Bacterial meningitis and meningococcal septicaemia are thankfully rare diseases. However, a failure to diagnose can have devastating consequences for patients.
A failure to diagnose these illnesses, resulting in a delay in treatment, can result in irreversible brain damage, organ failure and loss of one or multiple limbs. Damages for negligence claims involving meningitis can run into millions of pounds, especially where a young patient requires extensive and expensive care throughout their life. Because of this, there have been some high profile cases reported in the media and public awareness of the potential danger is high.
Diagnosis of bacterial meningitis and meningococcal septicaemia is a complex area because of the disease's similarities in its early stages to a number of other common, minor viral illnesses. A diagnosis of meningitis can therefore be easily missed, and the condition can develop very rapidly. By the time a correct diagnosis is made, the damage may already have been done.
The MDU undertook an analysis of all cases of either bacterial meningitis or meningococcal septicaemia that were closed between January 2013 and June 2016. During that time period, a total of 15 cases were settled.
The MDU paid out over £28m in respect of the 15 settled claims, with damages payments ranging from £90,000 to more than £5 million. Over 60% of the settled claims resulted in payments of £1m or more.
Of the 15 claims settled, 40% involved out-of-hours GP consultations, and at the date of incident, 40% of patients were under one year old. Over 26% of patients were between 30 and 65 years old.
Looking at all of the notified cases together, just over one third involved patients under 12 months old. In 2013, NICE introduced guidance on the assessment and initial management of fever in under 5s. This included a 'traffic light system' for identifying risk of serious illness.
The guidance advised that, 'Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or signs in the amber column and none in the red column should be recognised as being at intermediate risk. Children with symptoms and signs in the green column and none in the amber or red columns are at low risk.'
Here we compare two case reports of alleged failure to admit young patients to hospital, with different outcomes.
Case report 1
A three-month old baby was seen in the GP surgery with a history of fever. The GP documented a history of a fever starting the previous evening with a recorded temperature of 37.5°C. The baby was noted to be feeding well, had wet nappies and there was no history of any diarrhoea or vomiting.
On examination the GP recorded a temperature of 39.4°C. Heart rate was 140 and respiratory rate was 36. No rash or meningism was found and the baby was noted to be alert. An ear examination was normal and the baby's throat was mildly inflamed. The chest was clear and there was no evidence of respiratory distress or intercostal recession.
The GP diagnosed a viral illness. The parents were advised of 'red flag' symptoms and how to seek further help if the baby's condition deteriorated. The GP member had made a concise contemporaneous note of the history and examination findings.
The following day, the baby was admitted to hospital and was subsequently diagnosed with Group B meningococcal sepsis. A Letter of Claim was served, alleging the GP failed to suspect meningitis or meningococcal septicaemia. The Letter of Claim relied on the NICE guidelines, noting in particular that:
'Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis.'
It was alleged that urgent admission was required in light of the patient's presenting symptoms.
The MDU instructed independent experts, who advised that the member took a reasonable history and performed an adequate assessment of the patient, and provided appropriate follow-up advice and advice about red flags. The expert did note the temperature of 39.4°C, which is an 'amber' sign according to the NICE guidelines.
However, the expert advised that as this was an isolated sign in an infant who otherwise appeared well, the member's actions were reasonable. It was noted that in such circumstances the NICE guidelines advise that parents should be advised on the course of action should there be any deterioration and that the member had taken these steps.
In light of the supportive expert evidence, a Letter of Response denying liability was served, and the claim was subsequently discontinued.
It is not unusual for there to be a dispute between the parties in relation to the presentation at the time of the consultation with the doctor. In this case, the GP member was assisted by the full contemporaneous note made at the time of the consultation.
A diagnosis of meningitis can be easily missed, and the condition can develop very rapidly. By the time a correct diagnosis is made, the damage may already have been done.
Case report 2
A patient under 12 months old was seen by an out-of-hours GP, presenting with a temperature of 37.8°C. The temperature was reported as having remained the same for at least 24 hours and it was alleged the patient had had diarrhoea and vomiting the day before.
Two days later the patient was seen at home by the same GP regarding the same condition, which had not improved. The following day the infant was admitted to A&E with fits and was subsequently diagnosed with pneumococcal meningitis. The child suffered permanent neurological damage resulting in significant disability.
Court proceedings were issued alleging that the GP failed to take an adequate history which, if obtained, should have resulted in urgent admission. It was alleged that had the infant been admitted earlier, appropriate investigations would have been undertaken and the diagnosis made sooner. This would have resulted in earlier treatment, meaning the fits would have been avoided and the child would not have suffered any permanent neurological damage.
Unfortunately, the contemporaneous notes of the two consultations were brief. The independent neurology expert advised that if the infant had been admitted to hospital by the GP, treatment would have been started which would have avoided the neurological damage.
Due to the vulnerabilities in relation to the notes and also the neurology opinion that early treatment would have avoided the neurological effects, the MDU sought the member's consent to settle the claim.