A disabled man died after twice being sent home by A&E doctors who mistook his alarming symptoms for his learning disability, an inquest revealed.
Medics at the Whittington Hospital failed to correctly diagnose Gerald Yilmaz’s deadly brain abscess, wrongly attributing worrying neurological signs – such as confusion, drowsiness and a drooping eyelid – to his learning impairment.
The 37-year-old of Regina Road, Finsbury Park, visited A&E three times in as many days in July 2012.
But he was twice discharged by doctors who thought he had only an ear infection and a migraine, St Pancras Coroner’s Court heard on Tuesday.
Following the inquest, Gerald’s sister Sevim, 35, said: “We knew that something was not right. His eye was drooping, but they thought he was just like that.
“It’s devastating – we think about what would have happened if they diagnosed him earlier?”
The inquest has thrown a spotlight on the problem of “diagnostic overshadowing” – where symptoms are wrongly assumed to be the normal behaviour of patients with learning disabilities.
Mr Yilmaz’s family are determined that his death will have a lasting legacy, by forcing improvements at the Whittington and raising awareness.
Brother Muhammed, 22, said: “We hope this is the spark for change and we expect to see big changes from the Whittington. It’s not about individual blame, it’s about a system that’s broken.”
Beverley Dawkins, policy manager at the charity Mencap, who accompanied the family to the inquest, said: “This is the biggest thing that kills people with learning disabilities. The delay in diagnosis is something too many people with learning disabilities experience.”
Mr Yilmaz had the IQ of a seven or eight-year-old, the inquest heard.
He was diagnosed with an ear infection on July 2 and prescribed antibiotics by a GP.
Two weeks later he visited A&E but was sent home with more antibiotics. He returned the next day but was again discharged after being diagnosed with an ear infection and a migrane by Dr Edwina Lawson.
She told the inquest that diagnostic overshadowing was a factor in her mistakes.
Acting coroner Dr Shirley Radcliffe made it clear the symptoms should have raised alarm bells and Dr Lawson should have sought a second opinion at the very least.
Mr Yilmaz was finally sent for surgery at Queen’s Hospital in Romford after returning on July 17, but after three operations he died on July 23.
Dr Radcliffe recorded a narrative verdict, saying: “It’s more likely than not that earlier detection and treatment to the cerebral infection [which caused the abscess] would have prevented a fatal outcome.”
A report by the hospital, in Magdala Avenue, Archway, cited diagnostic overshadowing as the reason serious signs were missed.
The hospital has pledged to host training sessions, improve procedures and appoint a learning disabilities champion in the emergency department.
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