Section 1Diagnosis delays
A fatal complication of chickenpox
A four-year-old was ‘grumpy and irritable’ after The letter of claim stated that the GP registrar had failed
returning home from nursery. He then developed to conduct an adequate examination and had failed to
spots and his mother suspected chickenpox. heed the concerns of the mother. As a result of this
Over the next 24 hours the child developed flu like
substandard examination, the GP registrar had failed to
symptoms, went off his food and began to scream.
appreciate the seriousness of the boy’s condition and had
After a sleepless night he was unable to walk or stand
failed to refer him to hospital.
up and appeared to be floppy. It was also alleged that it was inappropriate to arrange
After four days his mother took him to the local surgery
for the child to be seen at the out-of-hours service if his
where he was seen by a GP registrar, a member of the
condition did not improve and that the registrar should
MDU. The member took a history and carried out a
have seen the patient himself if required. Criticism was
thorough examination. He documented that the patient
also raised that the GP registrar did not consult adequately
had a temperature of 39°C, and a chickenpox rash,
with either his trainer or his supervisor.
including lesions on his penis.
No oral lesions were seen. The chest and abdomen were
examined and capillary refill time was less than two
The outcome
seconds. The GP believed this patient was not sufficiently
dehydrated to require immediate hospital admission and
The GP registrar was distressed to receive the claim and
was satisfied he was drinking well and that no obvious
contacted the MDU. He explained that his supervisor had
secondary infection had been found. He felt that the
considered his assessment and management of the case
history of reduced urine output could possibly be related
entirely appropriate when he had discussed the matter
to the painful penile lesions.
with her that evening after surgery.
The mother was advised to give the child a lukewarm
The member also pointed out that his GP trainer had
bath to encourage urination and further advice was
visited the parents after the death of the child and had
given in relation to taking ibuprofen in addition to
been told by the parents that the child’s condition had
paracetamol.
improved after the GP consultation.
The mother was told that if the child’s temperature did
A GP expert report, commissioned by the MDU, supported
not come down, and if the child did not pass urine that
the registrar’s management and the MDU’s formal
evening, she should contact the out-of-hours service.
response to the letter of claim refuted the allegations of
The GP provided the mother with the contact details.
breach of duty by pointing out that a full history and
examination was carried out. The MDU cited expert
Two days later the mother contacted NHS Direct saying opinion and the GP registrar’s experience of examining
the child was still very unwell and was advised to take children as evidence that the examination had been
him to the A&E of a local children’s hospital. After an conducted properly. The claimant’s solicitors were invited
initial delay, a diagnosis of chickenpox was made. It was to discontinue their claim.
thought possible that transient synovitis/osteomyelitis
was responsible for the child’s reluctance to walk.
After some months, the hospital settled the claim,
admitting full liability and the case against our member
An x-ray of the right and left hips was normal, and an was discontinued.
ultrasound scan showed a 3 mm effusion of the left hip
with a normal right hip. It was agreed that the child
should be admitted and have IV fluids with analgesics.
Blood tests revealed a raised white cell count (17.8) and
a CRP of 190. According to the medical records no other
doctor then assessed the child until 11 pm and he didn’t
receive the recommended fluids.
Soon after this, the child deteriorated, suffered a
cardio-respiratory arrest and died. The cause of death
was recorded as toxic shock secondary to group A
streptococcus infection as a complication of chickenpox.
There was no evidence of osteomyelitis.
A claim was made against the GP registrar, his GP supervisor
and the children’s hospital.
“…the examination had been conducted properly.”
15
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