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 emergency GP. She explained that his temperature was 39.4 and that he was clingy and sleepy. Dr R assessed him at the emergency unit 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 the emergency unit.
He was very unwell by the time he was assessed in the unit. 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 influenza. A month later he was assessed at a fracture clinic and was walking unaided and fully weight-bearing. An x-ray 8 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.
JC had a hearing test two months after his illness which 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.
Learning points
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The National Institute for Health and Care Excellence in the UK have a useful traffic light system for identifying risk of serious illness in feverish children under five1. Along with other clinical signs, it requires GPs to check 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 care.
- 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], May 2013. nice.org.uk/guidance/cg160/chapter/recommendations#table-1-traffic-light-system-for-identifying-risk-of-serious-illness