Diagnosis of whooping cough

Occupations : General Practitioner

Complaint

The Commissioner received a complaint from a mother regarding the treatment and care of her daughter by the provider, a General Practitioner. The complaint was that:

The GP misdiagnosed the baby's illness;
The GP saw the baby going blue, vomiting, and coughing and still said that the baby's illness was not serious enough to warrant hospitalisation;
The phone call in which the GP apologised to the complainant was intimidating, and that the complainant did not want to go back to the Medical Centre and be sent away for the fourth time.

Investigation

The complaint was received by the Commissioner on 2 October 1997 and an investigation was undertaken.

Information was obtained from:

The Complainant / Mother
The Father
The Provider, a General Practitioner
A second General Practitioner ("the second GP")
A Visiting Midwife

The Commissioner also obtained and considered the ambulance report and the consumer's medical records from a Hospital and the GP's Medical Centre.

The Commissioner obtained advice from an independent General Practitioner.

Outcome of Investigation

Over a weekend in mid-July 1997 the complainant's baby (the consumer) had had diarrhoea and a chesty cough that the complainant said made the baby go "blue". The Visiting Midwife's referral notes that the consumer had green diarrhoea at this time. On the Monday, the complainant and her husband were referred by the Visiting Midwife to a doctor. They took their baby, aged nearly four weeks, to the Medical Centre. She was seen by the second GP, as the complainant's usual General Practitioner was away on holiday. The second GP gave the baby a thorough examination. She checked her ears, throat and chest and took her temperature. The complainant said that the second GP "couldn't find anything wrong [with the baby] but said to bring her back if [she was] vomiting with the diarrhoea". The complainant said the second GP asked whether they were first time parents and, when they said they were, she said they might be overreacting.

Two days later the complainant returned with the consumer to see the second GP as the baby was "bringing up all her feeds". The second GP noted the baby had a sticky left eye, phlegm at the back of her throat, a clear chest and a temperature of 36.6?C. The second GP diagnosed an ear infection and prescribed Amoxil (antibiotics). The complainant was told to return the following day if the diarrhoea and vomiting persisted. The complainant later recalled that the second GP mentioned the possibility of hospital admission if the consumer's condition got worse.

The complainant acknowledged that the Amoxil prescribed by the second GP had a positive effect - the consumer was able to sleep better and she seemed to be in less pain. However, she said the baby was having green runny bowl motions and her coughing got worse during the night.

The following day the complainant phoned the Visiting Midwife for advice, as the consumer was not improving. The Visiting Midwife came to see the consumer and after examining her phoned the Medical Centre requesting prompt reassessment of the baby. The Visiting Midwife wrote a referral letter to a doctor in which she noted that the consumer was vomiting, had "smelling" motions, low urinary output, weight loss and that the baby "visibly changes colour - purplish when coughs and tries to remove mucus". The Visiting Midwife said that when she saw the baby she was limp (i.e. had hardly any muscle response) but had not gone blue at this point. The complainant said she was advised by the Visiting Midwife to take the baby's clothes with her as in her opinion she would probably be sent to hospital.

The second GP was not available until 11am so the parents decided to see the GP (the provider who is the subject of this investigation) instead. The provider/GP gave the consumer a thorough examination, concurred with the second GP's earlier diagnosis of an ear infection and increased the dosage of Amoxil. The complainant said the GP was not concerned about the baby's "weight loss of 150 grams in 2 days". The GP said that he made a statement to the effect that a bowel motion could remove that amount of weight from a baby of the consumer's size. The GP said that the consumer was not limp during the consultation.

Both the complainant and her husband stated that that during that consultation, their daughter had a severe coughing fit, went blue and vomited. The complainant's notes in her "Well Child Health Book" for that day state:

"Although doc saw her [the baby] having a coughing fit, going blue, says he didn't think it was serious enough to send to hospital...She was also sick with the cough."

Both said that the episode lasted several minutes and was witnessed by the GP. In contrast the GP described the episode as coughing that lasted up to ten seconds, a minor phlegm obstruction and "a bit of a spill". The GP acknowledged that there was a change in the consumer's colour describing it as a form of pink to a darker pink colour, almost purple. The GP said he knelt down in front of the consumer to check her and noticed that the choking or phlegm in the throat episode had cleared itself. The GP said that if the consumer had been bad he would have put her on the oxygen in the next room. The father said he asked the GP what would make the consumer go blue. The GP said that there was a proper way of "winding a baby" and drew a diagram to illustrate this.

When the parents asked if the baby should be sent to hospital, the GP said that he did not think it was warranted. The GP said that the Amoxil, which was prescribed less than 24 hours earlier, should be given time to work. The GP said, although he could not recall the actual conversation, that there was not much discussion about hospitalisation of the consumer but he did say he would have arranged hospitalisation if he had been specifically requested. He also said that at the time the parents seemed satisfied with the service their baby had received. The consultation lasted approximately 20 to 25 minutes. The complainant and her husband were advised by the GP to bring the consumer back the following day if they were still concerned. The complainant confirmed these statements. The GP said he had reviewed the notes taken on the prior two visits to the doctor and read the midwife's letter and:

"I found no new evidence at the time to suggest admission or a change in diagnosis from the previous day but did express willingness to follow up if the situation changed."

Initially the consumer's condition improved but deteriorated in the evening the day after the consultation with the provider/GP. The next day the complainant rang the Visiting Midwife and told her that the consumer was vomiting and coughing. The Midwife, after discussing it with her advisors, advised her to go straight to Hospital.

The parents took their baby to Hospital. A note on the date of admission in the hospital records headed "Registrar Review" states:

"...Impression: (1) Possible Pertussis. Otherwise viral illness with coughing, paroxysm"

The diagnosis of whooping cough (confirmed bordetella pertussis) was confirmed several days later. The consumer was discharged from hospital six days later. The consumer was readmitted to Hospital in mid-August 1997 with a coughing spasm that led to an apnoea and was discharged after 4 days.

The Commissioner's independent advisor pointed out that there was some variance in the evidence as to whether any episode of coughing associated with changing colour and vomiting occurred in the consultation with the provider/GP. The Commissioner was advised:

"If this did occur then I feel it should have been recorded in [the GP's] notes which are otherwise reasonable except for an absence of any recorded follow-up advice.

From my experience whooping cough is a difficult illness to diagnose. The initial part of the illness, which may last one to two weeks, involves a catarrhal phase during [which] time it is rarely diagnosed as being whooping cough. Otitis media in this phase is often not uncommon either. This phase is usually followed by a period of two to four weeks of paroxysmal coughing which may be associated with vomiting and cyanosis (turning blue). In between these episodes the child may appear clinically well and may not have any significant clinical findings. In general practice a diagnosis of whooping cough is often made on the history rather than any diagnostic physical findings on examination.

Given that [the GP] saw [the consumer] six days after the onset of the illness, that his findings and those of the previous visits indicated that she had an upper respiratory tract infection with probably otitis media (red ear), and if he didn't witness a cyanotic (blue) coughing spell, then I think his assessment and management would have been very appropriate.

However, the Commissioner was advised that it was of some concern that both the parents and the midwife had witnessed the baby having episodes of changing colour to a blue or purplish colour when coughing and had reported this. The advisor said:

"It appears as though [the GP] may not have placed sufficient weighting on this bit of the history and obviously had not considered the diagnosis of whooping cough. A change of colour in a child who is coughing does not in itself give a reason for admission but would depend on other factors, which would include the child's age, general state of health and resources available in the community and of the parents. In this case it is extremely unfortunate that the midwife who had had more contact with the baby did not indicate to the doctor that she had intimated to the parents that hospital admission may be required. Despite this, [the parents] obviously asked about hospital admission but [the GP] was of the opinion that hospitalisation was not necessary at that time. There is a mortality associated with whooping cough, especially at this very young age, but it is usually associated with the development of pneumonia rather than due to the cyanotic coughing spells themselves."

The independent advice to the Commissioner concluded that:

"I do not think in this case [the GP] has breached the threshold of adequate care and it is my assessment that [the GP] did provide [the baby] with medical services of a standard that would be expected of a general practitioner in his situation."

He also pointed out that although the GP had access to the previous notes and midwife's letter, he only saw the baby on one occasion which made it more difficult for him to observe any changes which may have alerted him to the possibility of whooping cough.

The GP acknowledged that in hindsight what he saw was in fact the start of whooping cough but that at that time it did not fit that diagnosis. The complainant's usual General Practitioner spoke to her and asked the provider/GP to call her. The GP called the complainant in early September 1997. The GP expressed his regret to the complainant but she did not accept his apology. The complainant said that the key issue in her complaint was not that the GP "got it wrong" but that he witnessed her baby vomiting, coughing and going blue and did not consider it serious enough to refer her to hospital.

The complainant said the GP denied that the baby went blue and said the consumer had only been coughing for a few seconds. She disagreed and said the coughing had lasted a few minutes. The complainant said that she found the phone call from the GP "very intimidating". In a letter dated mid- September 1997, she said:

"He was very quick to let me know his qualifications. He also pointed out that I did wait two days, after seeing him, before taking my baby to hospital. I resent his implications very much . I find it unacceptable to try and make me feel guilty for not taking my daughter to hospital till the Saturday morning. I was not prepared to return to that surgery for a 4th time, just to be sent away again!"

When asked by the GP why she had not returned to see him the next day the complainant said "because I had already been to the surgery 3 times in 4 days and was feeling as if I was overreacting". The complainant said that the GP was calm and that she was getting upset and angry.

The GP said he thought he had acted with courtesy to the complainant and believes he was doing the right thing by trying to contact the complainant directly and apologise. He said he did not mention his qualifications in a threatening way but only in passing. The GP also denied that he stated to the complainant that she should have been to the clinic earlier. In a letter, undated, to the Commissioner the GP said:

"I am very sorry [the mother] felt intimidated by my phone call. This was certainly not intended. The reason I phoned was that I may promptly discuss the matter and express my disappointment [at] the way things had turned out. It is unfortunate that offence seems to have been taken that I enquired about the delay from the Thursday to the Saturday. A lot can happen to a child in two days and I was merely trying to obtain an update on how matters had progressed. In no way was I trying to imply that she [the mother] should have brought the child back. I feel it is unfortunate that she has interpreted my invitation to review the next day in a way it was not meant. I would like to reassure [the mother] that I always try to do my best for my patients and I am sorry that I was unable to diagnose [the baby's] whooping cough when I saw her. I am glad that the hospital was able to reach that diagnosis in the days following admission. I will bear her comments in mind to help with similar situations in the future."

The Code of Health and Disability Services Consumers' Rights

The following Rights are applicable:

RIGHT 1
Right to be Treated with Respect

1) Every consumer has the right to be treated with respect.

RIGHT 4
Right to be Treated with Respect

...
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

...
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.

Opinion: No Breach

In my opinion the GP did not breach Right 1(1) or Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

Right 1(1)

In my opinion the GP treated the complainant with respect. The GP had an obligation under Right 10 of the Code of Rights to respond to the mother's complaint. He did this swiftly and apologised to the complainant for failing to diagnose the baby's whooping cough. In my opinion the GP made a genuine apology and did not intend to intimidate the complainant.

Right 4(2)

I am advised that whooping cough is a difficult illness to diagnose, particularly in the early stages. I was advised that in general practice a diagnosis of whooping cough is often made on history rather than physical findings on examination. There is some conflict as to the length of time the consumer's coughing episode on the day of the consultation with the provider/GP lasted and what colour she turned during it. However, I have been advised that change in colour in a child who is coughing is not in itself a reason for admission to hospital. The GP saw the consumer on only one occasion and after a thorough examination did not consider the consumer's condition warranted hospital admission. The GP encouraged the parents to bring the consumer back if her condition deteriorated. In forming my opinion I have also considered the fact that the hospital did not initially diagnose whooping cough and did not reach this decision for some days after admission.

In my opinion the GP provided the consumer with medical services of a standard expected of a General Practitioner in this situation.

Actions: General Practitioner

The GP is reminded that he should make full records of all consultations including any follow up advice. Records should include the consumer's symptoms on presentation, details of what is found on examination and anything else which would assist either a colleague viewing and relying on the records or the GP's own memory.

Other Actions

While neither the second GP nor the Visiting Midwife were investigated, information obtained during the investigation suggests a need for greater co- operation among providers to ensure quality and continuity of care. In particular the Visiting Midwife raised the parents' expectations of their baby being admitted to hospital and she did not communicate this opinion to the provider/GP.

As a result of the above events, all providers involved with the care of the consumer leading to her admission to Hospital are reminded of their obligations under Right 4(5) of the Code, and will be forwarded a copy of this opinion.

A copy of this opinion will also be sent to the New Zealand College of Midwives and the Royal New Zealand College of General Practitioners for use as an educational tool.

For further information, contact: HDC Communications Section (09) 373 1060.