Implications for paediatricians following trial involving a failure to diagnose meningitis

Gill Edwards is a member of Baby Lifeline’s Multi-Professional Advisory Panel and a Partner within the Clinical Negligence team at Potter Rees Dolan. Here she comments on the potential implications for paediatricians following trial involving a failure to diagnose meningitis in a fifteen month old infant, which led to her developing a right hemiparetic cerebral palsy with permanent neurological deficit.

Overview of case

On 26th January 2006, 15 month old C was suffering with a mild temperature and appeared a bit withdrawn, according to her parents who initially put this down to teething.  Unfortunately the child's condition worsened - she became very lethargic, lifeless, had glazed eyes and a vacant stare. Her parent's called NHS direct and also arranged an emergency appointment with their GP that morning. By the time C reached the surgery, she appeared 'lifeless' in her mother's arms and had vomited. When seen by the GP, she was given an intramuscular injection of antibiotics - this accorded with advice given by the Chief Medical Officer since 1988 (and subsequently reinforced by the National Institute for Health and Care Excellence (“NICE”)) that antibiotics should be given by the first doctor who suspects the diagnosis, in a child, of invasive bacterial infection or meningitis. C was also given Calpol and the GP told her mother that he suspected C had contracted meningitis. 

The GP arranged for C to be taken by ambulance, under blue lights, to University Hospital, Southampton. He telephoned ahead and also wrote a letter to accompany the infant. In the course of the ambulance journey to hospital C appeared lifeless, with her mother initially fearing that she had died in her arms - however the paramedic was able to elicit a brief response by running a finger over the sole of the child's foot.

At the hospital, where it appeared her condition had improved slightly and was recorded as being 'alert', the doctor who examined C suspected tonsillitis and made a note that meningitis was 'not likely'. Her parents repeatedly questioned the diagnosis of tonsillitis and sought reassurance that meningitis had been ruled out. The child was kept in for 'observation purposes', underwent various tests and was administered with penicillin before she was discharged that same evening. 

Over the course of the next couple of days, C's condition worsened significantly.  Her mother asked if she could bring the child back to hospital, but was told to wait. She consequently took the child to see two different GPs - one thought the infant was suffering with an ear infection rather than tonsillitis and so prescribed alternative antibiotics, while another was very concerned that C might have meningitis and arranged for her to be seen by the Accident and Emergency Department of the hospital.

Upon their arrival at the hospital, C's parents queried again whether she might have meningitis, but they were told by medical professionals it was definitely tonsillitis. They asked for a lumbar puncture to be performed, but this was not done.

By the following morning, C's condition had deteriorated once again. She was examined by one of the doctors who saw her at her first hospital visit. This doctor formed the view that the probable diagnosis was still tonsillitis, however, in the light of the deterioration in her presentation he now thought a lumbar puncture was appropriate. Bacteria were seen in the spinal fluid which was thought (and subsequently confirmed) to be a pneumococcus - the doctor diagnosed a partially treated meningitis.

Unfortunately, C’s condition deteriorated even further. By 8th February, her smile appeared to be “wonky” and she was having problems with her right arm. Three days later her parents were informed that she had had a stroke. As a result of the pneumococcal meningitis C - which had been missed by clinicians at the hospital - the child developed vasculitis, leading to an infected perforator infarction with adjacent oedema, involving her left basal ganglia, which resulted in a right hemiparetic cerebral palsy with permanent neurological deficit.

Liability

At the recent trial, it was determined that if treatment for meningitis had been given to C on 26th or 27th January 2006, then she would have made a full recovery. Mr Justice Johnson added that the essence of the case was that "having regard to the findings made by Dr Dennison [the first GP to examine C], and the concern expressed by C’s parents, the hospital clinicians should have appreciated that there was a significant risk of a serious bacterial infection and should have administered intravenous antibiotics." University Hospital Southampton NHS Foundation Trust was found liable for C's injuries.

Potential implications for the practice of paediatrics

During the trial, the Defendant Trust’s legal team argued that, if the case were to succeed, it 'would have wide ranging implications for the practice of paediatrics and the NHS [because it] would mean that every child assessed by a GP as floppy, lethargic, glazed and vacant and blue light ambulance referred to hospital would have to be admitted, treated intravenously and given a lumbar puncture even if they were alert on arrival.' 

The Trial Judge, Mr Justice Johnson, did not agree and gave five reasons as to why:

1. There was more to this case than that, including the high fever and the administration of intramuscular antibiotics that confounded clinical examination at hospital.
2. There was no evidence that it is commonplace for these events [the administration of intramuscular antibiotics] to occur, such that there would be “wide ranging implications”: The GP who administered the antibiotics had only done this a maximum of 10 times in 15 years.
3. The NICE guidelines (drawn up by a diverse guideline development group after thorough consideration of all of the evidence and assessment of the implications) themselves require that consideration be given to intravenous antibiotics and a lumbar puncture in these circumstances.
4. If paediatricians are not following the NICE guidelines then the implications for children justify a change of practice.
5. No evidence whatsoever was provided to suggest that compliance with the NICE guidelines would have wide ranging (deleterious) implications for the practice of paediatrics.

Gill Edwards comments:

“It is right that consideration is given to implications for practice when standards of care are considered in individual cases and this cuts both ways, as there will also be some areas of practice which will improve as a result of lessons learned from errors. Medical practitioners and patients alike should be reassured that medical care will not be considered negligent if it accords with a responsible body of medical opinion and that opinion must also stand up to logical scrutiny. If guidelines have been put in place to avoid errors, then there needs to be a reasonable and logical explanation as to why they were not followed in a particular case.”

Gill is a Partner within our Clinical Negligence team here at Potter Rees Dolan. Should you have any questions about this article or clinical negligence, please do not hesitate to call our expert solicitors on 0800 027 2557. Alternatively, contact Gill directly here.