Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint concerning the diagnosis that the complainant's son was given by two general practitioners on two separate occasions. The complaint is that:
- A general practitioner ("GP") failed to diagnose meningitis in the consumer on a date in early February 1999 when he presented at an after hours medical centre with headache, fever and vomiting. In addition, when the consumer's father expressed concern to the GP about the possibility of this being meningitis, the GP advised it appeared to be a gastro-enteritis virus and prescribed buccastem and buscopan.
- A second GP failed to diagnose meningitis in the consumer on a day later when he presented at the after hours medical centre a second time with neck swelling and limited movement of his head. In addition, when the consumer's father expressed concern to the GP about the possibility of this being meningitis, the GP advised it was still a virus and prescribed voltaren.
The complaint was received by the Commissioner on 24 February 1999 and an investigation was undertaken. Information was obtained from:
- The Consumer
- The Complainant/Consumer's Father
- Provider/General Practitioner
- Provider/General Practitioner
- The Chairman of Complaints, After Hours Medical Centre
Regional Public Health Service 'Meningococcal Disease' sheet. The consumer's relevant medical records were viewed. A GP provided advice to the Commissioner.
Outcome of Investigation
The complainant took his 16-year-old son to an after hours medical centre at 7.46pm on a date in early February 1999, after he arrived home from surf lifesaving feeling ill with a bad headache, fever and he had vomited. The complainant advised that his son's face was red and his eyes appeared dark around the edges and he was also complaining that his body ached.
The complainant stated that his son was very fit at that stage due to his training for surf life saving.
At this consultation, the consumer was examined by a general practitioner who noted that his temperature was normal, his ears, throat and chest examination were normal, his heart sounds were normal and there was a generalised tenderness in his stomach. When the consumer's father expressed his concern about his son having meningitis to the GP, the GP told him that the consumer had a gastro-enteritis virus and prescribed him with buccastem and buscopan. The GP stated in her response to the Commissioner that:
"He had no other symptoms of meningitis, such as neck stiffness, photophobia or rash. My diagnosis was that he had gastro-enteritis."
The GP also advised the consumer to return to the after hours medical centre or to see his own GP if he got worse or his symptoms changed.
The next morning, the consumer's condition had deteriorated with a worsened headache and his neck was becoming stiff. The consumer's father once more took his son to the after hours medical centre around 6.55am where he was immediately examined by a second general practitioner.
The consumer's father again expressed his concern that his son could have meningitis. The consumer had limited movement in his neck. It was stiff and he could only move it a little to each side. He could not see his shoulders or place his chin on his chest. The consumer and his father confirmed that the GP examined the consumer's neck and explained that although the consumer's neck was swollen and he had limited movement of his head, this was not limited enough to be considered meningitis. The GP also carried out an eye test on the consumer. The GP advised that he assessed the consumer for bleeding in the brain and viral infection.
The GP stated that the consumer did not have an unsteady gait. If he had seen this, it would have indicated a problem with the consumer's nervous system and he would have documented it and referred the consumer on.
My advisor stated that meningitis is not obvious when there is no rash present and that the reasons for having a swollen neck include swollen lymph glands that would cause limited movement.
Further, when testing for neck stiffness in meningitis the neck feels like moving lead and resistance in the neck would be felt.
The GP documented that there was no meningism (neck stiffness), no focal neurological deficit and the consumer was alert and orientated with no confusion. The GP informed the consumer's father that his son had a muscular headache secondary to the viral illness and prescribed voltaren. The GP suggested follow-up if the consumer's symptoms deteriorated.
The GP stated in his response to the Commissioner that:
"I did a complete examination for meningitis, there was no neck stiffness, i.e. no meningism. [The consumer] was alert, orientated, normal mental state, no confusion, speech normal, able to communicate to me?As I can recall ?there was no rash on the body."
The GP included in his response to the Commissioner, written information available at the after hours medical centre, to demonstrate how he would make a diagnosis of meningitis. The GP advised that the most important symptoms of meningitis to be considered were fever, changed mental state and neck stiffness. The GP discussed the signs and symptoms on the information sheet with the consumer's father, though he did not give him the sheet, as he thought the complainant seemed well informed already. The Regional Public Health Service information sheet 'Meningococcal Disease' for 30 May 1996 states:
"Meningococcal septicaemia and meningococcal meningitis begin like the flu but the person will usually get rapidly worse. Fever, headache, drowsiness, stiff neck, red rash may be signs of meningococcal disease.It can be very hard to tell meningitis or septicaemia from the flu in the early stages."
In the Chairman of Complaints of the after hours medical centre's response to the Commissioner, he stated that neck swelling would not be"considered particularly relevant to consideration of meningococcal infection.
Occipital tenderness is recorded and could suggest muscular pain rather than meningeal irritation. [The general practitioner] has subsequently reported no skin rash was seen, though this was not noted at the time."
A day after presenting at the after hours medical centre the second time, the consumer deteriorated further. He was vomiting, had an intense headache and was having trouble walking. His parents took him to the hospital for further assessment where, firstly through a CAT scan and then a lumbar puncture, the consumer was diagnosed as having meningitis.
My advisor stated that the hospital undertaking a CAT scan would indicate that they did not know what they were dealing with and they might have been looking for a lesion as the cause of the headaches. Further, they advised that if the hospital only wanted to confirm that it was meningitis, they would have done a lumbar puncture straight away. Additionally, the consumer's symptoms were not definite up till then, and meningitis would occur usually over 24 hours rather than in the very protracted way the consumer's illness did occur.
The Chairman, in his response to the Commissioner, stated that the CAT scan would not be regarded as a useful test for meningitis, but "rather a method of ruling out other severe causes of headache (such as haemorrhage) and suggests that the hospital staff were also not immediately able to diagnose the meningitis." He further stated that a lumbar puncture is the definitive test for meningitis.
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Opinion: No Breach
In my opinion, the general practitioners did not breach Right 4(2) of the Code.
My general practitioner advisor stated that:
"The diagnosis of meningococcal meningitis or septicaemia can be very difficult in the early stages, as their presenting symptoms can be similar to those of viral illnesses. Once the meningitis or septicaemia is more advanced, the diagnosis becomes more obvious and can be confirmed by further investigations, e.g. lumbar puncture. The condition in its advanced stages can be fatal, so early diagnosis is essential. One should be suspicious of meningitis when a patient presents with fever, headache, drowsiness or increasing confusion, vomiting, and neck stiffness. When a purpuric septicaemic rash is present, the diagnosis is more obvious."
"There is not a specific number of symptoms of meningitis that must be present before a diagnosis is made,?When [the consumer] presented on [both days in early February] he had some of those symptoms but not enough to be certain of the diagnosis. Gastro-enteritis or other viral illness would certainly be among the differentials."
"This was a rather protracted course for this type of illness. Even then, it seems that a lumbar puncture was required to diagnose the meningococcal meningitis, as there had still not been the appearance of a septicaemic rash. A CT scan carried out first suggests that the hospital's consultants were also not clear as to the diagnosis initially."
Both doctors suggested medical follow up for the consumer if symptoms deteriorated. The general practitioners' plan of action in regard to a referral to the consumer's own GP was reasonable in the circumstances.
This case highlights the difficulty that general practitioners have in diagnosing meningitis, due to the presenting symptoms often being non-specific. In my opinion, the treatment provided by both general practitioners to the consumer was reasonable in the circumstances and therefore not in breach of the Code.
The Chairman of Complaints and my general practitioner advisor both commented that the recording of the consultation notes of both GPs were not up to the standard required of a general practitioner. The after hours medical centre's board has since emphasised the importance of record keeping to the GPs and all other doctors at the Centre.
This case highlights the importance that medical practitioners must take in listening to consumers who express concerns regarding meningitis or regarding extreme symptoms which have occurred rapidly. While meningitis is difficult to diagnose, parents are often more alert to the seriousness of symptoms than GPs, as they know their children's usual health status. Attention must be paid to their concerns and considered along with the presenting symptoms.
A copy of this report will be sent to the consumer's father, the general practitioners, and the Chairman of Complaints.
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