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Three-month-old baby diagnosed with E.coli meningitis (13HDC01651)

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(13HDC01651, 16 June 2015)

District health board ~ Paediatric emergency medicine ~ Bacterial meningitis ~ Diagnosis ~ Repeat presentations ~ Discharge ~ Right 4(1)

An otherwise well baby, aged 3 months, developed a fever during the day, and his parents took him to see his general practitioner (GP) that evening. The GP assessed the baby and recommended his parents obtain a urine sample to take to an after hours medical centre. The baby's parents collected a urine sample and, at about 9.30pm, the baby was assessed by a second GP at the after-hours medical centre. The GP recorded his impression that the baby had a urinary tract infection and appeared to be getting sicker. The GP referred the baby to hospital for paediatric assessment.

The baby's parents took him to the Emergency Department (ED) at the hospital, where he was assessed by an ED house officer, who recorded his impression that the baby had a febrile illness and should have a midstream urine test and await paediatric review. At midnight, the baby was seen by a paediatric senior house officer (SHO). After assessing the baby and obtaining a urine sample, the paediatric SHO diagnosed the baby with a "fever of unknown origin - probable viral illness", and discharged the baby with instructions for his parents to take him back to his GP the following afternoon.

The baby remained feverish and vomited three or four times the following day, so his parents took him back to his local medical centre, where he was seen by a third GP. The GP assessed the baby and referred him back to hospital, noting in his referral letter that the baby had deteriorated since his last medical review and seemed "somehow unwell". The baby's parents took him back to the ED, where he was sent straight to the Children's Acute Assessment Unit (CAAU).

At about 6.30pm, the baby was seen by a second paediatric SHO. The paediatric SHO assessed the baby and obtained a urine sample. She diagnosed the baby with viral gastroenteritis and planned to discharge him with a rehydration plan, paracetamol and advice about when to return for review. Prior to discharging the baby, the paediatric SHO discussed the diagnosis and treatment plan over the telephone with a paediatric registrar, who agreed with the proposed course of action.

The baby was discharged but remained feverish over the next few days. Three days later the mother took him back to hospital, where he was diagnosed with Escherichia coli (E. coli) meningitis and septic shock. The baby suffered significant neurological injury and permanent disability.

It was held that responsibility for the deficiencies in the care provided to the baby (specifically, the absence of senior clinical review) rested with the district health board (DHB). The DHB's Children's Acute Assessment Guideline (the CAA Guideline) did not require children re-presenting within a short time period to be assessed and discharged by a registrar. Where review by a registrar was required by the CAA Guideline (prior to transfer to the CAAU from ED), it did not occur in this instance because the process for seeking review had not been fully implemented. Accordingly, the DHB failed to provide services to the baby with reasonable care and skill and breached Right 4(1). 

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