Case 30 Treatment for tonsillitis
A 3-year-old girl, Lily, is seen at 7 pm in the Paediatric ED having had her second 3 minute typical uncomplicated febrile convulsion. Despite having had appropriate education and reassurance following her first convulsion two months previously, her parents dialled 999. When the ambulance crew arrived Lily had stopped fitting and by the time she reached hospital she was back to normal. The triage nurse documented in the shared medical and nursing notes that for the previous 12 hours Lily had symptoms of an upper respiratory tract infection and apparent difficulty swallowing. Her parents had given her paracetamol at 10 am. She was otherwise healthy, developmentally normal and fully immunized. Her father had had febrile convulsions as a child. Lily was on no regular medication. Her temperature was 39.7°C, pulse 96/minute, central CRT 2 seconds and her airway was patent with no stridor. She is given a dose of paracetamol. An hour later she is reviewed by the ST3 doctor. Her temperature has fallen to 37.5°C, her pulse to 88/minute and she is playing happily. She is flushed but alert with no rash or evidence of meningism. Cardiovascular, respiratory and abdominal examinations are unremarkable. Both eardrums are inflamed and her tonsils are swollen, erythematous and covered in pus. The doctor makes a diagnosis of a febrile convulsion secondary to tonsillitis. She explains this to the parents and they agree that if Lily is still relatively well two hours later than she can go home. In preparation, the doctor writes the discharge letter including a prescription for a 10-day course of penicillin V, noting that Lily had grown group A Streptococcus from a throat swab taken after her first febrile convulsion. The ST3 doctor agrees her management plan with the ST4.
What information is missing?
As per the protocol for dispensing drugs out-of-hours, two nurses check the penicillin so that all is done before the night team arrive. Both medical and nursing staff have their handovers. The department then became extremely busy with a child in the resuscitation room. The nurse now looking after Lily asks one of her junior colleagues to give the parents the antibiotics so that they can leave. The nurse ensures that Lily’s parents are happy to go and she is discharged home with safety net advice to return if they are worried.
What is still missing?
An ambulance crew rings an hour later to say that they are on their way back to the hospital having been called when Lily developed severe breathing difficulties 10 minutes after a dose of penicillin. They describe that she has widespread urticaria, lip and tongue swelling, stridor and wheeze. They have given 0.15 mls of 1/1000 intramuscular adrenaline and a 2.5 mg salbutamol nebulizer and are administering 15 litres/min of oxygen via a facemask. In the ED Lily requires a further dose of intramuscular adrenaline, 3 back-to-back salbutamol nebulizers, iv hydrocortisone, chlorpheniramine and a 20 mls/kg fluid bolus. She makes a full recovery.
Her parents write to complain that they had informed the triage nurse that Lily was allergic to penicillin and that she had previously developed a rash and wheeze following this drug. They had explained this the last time they were in and had been prescribed clarithromycin instead. Nobody had asked them about this and they assumed that this was noted in Lily’s records. They did not even think to check the bottle of medicine. The paperwork confirms that the triage nurse had clearly documented this history.
Expert opinion
This is a classic example of a systems error as well as there being some individual culpability. Lily’s management was exemplary except for the failure of all those involved to communicate and register the penicillin allergy. The triage nurse assumed that her partof the notes would be read and that the information would be communicated to others. The ST3 did not read the notes in detail and did not clarify the allergy history herself. Although joint paperwork is generally a positive development, one downside is that doctors do not always take as thorough a history as they would if clerking the patient from scratch. However, a drug and allergies history should always be taken. This should include details of the reaction because there are occasions when a dubious report can be challenged in the safe confines of the hospital, to establish whether the patient is truly allergic. Because of the likelihood that Lily would be discharged after a period of observation, no admission process was completed and no wristband was issued. The latter would have been red instead of white to alert staff to an allergy. Finally, multiple staff were involved, all of whom assumed that someone else had established that Lily was not allergic to penicillin and her parents assumed that the records were already clear from her previous admission.
Inpatient drug charts have a section for allergies that should be checked by ward pharmacists during an admission and when drugs are prescribed to take home, yet numerous national and regional audits have shown that up to 30% remain incomplete. The NHS Patient Safety Federation currently has a work stream entitled ‘No Needless Medication Errors’ and hospital trust comparative data for allergy documentation is published monthly. Few outpatient or ED prescriptions even include this crucial question. Nor do the written FP10 prescriptions used to get medicines from a local chemist. So the risk is multiplied out of hours or when prescriptions are dispensed without being vetted by a pharmacist. Electronic prescribing may help, but even this is only as good as the data entered. ‘Management of Medicines’ is one of the 16 core quality and safety standards of the Care Quality Commission, the independent regulator of health and adult social care services in England, against which providers are judged.
Legal comment
It was clearly negligent to administer penicillin to Lily and she suffered an anaphylactic reaction as a result. The mistake was spotted quickly. Appropriate treatment was provided and she made a full recovery. The hospital and doctors should apologize to the family.
If the parents pursue a claim, then damages should be limited to a few hundred pounds, but the full extent of the damages will depend on how severe the reaction was and how long it lasted.
