An inquest opened and adjourned today, 23 April 2018, into the death of six-year-old Oliver Hall, who died at James Paget University Hospital on 24 October 2017, less than a day after contracting the bacterial infection Meningitis B.
Oliver had been noticeably poorly and by the morning of 23 October 2017 he was lethargic, photophobic (averse to bright light) and complaining of a sore neck. Despite giving him infant paracetamol suspension, his temperature remained persistently high and he developed a rash, which his mother Georgie felt was non-blanching.
Georgie called the family GP before 10 am asking for an urgent appointment, emphasising that Oliver was unwell with a temperature which was not responding to medication. She was told that the earliest appointment was at 3.50 pm that afternoon, but to call back if there was any change.
Following further calls to the GP practice, Georgie called an advisor on NHS 111, who sent an ambulance. The ambulance crew arrived at around 1 pm. Georgie told the paramedics of her concerns - thus far Oliver had displayed all the classic symptoms of meningitis.
Missed opportunities to identify meningitis symptoms
However, despite the fact that Oliver’s other symptoms appeared to indicate otherwise, the ambulance crew dismissed meningitis apparently because the rash – especially a large bruise-like mark on his arm - was blanching and was discounted as a ‘trauma mark’ or ‘pinch. The paramedics therefore insisted that Oliver did not need to go to hospital, but such was Georgie’s anxiety about Oliver’s condition that they agreed to take him to the GP.
The ambulance arrived at the GP practice at around 2.30 pm. Again, Georgie described Oliver’s symptoms and voiced her concerns that it could be meningitis. Despite her concerns no investigation was made in relation to his photophobia or stiff neck.
Nor were any simple tests that could facilitate a diagnosis of meningitis performed (e.g. Kernig’s Sign, where the inability to extend the patient’s knees beyond 135 degrees without causing pain constitutes a positive test). The family were told that Oliver was well enough to go home.
Tragic consequences of repeated misdiagnosis of meningitis
By 6.30 pm that evening Oliver’s rash was getting worse. Georgie took her son back to the GP practice who immediately gave Oliver an injection of antibiotics and called for an ambulance. The couple had been waiting for half-an hour when they asked the GP if he could call to find out when the ambulance would arrive.
They were told that ‘no resource was available’ so Georgie and her husband Bryan decided to drive Oliver straight to hospital themselves, arriving at James Paget’s at around 8 pm.
Tragically, despite the best efforts of the medical staff at the hospital, Oliver passed away in the early hours of 24 October 2017.
Oliver’s death was reported to the coroner who initially recorded a conclusion of ‘natural causes’.
The family then turned to Shoosmiths, specialists in clinical negligence for help in getting the full facts about why their son, in their view, died needlessly.
Shoosmiths made representations to the Coroner and, on 4 January 2018, the senior coroner Dr Peter Dean reviewed the case and formally agreed to open an investigation with a view to a full inquest should further enquiries indicate this was necessary.
The importance of listening to parents’ concerns
Aside from perhaps the need to improve awareness among GPs of the simple tests available to diagnose meningitis (rather than simply relying upon just one clinical symptom in isolation), Kashmir Uppal, partner and specialist medical negligence solicitor at Shoosmiths, believes this case highlights an equally important issue: that of better recognition of parental concerns:
‘No one knows their child better than a parent, especially if that child is poorly or off colour. Given Oliver’s symptoms and the fact Georgie specifically and repeatedly asked whether this was meningitis, it is surprising that her concerns were apparently dismissed so readily without even simple tests that could have reassured her or confirmed a potentially life-saving diagnosis.’
‘The evidence obtained as part of a coronial investigation will help Georgie and Bryan understand what happened to Oliver and why their concerns were dismissed to ensure lessons are learned so that no other family has to go through what they have experienced.’
Above picture: Oliver Hall (Ollie)
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