The case of SC v University Southampton NHS FT involved a failure to correctly diagnosis pneumococcal meningitis. The decision was the first High Court decision on meningitis in over three years.
On the 26th January 2006, the 15 month old Claimant was examined by a GP. She was found to be floppy with a vacant stare and a temperature of 40.1. Concerned by his examination, the GP gave the Claimant an intramuscular injection of antibiotics and sent her to the Defendant’s hospital (University Hospital, Southampton) by a blue light ambulance with a referral letter querying a diagnosis of meningitis. The Claimant was examined and was diagnosed with tonsillitis. She was sent home. It was agreed by the parties’ experts that the Claimant was, in fact, suffering from a combination of a viral tonsillitis with a pneumococcal bacteraemia. She went on to develop a right hemiparetic cerebral palsy and permanent neurological deficit.
The Claimant alleged that there were failures to diagnose and treat her meningitis, and that her injuries would likely have been avoided with timely administration of antibiotics. The essence of her case was that, having regard to the findings made by the GP, and the concern expressed by the Claimant’s parents, the hospital clinicians should have appreciated that there was a significant risk of a serious bacterial infection and should have administered intravenous antibiotics.
In January, the Claimant was aged 15 months and became unwell. Initially, her condition did not appear to be serious – she was exhibiting a mild temperature and was presenting as a “bit withdrawn” (para 10). On the 26th of January the Claimant’s condition begin to deteriorate rapidly, and she developed pyrexia, lethargy, and had a “lifeless…. vacant stare” (para 10). At 11.50 a.m. Claimant attended her GP. Her pulse rate was assessed at 160-175 bpm, with a temperature of 40.1 degrees. The GP noted her lethargy and “glazed look” (para 12). In his GP notes, he recorded his impression as “meningococcal” (para 12). The GP injected intramuscular antibiotics, before calling an ambulance.
The Claimant arrived at the hospital at 1.15 pm. The reason for admission was given as “pyrexia? Cause” (para 16). She was seen at the hospital by Dr. Rowley, SHO, whose impression was that she had tonsillitis. She recorded that meningitis was unlikely. She admitted the Claimant for observation and, following review by the Consultant, Dr Roe, was discharged with oral penicillin. The Claimant’s parents questioned the tonsillitis diagnosis, seeking assurance that meningitis was ruled out. On the 27th January the Claimant was taken back to the hospital, as she appeared lethargic and ill. She was seen again by Dr Roe, who noted that she was better and was alert, although was still very lethargic. The impression was of a resolving viral illness and she was discharged home without follow up.
Her condition did not improve thereafter. On the 30th January, she was admitted to the hospital, a lumbar puncture was eventually performed and meningitis was diagnosed. Her physical condition continued to deteriorate and she suffered a stroke as a result of complications of the pneumococcal meningitis.
The Judge found that the care provided by the SHO on 26 January was reasonable.
Johnson J considered the central question in the case was whether Dr. Roe should have suspected that the Claimant had a serious bacterial infection and should therefore have given intravenous antibiotics. On the facts, Johnson J found that Dr. Roe’s treatment was substandard. It was the judge’s view that, whilst it was entirely reasonable to diagnose tonsillitis, Dr. Roe had fallen into a “trap” (para 130) because he had not appreciated that the intramuscular antibiotics had been masking the Claimant’s symptoms and that a truer picture had been presented by the Claimant’s GP. It was held that, if Dr. Roe had appreciated this masking effect, then it is likely that the Claimant’s other presenting symptoms (high temperature, lethargy, vacant expression) would have pointed towards a meningitis diagnosis. On the balance of evidence, Johnson J found that IV antibiotics would likely have been administered on the 26th of January and therefore the Claimant’s injuries would likely have been avoided.
Harriet Jerram, a clinical negligence barrister at Outer Temple, commented on the case:
This case demonstrates the hazards of going to trial. It was agreed by the experts that the Claimant had tonsillitis at the time of the index presentations. Unlike cases where an erroneous diagnosis is made, the treating doctors were right to diagnose tonsillitis. However, the Judge found that – even though that diagnosis was correct and even though appropriate treatment was instigated – there was negligence for failing to rule out a concurrent (and more serious) bacterial infection, even in the face of improvements in the Claimant’s condition. The Claimant’s key argument was that the Consultant should have recognised that those improvements had likely been brought about by the antibiotics administered by the GP. The Judge found that “the diagnosis of tonsillitis did not preclude the possibility of a secondary serious bacterial infection, particularly where there were symptoms and a history that were not obviously consistent with a diagnosis of tonsillitis and where a secondary bacterial infection was a real possibility”.
Whilst the Judge was keen to stress that it was not appropriate to judge the standard of care with hindsight, the standard of care expected of the ED doctors was high. Johnson J found that, although the Consultant made a positive diagnosis of tonsillitis, “nothing in the medical notes positively shows that he discounted all other possible diagnoses” (emphasis added). This almost amounts to a reversal of the burden of proof, with the Defendant being found liable due to a failure to consider, document and discount all possible diagnoses, even though the most obvious condition was correctly diagnosed and treated. Defensive medicine and note keeping is the inevitable consequence of such a judgment, although it is doubtful whether other Judges would impose an equivalent standard of care on doctors in the ED. Defendants are bound to argue – rightly – that the case does not express any general point of principle about exclusion of all possible alternative diagnoses.
A notable feature of the case was that there were no contemporaneous NICE Guidelines regarding the standard of care. The Judge therefore had to form a view on the standard of care by reference to various contemporaneous text books, as well as the expert evidence.
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