony, rolling around on the bed, and she just kept saying ‘my head, my head’,” she said.
Nicholas Park, a consultant neurosurgeon at the Royal Preston Hospital who treated Miss Halpin, said that by the time she was referred to his team, the morning after she attended A&E, her condition was ‘irretrievable’.
In giving a narrative conclusion, Dr Adeley said that while ‘the outcome is hugely uncertain’ had Miss Halpin been transferred to Preston earlier, he said ‘it might have made a difference’.
After the inquest Miss Halpin’s family told LancsLive: “Kerry is loved and deeply missed by family and friends and leaves behind a daughter, Sophia, aged eight, and son, Louis, aged four.”
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