“[WAC] I rang earlier today. I don’t know if you’ve got my details down because my little girl, she had a temperature and I went to emergency doctor earlier in my local area and he couldn’t find anything wrong. He said she’s got such a high temperature that she might have a water infection. He gave me some samples that I’ve got to take on Monday. She’s been very not herself. She’s still got a temperature. It went down but it’s gone back up to 40 now. She had two lots of calpol and I can’t keep giving it to her obviously coz I’ll overdose on it. … [Dr] You can alternate nurofen with calpol and paracetamols … you can give it to her now quite safely … but I want you to sponge her down … I want you to take all clothes off her. It’s better when you are sponging to take all clothes off her and get a basin of lukewarm water with a paper towel in it and rinse it, rub all over her body … and keep her with you tonight and if you are still worried at any time give me a call back.”
“SAW DR YESTERDAY AND THOUGHT SHE HAD A URINE INFECTION Does the toddler have any of the following? [ ] Drowsy (can’t be woken or aroused) [ ] More floppy than is normal [ ] Agitated and/or irritable for over 4 hours, and not calmed down when being held or cuddled [ ] Persistent weak/moaning cry [ ] Responds less to what is going on around or when talking to them - NO SLEEPY Does the child have any of the following symptoms? [ ] Not able to touch chin to chest [ ] Distress or severe eye pain with exposure to light [ ] Intense headache [ ] Mental confusion, or difficult to rouse - NO Does the toddler have any of the following symptoms? [ ] Bleeding under the skin [ ] Have pinpoint red or purple spots on the skin that remain when a glass is rolled over them - NO SLIGHT RASH THIS AM DISAPPEARED Is the toddler persistently pale or mottled? - NO PALE, WORSE THAN WHEN [SAW] DR … Does the toddler have any of the following symptoms? [ ] No tears [ ] Dry mouth [ ] Thirsty or drinking more than usual [ ] No wet nappies or passing less urine - NO DRINKING JUICE, NO MILK GIVEN, ADVISED TO DO SO. LAST WET NAPPY 12 [MIDDAY] Has there been any bile stained vomiting (green colour, not yellow) - YES VOMITED THIS AM YELLOW. LAST VOMITED 05:00 NHS District Nurse notes Advice Recommended 852 CP TEL ADVICE. MOTHER CONCERNED ABOUT CHILD, SPOKE TO DR LAST NIGHT WHO SAID TO CALL BACK IF WORSE. MOTHER THINKS SHE IS WORSE. ADVISED TO GIVE IBUPROFEN WITH CALPOL. IS TAKING URINE SAMPLE TO SURGERY TOM[ORROW]”
“21:54 Diagnosis entered O/E comfortable Temp 36.8 Ears normal, chest clear, no rash over body Imp: ? viral illness Plan: continue with ibuprofen and paracetamol prn Reassured Review prn [when necessary]”
“Telephone information received Temp 40.0 Not eating History and examination O/E Ears – [normal] Lungs – clear [cervical lymph nodes – present/raised]”
“[WAC] She is staring into one space she is not responding to light or anything [AC] Has she got a history of any problems? [WAC] No, she’s got a temperature as well 40 [AC] And she is conscious at the moment? [WAC] She’s actually gone to sleep … [WAC] She has just opened her eyes … [AC] So she is rolling her eyes and she has a high temperature has she? [WAC] Yea [AC] Has she got any other problems? [WAC] Not that I no no” [AC] Has she got a history of any problems? [WAC] No, she’s got a temperature as well 40 [AC] And she is conscious at the moment? [WAC] She’s actually gone to sleep [WAC] She has just opened her eyes [AC] So she is rolling her eyes and she has a high temperature has she? [WAC] Yea [AC] Has she got any other problems? [WAC] Not that I no no”
“History Patient has been teething for past week with fluctuating temperatures. Last night patient vomiting, no diarrhoea. Patient feels v warm to touch. Mum took temperature – 39 ºC Examination Airway – clear Skin tone – normal … Additional Information Mum says patient v lethargic. O/E patient eyes rolling not co-ordinated [NB. there is an issue about the correct interpretation of this last entry]”
“Patient brought in by ambulance. Placed in cubicle N [encircled]. observations recorded. Temperature 36.0. Nurofen given at 04:30. Patient stripped down by parents. Currently sleeping. Awaits A&E.”
“History from parents 05:45 Presenting complaint ↑ temperature History of Presenting Complaint 4/7 history of ↑ temperature – fluctuating. Vomited 3 times over last few days. Runny nose. Non-productive cough. º rash º diarrhoea. Bowels opening daily – normal Not eating much solids but drinking sips of water, juice etc Passed urine 3 times today Seen by GP, emergency Dr 2 times over last few days – No Abnormalities Detected Dropped off urine sample to GP – awaiting results Previous Medical History Nil No known drug allergies … On examination Looks well Alert and active Responsive and aware of surroundings Pink Well hydrated - moist mucous membranes - good skin turgor - capillary refill time less than 2 seconds Temperature 36.0 (post nurofen) Pulse 150/minute Respiratory rate 36/minute Oxygen saturation 98% Pupils equal and reactive to light and accommodation [i.e. responsive to stimuli] … Chest examination – [normal] Abdominal examination – [normal] Neurological examination - normal tone, power, co-ordination. Moving all 4 limbs spontaneously ENT examination – [both] ears, red, left more than right; throat – congested. Tonsils not enlarged. Pink. Nose – crusting around nostrils. Impression – Upper Respiratory Tract Infection Plan Reassure Regular calpol and nurofen Encourage oral fluids Discharge home [this was at 05:55] Advised to return if vomiting → not tolerating any oral fluids, non-blanching rash etc Parents happy with plan”
“unwell over weekend. Raised temperature, vomiting, seen A&E 4am today ‘viral illness’. On examination, lethargic, miserable, no rash, temp 40 degree (post calpol). ENT NAD, heart sounds normal, chest clear, abdo[men] NAD, bowels open normally but not passed urine much – discussed with paediatricians on call – assess Harold Ward (Harlow Hospital) tonight”
“Seen this morning on Harold Ward - arrived by ambulance. Child no better now – referred back to paediatricians. On arrival FB is drowsy, reluctant to open eyes but whingeing at slight movement. Observations recorded – I am not happy with this child – reluctant to allow mother to transfer. Although observations are within range except heart rate is raised [156]. Paed Registrar contacted and will come to see the child in A&E.”
“Nil pallor … nil rash … good hydration. Passing urine. Consciousness level – alert but lethargic … signs of meningism – nil … Throat mildly congested … signs of respiratory distress – nil … Abdomen – normal shape/no masses or palpable organs … Differential diagnosis – fever of ?source. ? urinary tract infection ? upper respiratory tract infection”
“… The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill; it is well established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art. … A doctor is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art … a doctor is not negligent, if he is acting in accordance with such a practice, merely because there is a body of opinion that takes a contrary view. At the same time, that does not mean that a medical man can obstinately and pig-headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion.”
“By 8-9pm that evening [the Saturday] FB’s condition had deteriorated further … FB was not keeping fluid down and this also worried me because I was scared that she would dehydrate. FB used to guzzle her juice down and so the fact that she was not eating, drinking or keeping any fluids down really worried me.”
“I am sure that the doctor did not pick up FB or examine her out of her chair. She did not wake up throughout the appointment.”
“I think he examined her in her chair. I do not remember anything about him examining her nose or throat, or checking her body for a rash. I do not remember his finger in her mouth. He would have had to lift her clothing. FB was asleep throughout the examination. I don’t remember having to calm her down. I don’t really remember the examination, but I would her crying or being stressed. She was in a purple chair, on the floor. I don’t remember him holding her.”
“her eyes were rolling; her eyes weren’t following my fingers and hands [and were] uncoordinated”
“her eyes were rolling – I literally mean, you could see just the whites of her eyes, and then … rolling back. I couldn’t say how many times that happened … [FB] was limp and lifeless”
“FB was drowsy and lethargic the whole time in A&E. I have a vivid memory of her sitting on her dad’s lap and him trying to engage her with toys. She refused to engage and nothing cheered her up. She [was] not at all playful and active … I have seen FB’s A&E records for this period and I completely disagree with the description of FB’s presentation. As indicated above at the time of being assessed by the A&E department FB was not with it at all. Under no circumstances could she be described as ‘alert and active’ as was put in her records. She was very lethargic and drowsy. I remained extremely worried about her because it was clearly not normal to have to spoon feed a baby with water as I had been doing, not that she was able to keep down the fluid in any event …”
“FB was on my lap, and on Paul’s lap. She allowed Dr Rushd to examine her. Me and Paul were passing [her] toys. We may have succeeded [in attracting FB’s attention]. I do not remember.”
“She sat between us”
“At approximately 15:00 on 29th September I received a telephone call from WAC on my mobile at work … I left work immediately and I went straight to WAC. As I arrived at WAC’s house [she] was carrying FB in her arms and coming out of the front door. I was absolutely horrified when I saw the state of FB. For a split second I actually thought that FB was dead. She was completely floppy in WAC’s arms. The only way that I can describe her is that she looked like an animal that had been hit by a car. I could not help it but I completely flipped out and said to WAC, ‘Please God tell me that she has not been like this for the whole weekend?’ WAC instantly broke down and starting sobbing ‘I have tried mum, but no one listened’ …”
“In accordance with my usual practice in 2003, on arrival I would have first elicited a history from [WAC]. I would have asked how long FB had been unwell, whether she had been given any medication and if so how long ago. I would have asked whether she had been vomiting or whether there had been any episodes of diarrhoea. I would have asked whether she had been taking fluids and eating. I would have asked whether she had a cough or cold symptoms and whether she had been seen by her own GP, if so I would ask what advice had been given. Due to the passage of time I have no recollection of the history given to me. Again, in accordance with my usual practice, I would then have examined FB taking into account the history provided to me. I would have examined her for signs of dehydration or sepsis, whether she was drowsy or floppy and whether she had a rash. If there had been any such signs I would have referred her to hospital.”
“In my note completed on the in car computer following the consultation, I recorded that FB appeared comfortable. This description meant that I would have found that FB was not crying or distressed, was alert and her breathing was normal. One can see by observing a child whether they are tachypnoeic [breathing rapidly] and whether they are wheezy or are in distress. If none of these symptoms are seen, I will describe the child as comfortable.”
“‘Comfortable’ could mean – the whole appearance of the child; it could have included, alert, happy and not in distress. If a child is not alert, I would have written ‘lethargic’, ‘not responding’ or ‘floppy’. If I had found anything like this, I would have written that in my note[s]. She was not lethargic or floppy … if [on examination] her level of alertness was satisfactory, that [would not have been] a significant feature.”
“It is likely my examination therefore took at least 25 minutes and indeed it would be my usual practice to take 30-40 minutes for an examination of this sort.”
“It is very unusual to write ‘looks well’. I am very happy seeing this child in this environment. There is nothing worrying me.”
“If I’ve put ‘responsive’, she is responding; she is responding to me as a strange lady. She was not lethargic, floppy or drowsy. I can’t remember if she cried or fought me; I’ve only written ‘responsive’.”
“… you think meningitis, that is drummed into you from day 1. You therefore do an examination to see if there are signs of infection in any organ.”
“If the mother had said, the child’s eyes were not tracking or were uncoordinated, I would have recorded it. That on its own is not a worrying sign. Rolling eyes can be voluntary. I would have taken it into consideration. But if her eyes were responding normally [on examination], that would not have altered the subsequent management.”
“Q: If you had been told FB’s eyes were rolling and not coordinating that, together with the rest of the history, should have led to a referral to paediatrics? A: no.”
“Q: If these things occurred [the eye-rolling etc.] either you did not ask the right questions, or the parents withheld the information? A: I agree” and slightly later: “usually, if [there are] rolling eyes, that is scary. I wouldn’t need to ask the right question; the parents would tell me first of all. In all my years in A&E and as a GP subsequently, you don’t need to ask the question.”
“[the experts] agree that we cannot place the time of onset of symptomatic meningitis much before 17:53 [on Monday 29th September], and for the purposes of further discussion, fix on 17:00 (acknowledging that this is arbitrary, but the best we can do) as the likely time of onset. Accordingly, [the experts] agree that on the balance of probabilities the blood/brain barrier was breached 8-12 hours before around 17:00 – that is, between 05:00 and 09:00 on 29th September. … [the experts] agree that such is the variation in progression of bloodstream infection of the BBB that it is not possible to identify on first principles the time of onset of bacteraemia by further back-extrapolation, but NN and SK do not alter their views, which are in agreement, as expressed in their reports, that on the balance of probabilities the start of the Claimant’s bacteraemia was on 27th September. GF thinks that this is too early for subsequent penetration of the BBB in the morning of 29th September, and thinks the bacteraemia was more likely to have started overnight on the 28th – 29th September. However, he agrees that we have little evidence on which to base on accurate time assessment.”
“NN and SK agree (GF deferring) that the course and pace of the Claimant’s infection on which we have agreed … does not allow us to conclude on the balance of probabilities one way or the other as to her likely appearance at this time on examination – possible conforming either to the Claimant’s mother’s or to Dr Rana’s description.”
“NN and GF The conclusion that NN has drawn from this paper [Bachur et al – see below] (with which GF agrees) is that children presenting with fever for which the cause is pneumococcal bacteraemia may appear not particularly unwell and that this was likely to have been so in the case of the Claimant. NN and GF both agree that the children in the Bachur paper who were not deemed ill enough to admit to hospital (noting just over 50% received either oral antibiotics or none) had evidence of significant systemic inflammation with median temp of 40 degree and median white cell count of 20,000 (significantly higher than that of the Claimant). NN and GF therefore both feel that the Bachur paper is relevant to this case. SK While SK agrees with thegeneralisation that feverish children with pneumococcal bacteraemia may not appear particularly unwell, he does not agree that the experience with cases reported by Bachur can be used to draw any helpful conclusion about the Claimant’s likely condition when seen by Dr Rana or Dr Rushd.”
“While I agree with the generalisation that children febrile with pneumococcal bacteraemia may not appear more than mildly unwell, I cannot agree with Dr Ninis that this would be so in the particular circumstances of FB’s case, in the face of her acceptance that the bacteraemia was of so high a level as already, in her opinion, to have led to breach of the BBB. In my opinion, Bachur’s paper is not an appropriate authority in the circumstances.”
“NN and SK (GF deferring to them on clinical issues) recognise that children in such a condition [namely, at 05:45 on 29th September] may be awake, eyes open and looking around – so to be described as ‘alert’ – while nevertheless having other clear signs of severe infection. A description of ‘responsive and aware of surroundings’ as recorded by Dr Rushd accordingly does not assist in determining the Claimant’s condition otherwise. NN and SK agree that children who are unwell with a high level bacteraemia and signs of systemic inflammation commonly show abnormal ‘state variation’. A child who cries and struggles when examination is attempted, but who calms down with her mother, has normal state variation, but one who remains unusually quiet or passive, or lies limply, pathetic even during unpleasant, unfamiliar manoeuvres such as medical examination, shows poor state variation. In context, poor state variation suggests a more serious infection. NN and SK agree that a child with high level bacteraemia would on the balance of probabilities show abnormal state variation and appear more unwell than a child who merely has a simply URTI.”
“(i) We agree that if the mother witnessed the convulsion this should have been elicited. IM and BL agree that it is possible that FB’s mother did not mention the convulsion [NB. I am ignoring Dr Lloyd’s opinion for these purposes. I have found that WAC did not mention the ‘convulsion’] (ii) Fluid intake – we have assumed that the question refers to total fluid intake (juice and water) and refers to an inadequate number of sips. We consider that the answer is ‘yes’ – this fact should have been elicited if it were found that FB had been taking only a few sips of liquid. IM points out that this does not give an idea of the volume of fluid or over how long a period of time. The volume ingested could have been large with many sips being taken or if only a few, then there would have been insufficient volume intake. It should be pointed out that the child had passed urine thrice … which would be reasonable for a 24 hour period … IM agrees [that taking only small sips of water should have raised Dr Rushd’s index of suspicion] if it is a small volume that was imbibed – see above … IM agree[s] that if it were found that Dr Rushd elicited a satisfactory history of adequate fluid intake, then no fluid challenge was necessary. (iii) The experts consider that it would have been reasonable for FB to be sent home provided that: (a) Dr Rushd’s account is preferred to that of WAC, (b) it were to be found that there was no convulsion, (c) it were to be found either that Dr Rushd (correctly) established satisfactory fluid intake or that FB took at least 90 mls of fluid without vomiting.”
“Starting the history taking by asking open questions is OK. But if open questions were asked, why did not the family detail the presentation, which was elicited by the ambulance corps and the paramedics. This should have been ascertained; the failure of sub-standard history taking.”
“It is quite common to see people present whenever [i.e. irrespective of the time of the day or night] with children with temperatures. It depends on parental anxiety, and on the quality of access to other services … we understand why parents come, and to manage their anxiety … Yes, there is a negotiation entailed in taking a history from parents. I have had to reprimand an SHO for asking, ‘why have you come at this time?’ … asking the question, ‘what is the problem?’ is usually adequate to ascertain the precipitator …”
“According to Dr Rushd, FB’s mother did not reveal this. I have previously indicated that this may not have led to FB being investigated or admitted if it were due to a febrile convulsion with an obvious source of focus.”