This January, the Meningitis Now campaign announced that 24 children in the UK under the age of one could have died from meningitis between 2013 - when the meningitis B vaccine was approved – and January 2015 – when the NHS continues to offer the vaccine only to those groups at increased risk of infection. All the while the NHS does not offer the vaccine to every baby in the UK, there is increased focus on this devastating disease and its long term effects.
The disease is an infection of the meninges, the protective membranes that surround the brain and spinal cord. It is usually caused by a bacterial or viral infection. Bacterial meningitis (B) is the more serious of the strains, and most cases of this disease are caused by bacterium called meningococcus. The disease, of course, can strike not only babies but adults, and one of the greatest challenges for practitioners confronted with a patient or parent concerned that symptoms are indicative of meningitis is to identify it correctly, given that the initial signs of the illness can be easily confused with other less severe diseases. Moreover, its onset can be sudden, and a patient can deteriorate quickly.
The consequences of meningitis if untreated or treated too late can be devastating. Death, brain injuries resulting in among other conditions, quadriplegic cerebral palsy, epilepsy, sensorineural deafness, learning difficulties and balance problems, as well as blindness and increased risk of encountering orthopaedic conditions in the future such as scoliosis are all significant risks. In B (A child) v Barnet and Chase Farm Hospital NHS Trust (Unreported, 31/10/13) the ill child’s life expectancy was reduced to just 31 years. A total settlement of £6,915,715 was reached between the parties. In that case, the four-month-old Claimant B was not admitted to hospital and did not receive prescribed antibiotics.
The amount paid out in that case was high but not abnormal. The MDU revealed figures in Summer 2013 showing that £28 million had been paid out in total on the behalf of its GP members to settle 17 medical negligence cases involving meningitis or meningococcal disease. The average pay out is around £1 million. As the vaccine remains elusive and as, tangentially, Out of Hours Provisions increase and GPs are correspondingly seeking private medical insurance, private insurers, GPs and other defence bodies alike continue to strive to find ways to minimise the risk of misdiagnosing the illness/failing to follow it up appropriately.
This article looks at a number of cases that had different outcomes, and how lessons can be learnt from them from the perspective of the practitioner, both in terms of minimising risk for the patient but also in terms of the insurers, practitioners and the follow up and aftercare procedure. Unusually, we focus on those cases where the Judge found for the GP in each instance, so that we can take positive messages from these cases.
In January this year a judge found for a GP who had advised a nine-year-old’s parents that their son was suffering from an infection of unknown origin. On this basis the GP did not refer the child to hospital but sent him home to rest. Tragically, it transpired that the boy had meningitis. The conclusion of the judge was that, on the basis of all the evidence, he preferred the GP’s account. He was impressed with the GP’s “careful and reliable” account of events and, in terms of causation, felt that even had the GP referred the child to hospital, at that stage the disease was not evident enough, and the hospital would have sent the child home without performing blood tests. Likewise, in Doy (A child) v Gunn (2013) the judge found for the GP in question and the same outcome was found inKnott v Leading (2010), where it was deemed that both the defendant GP and another GP had examined the patient for signs of meningitis – as proved by the notes – and it was felt that had the claimant presented with a rash of three spots as alleged by the mother of the patient, there was no way that both the defendant GP and the second GP that examined the claimant would have ignored these signs.
Contrast this with the case of Coakley v Rosie (2014) where it was found that the GP in question was negligent for failing to prescribe penicillin and refer the patient immediately to hospital and that the GP’s negligence had caused the patient to suffer meningitis and resultant blindness and associated conditions.
How can such apparently similar scenarios result in such different outcomes?
In the cases cited above, the patients presented with similar flu like symptoms. There was debate over the extent, presence or otherwise and distinction of the rashes in these cases, and in each case a general examination of the patient had been performed.
The first case mentioned involved a GP who had himself suffered meningitis as a child and was therefore apparently particularly alert to the risk. Certainly his notes demonstrated an awareness of the illness, and that he had performed a thorough examination whose results were not indicative of meningitis being present. In Doy, even though the notes were actually lacking (and this should NOT be emulated), the GP had clearly examined the child for a rash, for general unwellness, had checked the ears and there was no evidence that meningitis had developed at the time. In the Coakley v Rosie case, Dr Rosie’s notes were lacking. While on her oral evidence she looked at a rash on the patient’s back and examined her neck for stiffness, this was not corroborated in her notes, and it seemed to the court that if she had looked at the rash in detail she had misinterpreted its symptoms. She was also deemed to be not sufficiently aware of the signs of meningitis as she had failed to enquire about the claimant’s complaints of severe headache.
A lot therefore depended on the thoroughness of the GP in question, the reliability of their notes and whether they should reasonably have considered that meningitis were present. If the patient themselves, or the patient’s carer/parent/companion mentions a concern that meningitis could be present, while a GP should always be alert to this possibility themselves, extra care should be taken to check for possible symptoms and, crucially, to note down the reasoning behind a decision not to refer the patient to hospital or consider antibiotics or penicillin. Great attention must be paid to whether the presentation of the patient is serious enough to merit referral. It is clear that a working knowledge of meningitis and an examination that reflects this must be obvious. In reality this means questioning the patient for signs of headache and rash, taking a history of the length of the illness, examining for stiff neck and noting all these points down. Doing so in cases where the patient does not end up having meningitis would not be overkill – it is far better to be safe than sorry.
We would also observe that it is clearly easier for an adult to describe their symptoms than a child, and to this extent, while in these cases the findings were against the cases involving children and for the case involving an adult, there is no replacement for a GP to spend as long as possible examining the child, asking the parent/carer/companion about the symptoms and noting these down in great detail, and exercising caution when in any doubt.
One factor to take into account is that the examinations of the patients in these cases pre-dated the 2010 NICE guidelines that came into force relating to the management of meningitis in children. There is no doubt that these guidelines should be followed. However, it still appears that despite the existence of the guidelines, the number of claims has not abated, largely due to the difficulty of correctly identifying meningitis specific symptoms. Practitioners cannot therefore rely upon the Guidelines alone, and must treat each patient as an individual with specific presenting symptoms, and pay a lot of attention to the patient’s history as well as use their own knowledge of the illness to examine the patient and note the reasoning behind making a referral or alternatively advising the patient to return home to rest.
A failure to diagnose meningitis may not necessarily be negligent if the GP’s management can be shown to be competent and reasonable. A full clinical record of the consultation including the history and examination and details of the follow up advice is essential for good patient care and can assist in the defence of the claim.
It is also noteworthy that NICE are to review their meningitis guidelines in March 2015 and it is therefore hoped that they may be able to produce even clearer steps for practitioners to follow. We shall look again at this issue upon publication of the review.