Case 28 A bad case of ’flu
During the early phase of an influenza A pandemic, a 10-year-old boy, Michael is brought to the Paediatric ED at his local hospital by his parents. He has a 2-day history of fever, headache, severe myalgia and cough. He has previously been well, except for having problems with recurrent boils over the last 6 months, which have also affected his 7-year-old sister. His observations show a temperature of 38.7°C, heart rate 100/minute, respiratory rate 19/minute, oxygen saturation 97% in air. He is seen by a FY2 doctor, who takes a brief history and performs a basic physical examination which is recorded as normal. She makes a clinical diagnosis of influenza, and requests a nasopharyngeal aspirate (NPA) to confirm the diagnosis.
What would you do?
In keeping with departmental guidelines Michael is prescribed osteltamivir and is discharged home with advice to take antipyretics. Two days later he is brought back to the ED because he has developed vomiting and diarrhoea, intermittently he complains of feeling dizzy and he still has a fever, cough and malaise. Michael’s observations show a temperature of 39.5°C, heart rate 135/minute, blood pressure 98/48 mmHg, respiratory rate 35/minute, and oxygen saturation 93% in air. A family friend had recently been treated with osteltamivir and developed vomiting, which he had been told was probably due to the medication, and Michael’s parents are rather angry that they were not informed about the possible side effects of the osteltamivir. Michael is seen by the same FY2 who checks the results from the previous attendance and sees that the NPA was positive for Influenza A. She examines him again and notes that he appears flushed, he is not dehydrated, capillary refill time is less than 1 second and his chest has scanty bilateral crepitations.
What would you do now?
Seeing that nausea, vomiting and dizziness are possible side effects of osteltamivir and also symptoms of influenza, the doctor documents a detailed discussion with Michael’s family about the possible causes of the current symptoms and advises the parents that they should stop the osteltamivir treatment, continue symptomatic treatment with antipyretics, maintain adequate hydration and return if the symptoms persist for more than 48 hours.
Unfortunately Michael is brought in by ambulance the next morning, having coughed up blood and then collapsed on the floor when his parents tried to get him out of bed. He has signs of shock and requires intubation and massive fluid resuscitation prior to transfer to a PICU. His condition deteriorates due to severe haemorrhagic pneumonia and he becomes impossible to ventilate and has several cardiorespiratory arrests before dying 9 days after his initial presentation. Tracheal aspirates and blood cultures grow methicillin sensitive Staphylococcus aureus, which is later found to produce the toxin Panton-Valentine Leukocidin (PVL).
His parents subsequently institute proceedings to try to sue the hospital stating that the diagnosis of pneumonia had been missed and that the delay in treatment resulted in a fatal outcome.
Expert opinion
Bacterial pneumonia is one of the most common complications of influenza in children and can lead to bacteraemia and sepsis. Although this is most frequently caused by Streptococcus pneumoniae, influenza is also a risk factor for severe necrotizing pneumonia caused by PVL toxin-producing Staphylococcus aureus. Some patients who have carriage of this organism have a history of recurrent boils / skin abscesses, as in this case. The initial management of Michael was appropriate with the prescription of osteltamivir being consistent with the guidelines; however, warning signs were missed when he presented the second time. Although the symptoms of fever, diarrhoea, vomiting and ‘dizziness’ are compatible with influenza, symptoms would normally be starting to improve 4 days after the onset of fever, and especially following osteltamivir treatment. The findings on examination of a flushed child with tachycardia, very rapid capillary refill, tachypnoea and borderline low oxygen saturations are suggestive of sepsis with peripheral vasodilation. Diarrhoea and vomiting are often features of toxin mediated Staphylococcal disease and the ‘dizziness’ may actually have been due to postural hypotension, a sign of impending circulatory decompensation. The significance of the scanty bilateral crepitations on chest examination was also not appreciated as a sign of developing pneumonia, and was presumably attributed to influenza. Although the junior doctor documented an extensive discussion about osteltamivir and its side effects, she did not appreciate the significance of the clinical findings in this case, and did not discuss the case with a more senior colleague. It is likely that the failure to diagnose signs of a severe infection at an early stage contributed to Michael’s death.
Legal comment
A careful witness statement needs to be taken from the FY2, detailing her findings at each of the two consultations. Can she explain how she interpreted the new findings on the second consultation?
Her statement will then be put to an expert to see if any defence to breach of duty can be made. There should also be an investigation into the likely course of events had the correct diagnosis been made at the second consultation. What treatment would probably have been given and when? Would it have been sufficient to stop the development of the bacterial infection and prevent death?
If, on the balance of probabilities, the infection was already so advanced that treatment would not have been effective and would not have prevented the death, then the hospital could in theory defend this case, because the damage was not the result of any breach of duty.
However, the Trust is likely to wish to settle this case. The parents might expect compensation for the pain and suffering of their son before death, and the statutory bereavement damages of £11,800.
