“In nearly all patients who develop shock and in most patients with meningitis, the beginning of the bacteraemic phase is marked by the onset of chills, acute fever, low back pain, thigh pain or generalised muscle aches. Within a few hours ‘fulminant meningococcal sepsis’ (FMS) may develop without signs of meningitis. This condition is characterised by high concentrations of endotoxin and cytokines Cytokines are cell signalling molecules that aid cell to cell communication in immune responses and stimulate the movement of cells towards sites of inflammation, infection and trauma. In excess , a so-called cytokine cascade, they can cause severe tissue damage and organ damage. Cytokines release molecules that influence cell function, mediate inflammatory damage and affect blood vessel function. in plasma. Because one of the striking features of meningococci is their propensity to invade the meninges, patients with less marked bacterial proliferation in the bloodstream and less cytokinaemia, present after 18 to 36 hours with meningitis. In these patients (of whom, as I will find, the Claimant was one), blood cultures are often negative at the time of hospitalisation. Due to the limited growth of bacteria in the bloodstream and the seeding of meningococci in the subarachnoid space, patients with meningitis have compartmentalised high concentrations of endotoxin and cytokines in the CSF.”
"... the CSF can be conceptualised as a localised area of host immunodeficiency facilitating unrestrained proliferation of (the pathogen) which, if untreated, overwhelms the host until death."
“Of the 177 patients with meningococcal infection (six of whom were diagnosed on clinical grounds alone), 70 (40%) had a purpuric rash on presentation, 32 (18%) a petechial rash and 10 (6%) erythematous or maculo-papular rashes.....”; 65 (36%) patients were without a rash, and in another, relied upon by Dr. Cranfield, the expert in general medical practice called on behalf of the Defendant: “Majority of bacteriologically proven cases of meningococcal disease develop a rash during some stage of the illness • the rash can be extremely diverse (with different presentations in different skin types) and the rate of progression may vary rapidly as well • a non-blanching haemorrhagic rash is a characteristic feature of meningococcal disease • the rash may be absent, scanty or it may be blanching in the early stages • a blanching maculopapular rash at early stages of the disease may develop into a non blanching rash as the disease progress”
" ...initiating antibiotic therapy before advancement of disease severity should be the major therapeutic goal for physicians treating patients who have bacterial meningitis"
“Antibiotics are the cornerstone of treatment.... Antibiotic therapy should be started as early as possible. .... postponement of antibiotic therapy will result in an increase in bacterial biomass and a more harmful inflammatory response" Van Dueren et al at 5/972, op.cit. and "What evidence-based recommendations can be made with regard to the timing of antimicrobial administration in patients who present with suspected or proven bacterial meningitis? The key factor would appear to be the need to administer antimicrobial therapy before the patient's clinical condition advances to a high level of clinical severity, at which point the patient is less likely to have a full recovery after treatment with appropriate antimicrobial therapy..... The logical and intuitive approach is to administer antimicobial therapy as soon as possible after the diagnosis is suspected or proven." Practice Guidelines for the Management of Bacterial Meningitis [ISDA Guidelines]: Tunkel et al. [5/ 946]. and " ..in all adult patients in whom a diagnosis of bacterial meningitis is suspected, general practitioners should give benzylpenicillin 1200mg (two mega units) without delay ideally by intravenous injection (or by intra muscular injection if a vein is not available, while arranging urgent transfer to hospital ....... Delay in therapy after arrival in an emergency department is associated with adverse clinical outcome when the patient's condition has advanced to the highest stage of prognostic severity. Evaluation of the Glasgow Coma Scale The Glasgow Coma Scale or GCS is a neurologicalscale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). in 100 consecutive patients with meningitis (bacterial, viral, tuberculous, cryptococcal and others) showed a good correlation between Coma Scale and clinical outcome and CSF protein level on admission. Eighty per cent of those with a coma score greater than 12 had a good neurological outcome, whereas 88% with a score of eight or less had a poor outcome." N. Begg et al. op. cit. and finally “This study provides compelling evidence that delays in the administration of antibiotics are associated with death in adult acute bacterial meningitis. In the multivariate logistic regression analysis, a delay of > 6 h in the administration of antibiotics after presentation, independently conferred an 8.4-fold greater risk of death from meningitis. Furthermore, the effect of treatment delay on case fatality rate was incremental; greater delays resulted in higher case fatality rates.”
“4. On7 January 2008 the Claimant woke up late feeling much worse. She noticed she had a rash on the palm of her left hand, across both her lower arms and across her midriff. Her right arm was spotty and dark pink. The rash was spidering and the spidery parts were purple with gaps between the dots. However, the rash was not raised or itchy. The rash did not hurt save for a spot on her arm that felt sore when she pressed it. 5. The Claimant telephoned the surgery arranged an appointment to see the Defendant at 5.20 pm.”
“4. On 7January 2008 the Claimant woke up late feeling much worse. She noticed she had a rash on the palm of her left hand, across both her lower arms and, later in the day, across her midriff. The Claimant telephoned the Surgery and arranged an appointment to see the Defendant at 5.20 pm. 5. The Claimant remained unwell during the day and slept for the most part. By the time she was driving to the surgery for her appointment she noted that her right arm was spotty and dark pink. The rash was spidering and the spidery parts were purple with gaps between the dots. However, the rash was not raised or itchy. The rash did not hurt save for a spot on her arm that felt sore when she pressed it.”
“25. On 7 January I woke up late. I was feeling really horrible. I had woken up at about 10.30 and saw that I had a rash on the palm of my left hand, both of my lower arms and across my midriff." She then described, in detail, how, on getting out of bed, she had first been alerted to the rash on her midriff, of what was then her unclothed body, by the reflection in a large mirror in her bedroom, and how she had had used the mirror to check other parts of her body as best she could. She then referred to a telephone call to her husband preceding her call to the Surgery, and to telling him that she “felt really unwell and .... had a strange rash.”
“27. In the morning on my left lower arm the rash extended from the inside crook of my elbow approximately 5-7 inches down my arm. The rash did not extend as far as my wrist. The rash was only on the inside of my arm and not on the outside of my arm. I had a number of pinky small dots on that arm. I did not count them but would estimate there were around 30 or more. The size of the dots were about the same size as if you made a mark with the tip of a felt pen or the same size as the head on a flat headed dressmaker pin. The dots were not joined together, they were several millimetres apart. I would describe them as evenly distributed; they were not clustered. The spots were not as dark as a port wine stain but they were darker than a pink Angel Delight whip. 28. On my lower right arm I had a couple of large spots. These spots were on the inside of my lower right arm not on the outside of my lower right arm. The largest spot was approximately 4 inches down from the crook of my elbow with the second spot approximately a further 3 quarters of an inch along the inside of my lower right arm. One of the spots was slightly larger than the other and was about the same size as the end of a cigarette. Both of these spots had spidery like tentacles radiating from them like a starburst. At this stage, meningitis had not occurred to me, however, on touching the rash with my fingertips the surrounding capillaries did not change colour. It was tender to the touch and looked more like a very fresh and livid bruise. I can recall that in the morning both spots on my lower right arm were a few shades darker than the spots on my lower left arm. 29. On the palm of my left hand I had 4 small reddish spots. These four spots were smaller than the spots on my lower right arm. They were about the same size as a compass prick. They were more of a reddish colour than the spots on my lower right arm and were more spaced apart. They had about 1.5 cm between them and were like the four corners of an offset square. 30. The spots on my midriff appeared to look slightly larger than the ones on my lower left arm but were the same colour. I would estimate that there were at least double the amount of spots on my midriff than my lower left arm. The spots covered a good roll of fat around my middle. The spots were more congested towards the middle area of the rash and towards the outer edges they became more spread out and random.”
“I can recall trying to wake myself up but did not feel like I could get up. The alarm went off and I just lay there until I suddenly realised that unless I moved quickly I was now going to be late for my appointment at the surgery...”
“I checked my midriff and lower arms to see if the rashes were still there and the rashes on both lower arms appeared to be slightly darker than when I inspected them in the morning.” adding: “...it was whilst driving to the appointment with my sleeves rolled up that I looked at the rash on my forearms and hand and I noticed that the spots were darker, in particular the ones on my lower right arm and the left palm of my hand.”
‘... is suffering from respiratory infection since 28/12/07 & unlikely to be fit until 14/01/08’
“I realised the Claimant was very ill and her family were angry. I put down what I could remember - but not to defend myself - what I could recall of the consultation. Some of it is what is in the witness statement and not in the notes.”
“I did mention cough and headache. I don’t recall being asked if I had a bad cough. I didn’t convey the impression that the cough was the worst symptom. I believe I used the expression ‘I think my head is going to explode’ and conveyed ‘pressure’ in my head [the Claimant then demonstrated this by drawing her hands down across both cheeks from the area between her eyes]. I did use the expression ‘the man in the iron mask, like the Lemsip advert’. I was trying to convey that I had a very severe headache. She said nothing specifically in response.”
'Failed to achieve L(umbar) P(uncture) x 3 Abandoned R.Thomas - D/W husband at bedside Working diagnosis is bacterial meningitis He understands that we awaiting tests results to guide ABX (antibiotics) Rx (treatment) and to confirm the abac (bacteria). However, as I have not been able to do a L P and I think the blood cultures were done post commencement of ABX we may not ever confirm the diagnosis or grow a bug. Skin lesions not characteristic of meningococcus Not behaving as septicaemic Very agitated and clasping head'
'Phone call Hampshire & IOW Health Protection Unit 0845 055 2022 (or via ? switchboard OOHs) Report to them if Meningococcal disease confirmed or 'probable' on clinical grounds At present ... 'possible'
'Rash subsiding now Rx(Treat) as meningococcal meningitis'
'Raised our concerns that patient may not make a complete neurological recovery + risk of meningitis complications (cranial nerve palsies, blindness, deafness) and encephalitis complications (memory loss, personality changes, brain damage) and risk of death. There is still possibility of complete recovery but may be prolonged period of cerebral irritation...'
'MRI/very useful and shows no evidence of demyelination or infarction.'
'pupils : non reactivity'
‘ Admission Diagnosis : Meningococcal meningitis Aspiration pneumonia ...... Meningococcus confirmed with PCR 17/1/8’
“But where you get a situation which involves the use of some special skill or competence, then the test as to whether there has been negligence or not is not the test of the man on top of a Clapham omnibus, because he has not got this special skill. 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 ... he is not guilty of negligence if he has acted in accordance with practice accepted as proper by a responsible body of medical men skilled in that particular art ... Putting it another way round, a man is not negligent if he is acting in accordance with such a practice merely because there is a body of opinion who would take a contrary view.”
“ a doctor is not negligent if he acts in accordance with a practice accepted at the time as proper by a responsible body of medical opinion even though other doctors adopt a different practice.”
“[Counsel for the claimant] submitted that the judge had wrongly treated the Bolam test as requiring him to accept the views of one truthful body of expert professional advice even if he was unpersuaded if its logical force. He submitted that the judge was wrong in law in adopting that approach and that ultimately it was for the court, not for medical opinion, to decide what was the standard of care required of a professional in the circumstances of each particular case. My Lords, I agree with these submissions to the extent that, in my view, the court is not bound to hold that a defendant doctor escapes liability for negligent treatment or diagnosis just because he leads evidence from a number of medical experts who are genuinely of the opinion that the defendant’s treatment or diagnosis accorded with sound medical practice.”
“I had not appreciated that an attempt had not been made to test non-blanching.”
“The works of learned and qualified authors forms part of the general corpus of medical and scientific learning on the subject and can be relied upon and adopted by suitably qualified experts. These experts may have their opinions tested in the light of the literature”
“I mentioned a time of 6 hours meaning the time at normal dosing regimen for penicillin tissue levels to reach a steady state (optimal concentration) and to have maximum effect. However, this would notapply had Dr. Rosie administered penicillin and then referred Mrs. Coakley to hospital. In these circumstances the hospital staff would on balance of probabilities have administered intravenous ceftriaxone on arrival. This would have resulted in maximal antibiotic effect much sooner and accelerated the reduction in inflammatory response. Therefore the 6 hours is only relevant if no additional antibiotic was given on arrival at hospital” (my emphasis added) By way of what was, in my judgment, no more than clarification of his opinion, he added: “There is no good reason for thinking that a delay of 5½ hours would make no difference to Mrs. Coakley’s condition. This is against the weight of the literature especially considering the intact condition of Mrs. Coakley when she saw Dr. Rosie and the absence of any poor prognostic indicators at that point.”
“There were probably two processes that combined to cause her loss of vision. The first comprised the meningitic inflammatory process affecting the optic nerves, and the second involves the elevated intracranial pressure as documented at lumbar puncture and as seen on the CT scans. ... There is unanimity amongst the experts that earlier treatment offers the best prognosis and particularly in the case of meningitis, the earlier administration even by an hour or so can have a dramatic beneficial effect on outcome... At the time Mrs Coakley presented to her general practitioner on7 January 2008 , she had no neurological deficits and had a normal Glasgow Coma Scale. There were no features of vascular collapse. She was therefore in a good prognostic group (no hypotension, no altered mental status, no seizures) in contrast to her condition when she was admitted to hospital”
“ treatment at this time (5.20 pm) may possibly have led to a better outcome but ... even with the administration of intramuscular penicillin at 17.20, Mrs. Coakley would still have had the possibility of major neurological deficit.” 88. In his original report, but without any reasoning at all, he had concluded: “My view is that the outcome might have been better if high dose antibiotics had been given earlier in the evening, but this chance is impossible to quantitate and, even on the balance of probabilities, it is not possible to say whether the outcome would have been any different”
“a delay of a few hours would not alter an event (the blindness) which was so remote in time”
“I agree that the Claimant could have been suffering from meningitis which I did not identify. I presume she had a meningococcal rash on the basis of what the experts say. I agree she could not have been suffering from an urticarial rash at the time she consulted me. Therefore I was wrong!”
“In the event that the court does not accept the Claimant’s primary case, in particular because it considers that the current state of medical knowledge does not allow such a finding to be made, the Claimant further argues that the principles in Bailey apply and she succeeds on causation if she can show that the Defendant’s breach of duty materially contributed to her injuries, in other words, that but for the negligence she would have had a materially better outcome.”
“I do not consider that medical science can determine whether there was a critical time before which treatment would have been effective, and after which treatment would have been ineffective. The progression of the disease is necessarily gradual, and will vary between patients. What I think can be said is that the delay between 04.00 and 07.00 in the commencement of treatment would have made a material contribution, more than negligible, to the development of (the Claimant’s) gangrene and the amputation of her feet.”
“the natural corollary is that the timing of treatment has a direct and proportionate impact on outcome such that delay in treatment causes greater loss of optic nerve axons, resulting in a progressive worsening of vision. Any such worsening or deterioration in vision would amount to a material contribution to the claimant’s injuries. Bearing in mind Mr Elston confirmed that only 10% of optical nerve axons were necessary in order for the Claimant to retain functional vision, it would mean that the optical nerve axons would have had to have been already more than 90% obliterated (or an irreversible process already set in train for the optic nerve axons to become more than 90% obliterated) for the delay not to have made a material contribution to the outcome.”
“The mere expression of opinion or belief by a witness, however eminent, that (the vaccine can or cannot cause brain damage), does not suffice. Most importantly this involves an examination of the reasons given for his opinions and the extent to which they are supported by the evidence. The judge also has to decide what weight to attach to a witness’s opinion by examining the internal consistency and logic of his evidence; his precision and accuracy of thought as demonstrated by his answers; how he responds to searching and informed cross-examination and in particular the extent to which a witness faces up to and accepts the logic and proposition put in cross-examination or is prepared to concede points that are seen to be correct; the extent to which a witness has conceived an opinion and is reluctant to re-examine it in the light of later evidence, or demonstrates a flexibility of mind which may involve changing or modifying opinions previously held; whether or not a witness is biased or lacks independence.”