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"Inappropriate discharge and wrong diagnosis leading to failure to recognise stroke symptoms"

About: Angliss Hospital Box Hill Hospital Maroondah Hospital

(as a relative),

My elderly mother was rushed to Box Hill ED with stroke symptoms twice in four days, seemingly recovering completely both times, which led the doctors to diagnose her with sporadic hemiplegic migraines.

Both times she was only kept in overnight and discharged the next morning. The second time this happened however, she deteriorated significantly again overnight/before discharge. She was discharged to my sister while weak, confused, unable to communicate clearly, unable to use her right hand properly and unable to swallow without coughing. The deterioration of her condition since the night before, when she had been coherent, communicative and capable after her symptom reversal in the ambulance, was not discussed with my sister. The discharge happened in a rush in the hallway.

When my sister questioned the nurse about my mother's symptoms the nurse said they would resolve in a few days "once the medication has had time to work".

Given my mother's confused condition, the discharge was not sufficient - my mother had scripts for medication, but wasn't in a fit state to remember information, so my sister only knew about the scripts because she asked the nurse about them. Also my mother lives independently and there was no discussion about her need for extra care or supervision.

Because she had been discharged in this condition, when my sister, worried about her, asked for advice from 'Nurse On Call', they reassured her that if her condition was unchanged from discharge she wouldn't need to be returned to hospital.

Despite this advice my sister took her to the Angliss the next morning and she was transferred to Maroondah where they diagnosed her as having had a stroke. Given the delay to diagnosis she was not considered for thrombolysis treatment. The diagnosis of sporadic hemiplegic migraines was clearly wrong, yet the deterioration of her symptoms whilst at Box Hill hadn't been acknowledged as any cause for concern. This has led to a lot of stress and confusion in my family and a feeling of distrust of the system, which did not communicate well, or consider the possibility of a misdiagnosis.

Even if the diagnosis of hemiplegic migraine had been correct, the choice to discharge my mother at this time and the coordination of the discharge, was inappropriate - she had deteriorated and needed medical attention. She subsequently spent several days in hospital and is now in a rehabilitation centre facing life with a permanent disability.

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Response from David Plunkett, Chief Executive, Eastern Health 7 years ago
David Plunkett
Chief Executive,
Eastern Health
Submitted on 5/04/2017 at 1:25 PM
Published on Care Opinion at 1:26 PM

picture of David Plunkett

Dear Misdiagnosed,

I am very sorry to read about your mother’s recent experience at Eastern Health.

I would like to follow this up to see what we can learn from this situation and also to provide you with some feedback and more details about this. As the information provided here is de-identified, I would be grateful if you would write to me privately at so that I can follow-up quickly and get back to you. You can be reassured that any personal details will not be released on this website and that this request for information is to help us investigate your concerns in a timely manner. Once again, I am very sorry to read about what happened and hope to hear from you very soon.

Kind regards,


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