A not so simple fever - medical case study

DAY ONE

MRS Y brings her six-month-old baby girl to see her GP – Dr H – as the child has been unwell for more than a week. The baby has a cough, runny nose, high temperature, diarrhoea, is lethargic and will take breast milk but no solids. Mrs Y tells Dr H that an out-of-hours doctor had seen the baby when she first became ill several days before and prescribed antibiotics and a liquid paracetamol. Worried that the symptoms seem to be persisting, Mrs Y wants Dr H’s opinion. The GP examines the baby’s chest, throat and ears but finds no abnormality. The doctor tells Mrs Y to keep the child cool and continue with the paracetamol.

DAY THREE

The baby’s parents contact a second out-of-hours doctor in the early hours of the morning as the child is still coughing and feverish. They tell the doctor that the baby has also been vomiting and is showing signs of having stomach cramps. He advises them to see their own GP that same day. The parents take the baby back to their practice as soon as it opens that morning and she is seen this time by Dr Q. The doctor notes that the child has an upper respiratory infection and has a fever but the clinical examination is clear. She prescribes a further course of antibiotics and liquid paracetamol. Dr Q makes no record to indicate if the child has been vomiting or showing signs of stomach cramps.

DAY FOUR

When the baby’s condition fails to improve, Mrs Y again calls an outof- hours service and speaks to Dr R. She tells the doctor of the baby’s history, that she has been vomiting and also has a high-pitched cry. Dr R doesn’t examine the baby and advises Mrs Y to keep the child cool and stop administering antibiotics in a bid to stop the vomiting. Several hours later Mrs Y seeks help from another out-of-hours doctor, who refers the baby for a paediatric assessment. Later that day the baby is diagnosed with pneumococcal meningitis and admitted to hospital.

ONE WEEK LATER

The baby dies of an intracranial bleed among other complications from the meningitis.

Mr and Mrs Y raise a claim of medical negligence against Dr Q and Dr R for failing to diagnose their child and failure to refer. They allege that if the child had received hospital treatment sooner, she would have survived. An initial complaint against Dr H is withdrawn following expert advice.

MDDUS represents Dr Q while Dr R is represented by another medical defence organisation. An expert report commissioned by MDDUS is critical of the notes taken by Dr Q for not including enough detail of the consultation, including the presence or absence of relevant symptoms. Dr Q claimed she had checked for signs of meningitis but did not note any specifics of the examination. The report also concludes that an inability to detect any clinical signs that might have explained the child’s high temperature should have prompted Dr Q to look for other possible signs. The report also criticises Dr R for not arranging for the child to be examined, despite her having been unwell for more than a week.

MDDUS also obtains expert evidence in regard to causation which determines that had Dr Q or Dr R referred the child at the time of consultation then this would have made a material difference to the eventual outcome in the case.

Due to the conflicting claims made between the parents and the doctors in regard to the child’s symptoms and subsequent care, and the absence of comprehensive medical notes to substantiate Dr Q’s position, MDDUS agrees a settlement with Mr and Mrs Y which is shared equally by Dr R’s MDO.

KEY POINTS

• Be aware that classic signs of meningitis (neck stiffness, bulging fontanelle, highpitched cry) are often absent in infants with bacterial meningitis.
• Always take comprehensive notes – including positive and negative test results – when examining a febrile child.
• Be familiar with standard clinical guidelines when dealing with feverish illness in children.