Diagnosis of meningitis

Complaint

The Commissioner received a complaint from a mother about the care provided for her two-year-old daughter, (the consumer), by four General Practitioners and a Hospital. The complaint is that:

• One evening in late March 1997 the complainant took the consumer to an Accident and Medical Clinic. There she was attended by a General Practitioner ["the first GP"].
• Meningitis was not diagnosed by this GP. His diagnosis was tonsillitis and Augmentin was prescribed.
• The following day the complainant telephoned a different doctor's surgery and told the receptionist that the consumer was very sick and she wanted an appointment to see the doctor ["the second GP"].
• The receptionist said that the second GP was fully booked that day and did not offer any alternatives.
• The same day a third GP attended the consumer and did not diagnose meningitis. The third GP diagnosed tonsillitis and prescribed Maxolon for nausea.
• The next day a fourth GP attended the consumer and did not diagnose meningitis.
• The staff at the Hospital did not advise the complainant that her daughter had meningitis until after her death.
• The staff at the Hospital did not inform the complainant or her family that the consumer's illness was infectious until two days after her death and after the family had left the hospital.

Investigation

The Commissioner received the complaint on 14 July 1997 and an investigation was undertaken.

Information was obtained from:

• The Consumer's mother / Complainant
• The First General Practitioner / Provider
• The Third General Practitioner / Provider
• The Fourth General Practitioner / Provider
• The Director, Paediatric Intensive Care Unit, Hospital
• The Paediatric Anaesthetist / Intensivist, Paediatric Intensive Care Unit, Hospital
• The Second GP's Receptionist

The consumer's clinical records and documentation relating to her admission to Hospital were obtained and viewed. The Commissioner obtained advice from an independent General Practitioner.

Outcome of Investigation

In late March 1997, the consumer began to suffer from vomiting and diarrhoea, having been generally unwell for about a week and a half. Her mother, the complainant, took her to an Accident and Medical Clinic, where she was seen and examined by the first GP at 6.55pm.

In the consumer's clinical records, the first GP noted that her tonsils and eardrums were inflamed and diagnosed tonsillitis and bilateral otitis media (inflammation of the middle ear). The first GP also noted that despite having a fever of 39 degrees, the consumer was attentive and co-operative. The first GP prescribed an antibiotic, Augmentin, and recommended that the consumer be seen by her General Practitioner if there was no improvement in her condition.

In a letter to the Commissioner, the first GP states that he has frequently been involved in the treatment of children with meningitis and that he is well aware of the relevant features of the disease. The first GP states that no such features were apparent when he saw the consumer.

The following day the consumer's condition worsened. In her letter to the Commissioner, the complainant states that she telephoned the consumer's General Practitioner, (the second GP), and was told by his receptionist that he was fully booked and would be unable to see her. The second GP's receptionist denies that she received this telephone call from the complainant and states that patients are never denied appointments in urgent situations.

That evening, a friend of the complainant contacted the third GP, who agreed to make a house call and see the consumer. The third GP examined the consumer and recorded that she had a fever, tachycardia (rapid heartbeat), red eardrums and signs of a mild respiratory infection. The third GP noted that the consumer was well hydrated and when he manipulated her neck, there was no sign of discomfort. The third GP prescribed an anti-emetic, Maxolon, to help keep the antibiotic down and advised that a small amount of paracetamol should be given. The third GP also suggested that the consumer should receive fluids frequently and that if there were still concerns about her health the next morning, she should be taken to the surgery.

The next day, the consumer's condition had not improved. The complainant took her to the third GP's surgery, where she was seen by the fourth GP at 9.15am. The fourth GP was advised of the consumer's three day history of vomiting and diarrhoea. On examination, The fourth GP noted that the consumer's temperature was 38 degrees, her tonsils were raised and her ears were slightly red. The fourth GP also observed that the consumer's neck was not stiff, she was not dehydrated and there was no rash on her trunk or limbs. The fourth GP considered the possibility of meningitis, but due to the absence of any neck pain or a rash, rejected this in favour of a diagnosis of gastro-enteritis. The fourth GP suggested that the consumer's condition may have been being aggravated by the antibiotic and recommended that the Augmentin be discontinued. The fourth GP prescribed Phenergan as an anti-emetic and informed the complainant that the consumer should be admitted to hospital if her condition had not improved by 4.00pm that day.

During the day, the consumer's condition further deteriorated. She developed extreme limb stiffness and began to have convulsions. The complainant took the consumer to Hospital, where she was seen in the Emergency Department at 7.00pm. An anticonvulsant, Diazepam, was administered intravenously. An antibiotic, Cefotaxime, and an antiviral agent, Acyclovir, were also given to treat possible cerebral infection. The consumer had a further convulsion at 7.30pm and was admitted to the Intensive Care Unit at 8.00pm. A specialist was in charge of her care. The consumer was intubated and artificial ventilation was started. A CT scan revealed that she had suffered gross cerebral oedema (brain "swelling"). Clinical notes record that the results of the scan were considered to be consistent with a diagnosis of meningitis or encephalitis. Attempts made to reduce the swelling were unsuccessful and the consumer's pupils became fixed and dilated.

According to clinical records, the specialist discussed the consumer's condition with her family at 10.30pm. They were informed that her condition was critical, that its cause was unknown and that she could die during the night.

The following day, a cranial nerve assessment revealed that the consumer had become brain dead. Life support was disconnected and the consumer died at 8.15pm.

The specialist wrote to the third GP that day and informed him of the consumer's admission to hospital and subsequent death. In that letter, the specialist states:

A post mortem examination conducted the day after the consumer's death revealed that the consumer had died from meningococcal meningitis.

The complainant states that her family was not informed that the consumer had died from meningitis until they were visited by representatives of the Crown Health Enterprise two days after her death. The complainant's family was informed of the highly contagious nature of the condition and several family members were given preventative medicine.

The Code of Health and Disability Services Consumers' Rights

Opinion: No Breach - First GP

Right 4(2)

In my opinion, the first GP did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

I was advised by an independent General Practitioner that the first GP's examination of the consumer was adequate, that diagnoses of tonsillitis and otitis media were consistent with her symptoms, and the treatment was appropriate.

In my opinion the first GP examined the consumer thoroughly and made a diagnosis that was consistent with his findings. The consumer's presenting symptoms were not indicative of meningitis. In my opinion the first GP's examination, diagnosis and treatment met professional standards and he did not breach the Code of Rights. The first GP also emphasised the need for the consumer to be reviewed should her condition not improve.

Opinion: No Breach - Second GP

Right 4(2)

In my opinion, the second GP did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

I accept that the complainant made a telephone call to the second GP. However, there was insufficient evidence that the urgency of the situation was conveyed to his receptionist who states that patients are never turned away in situations of urgency.

Opinion: No Breach - Third GP

Right 4(2)

In my opinion, the third GP did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

I accept my independent General Practitioner's advice that the third GP's examination of the consumer was adequate and that the diagnosis of persistent otitis media and treatment was appropriate.

The third GP made a thorough examination of the consumer and considered that her symptoms supported the diagnosis made by the first GP. The third GP also recommended that the consumer be seen again if there were further concerns for her health.

In my opinion the GP's examination, diagnosis and treatment met professional standards and he did not breach the Code of Rights.

Opinion: No Breach - Fourth GP

In my opinion, the fourth GP did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

The fourth GP examined the consumer thoroughly and considered the possibility of meningitis, but the consumer's symptoms did not indicate that this was an appropriate diagnosis.

My advisor stated that the fourth GP's examination of the consumer was adequate and that a diagnosis of antibiotic exacerbated gastro-enteritis was appropriate, noting that, "Augmentin is recognised as producing diarrhoea and vomiting." The consumer was already nauseous prior to consulting the third GP and her condition became worse after taking the Augmentin.

In my opinion the fourth GP's examination, diagnosis and treatment met professional standards and did not breach the Code of Rights. The fourth GP also stipulated that admission to hospital would be required if there was no improvement in the consumer's condition.

Opinion: No Breach - Hospital / Crown Health Enterprise

Right 6(1)

In my opinion, the Crown Health Enterprise did not breach Right 6(1) of the Code of Health and Disability Services Consumers' Rights. While meningitis was seen as a possible cause for the consumer's condition, this was not able to be confirmed until a post-mortem examination was carried out. The doctors involved in the consumer's care informed the complainant and her family that her condition was serious and that its cause was unknown. This is clearly recorded in the consumer's clinical records.

Actions

I note that the usual presenting symptoms of meningitis were absent in the consumer's case. Given the absence of the expected features of Meningococcoal disease, it was reasonable for the first GP, the third GP and the fourth GP not to diagnose meningitis. Despite performing extensive tests staff at the Hospital were also unable to confirm that the consumer had been suffering from meningitis until the results of a post mortem examination had been obtained.

I also wish to record that the complainant provided exemplary parental care for the consumer. The doctors who attended to the consumer all noted that she was well hydrated. The complainant did all that was possible for her daughter.

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