Meningitis case histories

Teddy bear in a corner

Child diagnosed with meningococcal septicaemia

A mother called her GP practice just after midday, requesting a visit for her two and a half year old son, who had a temperature of 41° with diarrhoea and vomiting. The mother had also noted spots on the child's forearm. She was advised to bring her child to the surgery that evening.

Later in the afternoon, the mother called the practice again, making another request for a home visit, as she felt her child needed to be seen earlier. She told the receptionist her child was 'floppy and lethargic'.

An MDU GP member responded to this request and visited the child at home. She noted that the child had been unwell for 24 hours and had a temperature of 39°. On examination she found no abnormality, aside from a rash on the child's limbs, which she thought was not haemorrhagic. The child remained pyrexial throughout the afternoon and continued to have diarrhoea and vomiting.

Some five hours after the GP's visit, the parents called an ambulance and the child was taken to hospital where he was diagnosed with meningococcal septicaemia. Following intensive treatment, the child recovered, but unfortunately both feet and the tips of several fingers were amputated.

Five years later, a claim was brought against the GP member alleging that her assessment of the patient had been negligent. It was alleged that, at the time of the consultation, the child had photophobia, and that he was systemically unwell with a pyrexia and history of diarrhoea and vomiting. It was also alleged that as the child was lethargic and floppy, a greater level of care should have been given. It was alleged that had the GP referred the child to hospital, broad spectrum antibiotics would have been administered within 30 minutes and the child would have suffered no or no significant injury.

The MDU investigated the claim and obtained a number of expert opinions. A GP expert concluded that if the evidence of the patient's mother was accepted regarding the child's condition at the time of the consultation, then the GP member provided substandard care in not arranging immediate admission to hospital. He also commented that if a child was being described as unwell with a temperature of 39°, he would normally admit the child to hospital.

An expert in infectious diseases advised the MDU that septicaemia had probably started during the morning of the child's illness. The crucial factor was the type of rash described by the mother. If the rash was haemorrhagic at the time the child was referred to hospital then, on the balance of probabilities, complications would still have developed but would have been less extensive. If the rash was non-haemorrhagic when the patient was referred and the child had received appropriate antibiotics, the septicaemia would have been controlled and the complications would not have developed.

An expert paediatrician concurred with this view and also commented that in about a third of cases of meningococcal septicaemia, the purpuric rash is preceded by non-purpuric, non-descript pink spots indistinguishable from many viral rashes that often accompany children's illnesses. The experts agreed that the rash was non-haemorrhagic at the time of the GP consultation.

The GP member's legal team advised that given the receptionist's description of a lethargic and floppy child, the GP member's note indicating that the child was unwell with a temperature of 39° and a rash, and the GP expert's view that he would have admitted the child to hospital, it was likely that the claimant would succeed should the case proceed to trial. All experts agreed that, had the child been admitted, on the balance of probabilities he would have made a complete recovery.

Having heard the legal team's advice, the MDU member advised that she would prefer the case to be settled. The MDU then instructed experts in rehabilitation medicine, orthopaedics, occupational therapy, physiotherapy, assistive technology, accommodation and educational psychology in an attempt to quantify the claim.

The orthopaedic surgeon confirmed that the child would remain severely disabled and that further surgery was unlikely to help. It was agreed that allowances should be made for wheelchair provision throughout his adult life, together with new prostheses every few years until adulthood.

An accommodation expert advised that the child would require a bungalow with sufficient space to accommodate the use of a wheelchair and room to extend and it was agreed that he would also benefit from physiotherapy and occupational therapy.

Although the claimant would have physical limitations on what he could do, it was deemed that he could gain employment in the future. The claimants pleaded their case on the basis of a full loss of earnings and large care costs into the future – an estimated sum of £5.5 million. After negotiation, the case was settled for £3.5million.

Learning point

A temperature of greater than 38°, with vomiting and diarrhoea, may indicate a diagnosis other than gastroenteritis. Not all meningococcal rashes are non-blanching.

Patient presenting with ear pain

A 38-year old patient contacted the out-of-hours service over a weekend. The triage notes indicated that the patient had a cold and a bad earache. An out-of-hours MDU GP telephoned the patient who gave a five-day history of cold symptoms, shivers, deafness in the right ear and left earache that had been eased by analgesia. The patient was advised to continue with the current treatment of analgesics and anti-inflammatories.

Ten hours after the first consultation the patient phoned back and was advised to attend the out-of-hours base. On arrival, she was seen by a second MDU GP who recorded a history of frontal, bilateral headache and 24 hours of throbbing ear pain and sweating. She had a temperature of 40° and a pulse of 112 beats per minute. The GP diagnosed acute left otitis media and prescribed erythromycin. The patient was advised to see her own GP the following day.

Twelve hours later, the patient was found collapsed at home and an ambulance was called. On admission to the emergency department with a GCS of 8/15 and a pyrexia, a diagnosis of pneumococcal meningitis was made. The patient suffered hemiplegia.

Some three years after the event, the patient brought a claim against the second GP, alleging that the doctor should have referred her to hospital immediately. The claimant's solicitors advised that if she had been referred, a lumbar puncture would have been undertaken leading to the diagnosis and IV antibiotics would have been given earlier. With an earlier diagnosis, the claimant would not have suffered permanent neurological complications and would have made a full recovery.

The MDU asked an independent GP expert to advise on the GP's standard of care. The GP expert advised that a pulse of 112 and a temperature of 40° are both abnormal to a degree that would be unusual for otitis media. The expert advised that it would be necessary to take care in assessing such a patient as the clinical signs were not sufficient to explain the earache and the bilateral frontal headache.

There was a factual dispute about whether the patient had neck stiffness and was drowsy. The GP member did not document the patient's state of alertness nor whether she had neck stiffness or photophobia.

An expert opinion was also obtained from a consultant in infectious diseases who confirmed a clear association between acute otitis media and the local and direct spread of pneumococcal meningitis to the central nervous system. He advised that even with earlier treatment the patient would have still had neurological sequelae as a single dose of an appropriate IV antibiotic would have been insufficient treatment. The MDU instructed a consultant microbiology expert who agreed with this advice.

The claimant's neurology expert said that if the diagnosis of meningitis had been made at the time of the consultation then it was likely that the patient would not have suffered permanent neurological complications. While pneumococcal meningitis is a severe illness with significant mortality and morbidity, the good prognostic factors in this case included the fact that the claimant was otherwise healthy.

A conference took place with the MDU barrister and the experts to review the merits of the claim. The barrister advised that the MDU member was vulnerable to a finding of negligence in view of the failure to record the negative symptoms and take account of the fact that the patient was systemically unwell. It was thought that the case on causation was finely balanced as to whether the patient would have avoided all of her neurological complications had she received antibiotics earlier.

The case was eventually settled for £250,000, a quarter of the damages originally claimed. There is an otitic aetiology in 30-50% of cases of pneumococcal meningitis. Hearing loss is a common finding and occurs early in the illness.

Dr Sharmala Moodley
Deputy head of claims

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