A fatal complication of chickenpox

Over the next 24 hours the child developed flu like symptoms, went off his food and began to scream. After a sleepless night he was unable to walk or stand up and appeared to be floppy.

After four days his mother took him to the local surgery where he was seen by a GP registrar, a member of the MDU. The member took a history and carried out a thorough examination. He documented that the patient had a temperature of 39°C, and a chickenpox rash, including lesions on his penis.

No oral lesions were seen. The chest and abdomen were examined and capillary refill time was less than two seconds. The GP believed this patient was not sufficiently dehydrated to require immediate hospital admission and was satisfied he was drinking well and that no obvious secondary infection had been found. He felt that the history of reduced urine output could possibly be related to the painful penile lesions.

The mother was advised to give the child a lukewarm bath to encourage urination and further advice was given in relation to taking ibuprofen in addition to paracetamol.

The mother was told that if the child's temperature did not come down, and if the child did not pass urine that evening, she should contact the out-of-hours service. The GP provided the mother with the contact details.
 
Two days later the mother contacted NHS Direct saying the child was still very unwell and was advised to take him to the A&E of a local children's hospital. After an initial delay, a diagnosis of chickenpox was made. It was thought possible that transient synovitis/osteomyelitiswas responsible for the child's reluctance to walk.
 
An x-ray of the right and left hips was normal, and an ultrasound scan showed a 3 mm effusion of the left hip with a normal right hip. It was agreed that the child should be admitted and have IV fluids with analgesics.

Blood tests revealed a raised white cell count (17.8) and a CRP of 190. According to the medical records no other doctor then assessed the child until 11 pm and he didn't receive the recommended fluids.

Soon after this, the child deteriorated, suffered a cardio-respiratory arrest and died. The cause of death was recorded as toxic shock secondary to group A streptococcus infection as a complication of chickenpox. There was no evidence of osteomyelitis.
 
A claim was made against the GP registrar, his GP supervisor and the children's hospital.

The letter of claim stated that the GP registrar had failed to conduct an adequate examination and had failed to heed the concerns of the mother. As a result of this substandard examination, the GP registrar had failed to appreciate the seriousness of the boy's condition and had failed to refer him to hospital.
 
It was also alleged that it was inappropriate to arrange for the child to be seen at the out-of-hours service if his condition did not improve and that the registrar should have seen the patient himself if required. Criticism was also raised that the GP registrar did not consult adequately with either his trainer or his supervisor.

The Outcome

The GP registrar was distressed to receive the claim and contacted the MDU. He explained that his supervisor had considered his assessment and management of the case entirely appropriate when he had discussed the matter with her that evening after surgery.

The member also pointed out that his GP trainer had visited the parents after the death of the child and had been told by the parents that the child's condition had improved after the GP consultation.

A GP expert report, commissioned by the MDU, supported the registrar's management and the MDU's formal response to the letter of claim refuted the allegations of breach of duty by pointing out that a full history and examination was carried out. The MDU cited expert opinion and the GP registrar's experience of examining children as evidence that the examination had been conducted properly. The claimant's solicitors were invited to discontinue their claim.

After some months, the hospital settled the claim, admitting full liability and the case against our member was discontinued.

This page was correct at publication on 22/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.