Missed meningitis

JC was a 20-month-old boy who had been up all night with a fever. It was the weekend so his mother rang the out-of-hours GP. She explained that his temperature was 39.4 degrees and that he was clingy and sleepy. Dr R assessed him at the out-of-hours centre and documented that there was no rash, vomiting or diarrhoea. His examination recorded the absence of photophobia and neck stiffness. He stated “nothing to suggest meningitis”. Examination of the ears, throat and chest were documented as normal. He noted that his feet were cool but he appeared hydrated. Dr R diagnosed a viral illness and advised paracetamol and fluids. He advised JC’s mother to make contact if he developed a rash, vomiting, or if she was concerned.

JC’s mother felt reassured so she took him home and followed the GP’s advice. JC remained tired and off his food over the next two days. The following day he began vomiting and mum could not get his temperature down. He seemed drowsy and was just lying in her arms. She took him straight to A+E.

He was very unwell by the time he was assessed in A+E. The doctors noted that he was pale, drowsy, and only responding to pain. His temperature was 38 degrees and his pulse was 160bpm. A diagnosis of “sepsis” was made. Full examination revealed neck stiffness and he went on to have a lumbar puncture. This confirmed meningitis with Haemophilus influenzae.

JC was treated with IV fluids, ceftriaxone and dexamethasone and showed great improvement. Four days later he developed a septic right hip needing aspiration and arthrotomy. The aspirate revealed Haemophilus influenzae. A month later he was assessed at a fracture clinic and was walking unaided and fully weight-bearing. An x-ray eight years later showed that the right femoral capital epiphysis was slightly larger than the left. His mother claimed that he complained of daily hip pain, giving way and morning stiffness.

Two months after his illness JC had a hearing test that showed moderately severe sensorineural hearing loss. Despite hearing aids JC had delayed speech and language development. His mother was upset because he struggled with poor concentration at school and found it difficult to interact in groups.
JC’s mother made a claim against Dr R, alleging that he failed to diagnose meningitis and admit her son. She felt that if his meningitis had been treated earlier his hearing could have been saved and he would not be at risk of arthritis in his hip in later life

Expert opinion

Medical Protection obtained expert opinion from a GP, a professor in infectious diseases, an orthopaedic surgeon and a consultant in ENT.

The GP thought Dr R had made a comprehensive examination of a febrile child and had demonstrated an active consideration of the possibility of meningitis. He commented that the features of many childhood viral illnesses are indistinguishable from the very early stages of meningitis. He noted that Dr R had advised JC’s mother to make contact if he deteriorated. He was a little critical of Dr R for not recording JC’s vital signs such as pulse and temperature. He felt this was an important part of determining a child’s risk of having a serious illness.

The professor of infectious diseases thought that JC did not have meningitis when he saw Dr R but was likely to be in the bacteraemic phase of the illness. This phase shares features with many other more trivial infections. He explained that Haemophilus influenzae meningitis can present in an insidious fashion over several days. He felt that the vomiting three days later may have signified cerebral irritation due to meningitis.

The orthopaedic surgeon noted the minor x-ray abnormalities in JC’s right hip. He felt that given the patient’s excellent initial recovery and the minor x-ray changes it was difficult to explain the alleged hip symptoms as children with coxa magna generally have no symptoms even with contact sports. He thought that JC would have a lifetime risk of needing hip replacement of 12-20% due to past septic arthritis.

The ENT consultant concluded that JC would need to use hearing aids for the rest of his life. He felt that his speech and language development had also been compromised by poor hearing aid usage.

In response to the Letter of Claim from the claimant’s solicitors, Medical Protection issued a letter of response denying liability based on the supportive expert opinion and the claim was discontinued.

Learning points

• NICE have a useful traffic light system for identifying risk of serious illness in feverish children under five1 other clinical signs, it requires GPs to check . Along with pulse, respiratory rate, temperature and capillary refill time in order to categorise them into groups of low, medium or high risk of having serious illness. 
• Safety netting is an important part of a consultation. In this case Dr R advised the mother to contact services again if he deteriorated. This helped Medical Protection defend his case.
• In some cases claims can be brought many years after the events. This makes good note-keeping essential as medical records will often be the only reliable record of what occurred.  

References

Fever in Under 5s: Assessment and Initial Management, NICE guidelines [CG160]