Diagnosis of a viral infection

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Complaint

Parents complained about the treatment their son, ("the consumer"), received from the provider, a general practitioner. The complaint was that:

• The consumer was seen by the GP in early August 1998. He had been frothing at the mouth, was not feeding and was crying all the time.
• The GP checked his ears and listened to his chest. He informed the parents that their son had the flu and a throat infection.
• The GP wrote a note for the parents to give their general practitioner when they saw him next.
• The GP told the parents to take their son home and give him panadol.
• The parents were unhappy with the GP's diagnosis and took the consumer to see their own general practitioner, who examined the consumer and sent him to Hospital. The consumer was transferred to Intensive Care and remained there for four days.

Investigation

The complaint was received on 1 October 1998 and an investigation was commenced. Information was obtained from:

• The Complainants / Consumer's parents
• The Provider / General Practitioner
• The family's General Practitioner
• A Paediatrician, Hospital

Relevant clinical records were obtained and viewed. The Commissioner obtained advice from an independent General Practitioner.

Outcome of Investigation

At the time of the complaint the consumer was four weeks old. He slept poorly one night in early August 1998 and woke up crying at 2.00a.m. The next morning his parents discussed whether or not to take him to the doctor.The consumer's Plunket Nurse was due that morning and they agreed to wait until she had visited. The Plunket Nurse told the mother that the baby should see a doctor.

The complainants live in a rural area. The family car was out of service and as their own General Practitioner was in the city, the complainants decided to consult a local General Practitioner. They telephoned the local GP's clinic and were told to bring their son in straight away.

The father advised the Commissioner that the child was seen by the GP between 10.00-10.30a.m. The mother remained with her son throughout the consultation. The mother said she told the GP that her son was frothing at the mouth, was not feeding well and was crying like he was in pain. She said the consumer was frothing from the mouth during the consultation and this was her main concern. The GP checked the consumer's ears, chest and throat and told the mother he had a throat infection and the flu. He told the mother to give the consumer Panadol and wrote a note for her to give to the family's GP.

The GP's clinical note, the contents of which were also presented in letter form for the mother to give to the family's GP, recorded:

"[August]1998 URTIReferred by Plunket - not feeding well. Has a cold. Concern re ears, throat. O [observation] Mild red throat. Chest, ears, adb [abdomen] NAD [no abnormalities detected]. No thrush. Nasal discharge.A Coryza [common cold]/URTI [upper respiratory tract infection]. Advised re feeding, nose, occas paracet [occasional paracetemol].See sos [when necessary]."

The GP advised the Commissioner that he did not dispute the contents of the parents' letter of complaint. He indicated in a letter to them dated late August 1998 that:

"I examined [the consumer] midmorning on [that day] and considered that he had an upper respiratory viral infection with no serious cause for concern at the time. General advice was given, as antibiotics are not indicated without a clear cut bacterial infection.

As is my usual practice I emphasised that he should be reviewed again immediately by myself or his own doctor should his condition deteriorate, as occasionally viral infections in babies can progress within hours to the chest, or lead to other complications.

This appears to have been the case, but I had no way of knowing that this would occur when I saw him."

The mother said the GP did not ask her about the frothing and she was not told why it was happening. She said he commented on the fact that the consumer was not feeding well but offered no advice. The mother also said the GP did not tell her to come back or go to her own general practitioner if the consumer became worse. She said the GP did not discuss symptoms which would indicate the consumer was deteriorating.

The mother took the baby home. She was concerned because she did not think it was acceptable to give a four-week-old baby Panadol. The complainants decided to take their son to see their family GP in the city. They telephoned to make an appointment and were advised to bring the consumer straight in.

The father advised the Commissioner that they arrived at 1.30-2.00p.m. and were seen straight away.The father said the family's GP removed the consumer's clothes and examined him with a stethoscope. He also examined the consumer's ears, nose, throat and fontanelle. The father said the consumer had become limp by this stage.

The family's GP telephoned the Hospital. He gave them a referral letter and advised the complainants to take the consumer straight there. The father said the family's GP indicated the consumer's condition was quite serious but said he was not 100 per cent sure what was wrong.

The family GP's referral letter stated:

"This lovely little man has been causing concern to his parents over the last 24 hours. He was born by NVD [normal vaginal delivery] 4 weeks ago and has been breastfed. I am concerned as he has otherwise been well and I am the second Dr he has seen today. OE He is a sluggish sleepy and irritable babe when handled. Lots of mucous and breathing open mouthed. Slight left conjunctivitis and poor suckle reflex.Tachycardic? rate, no murmurs and chest clear as far as I can tell."

The consumer was examined at the Hospital. He was admitted for tests and transferred to the Neonatal Unit for close observation. The consumer experienced a number of apnoea attacks within the first 24 hours of his admission to the Neonatal Unit.

The consumer was discharged from the Hospital four days later with a diagnosis of RSV bronchialitis. He was provided with an apnoea monitor for use at home. The mother said she was told by hospital staff that if her son had not been brought to the hospital he would not have made it through the night. The Clinical Team Leader responsible for the consumer's care in the Neonatal Unit advised the Commissioner that RSV bronchialitis sometimes presents with apnoea but that in his experience, it would be most uncommon for a baby with this diagnosis to die suddenly and unexpectedly in a cot-death situation.

The father advised the Commissioner that the consumer has since made a full recovery.

The Code of Health and Disability Services Consumers' Rights

Opinion: No Breach

In my opinion the GP did not breach the Code of Health and Disability Services Consumers' Rights as follows:

Right 4(2)

My advisor informs me that the GP performed an adequate examination, his findings on examination were correct, the diagnosis of a viral infection was correctly made and Panadol was correctly prescribed. The GP noted that the consumer's chest sounded clear. This was noted by the family's GP and staff at the Hospital. While the mother was concerned that the consumer was frothing at the mouth this was noted in the hospital notes as saliva. It was not a significant symptom from a medical point of view and was probably caused by the consumer's blocked nose.

The GP's examination notes were adequate, as was the content of the note he provided to the family's GP. The mother complained that she was not told to return or take the consumer to her own general practitioner if the consumer deteriorated, and that the GP did not indicate those symptoms which would indicate the consumer was getting worse. The GP's letter to their family GP recorded "See sos [when necessary]". I am satisfied on the basis of the GP's clinical records that he did discuss the need for the consumer to receive an immediate review should his condition deteriorate.

The father and the mother were concerned about the GP's diagnosis. However, the family GP's findings on examination did not differ significantly from those of the provider/GP. While the family GP noted that the consumer was irritated and sluggish during the examination the father advised at interview that the consumer had become floppy by this time, indicating this was not part of the consumer's presentation to the provider/GP. The family GP's referral made no mention of the fact that he believed the consumer to be seriously ill. He noted his concern that the consumer had been otherwise well but that he (the family's GP) was the second doctor seen that day. Furthermore, the Hospital's clinical notes did not differ significantly from those of the provider/GP except to indicate that the consumer appeared unwell by the time he presented at the hospital, 4-6 hours after he was seen.

The complainants complained they were told by hospital staff that the consumer would have died if he not been taken to the hospital that day. The Paediatrician advised it would have been most uncommon for a baby with the consumer's diagnosis to die suddenly and unexpectedly.

In my opinion the GP provided services of an appropriate standard and did not breach Right 4(2) of the Code of Health and Disability Services Consumers' Rights.

Actions

It would appear that the complainants' dissatisfaction with the standard of service received from the GP arose partly as a result of information they received from staff at the Hospital. A copy of my opinion will therefore be forwarded to the Chief Executive Officer of the Hospital, with a request that this opinion be discussed with staff involved in the consumer's care as a tool to assist in the quality of information that is conveyed to consumers or their caregivers.

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