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Difficulty getting through

01 September 2009

Z, a five-year-old girl, had been born prematurely and developed hydrocephalus following intraventricular haemorrhages that occurred in the neonatal period. A ventriculo-peritoneal shunt had been fitted to relieve the hydrocephalus. She had developed well and could walk and play with her siblings. Over the previous two years the shunt had malfunctioned three times and had needed revision and replacement. Each of these episodes had been linked with viral infections.

Z’s mother had become concerned, because Z had vomited and felt very hot to touch over the last 24 hours. She rang the surgery and spoke to Dr X, a GP registrar. Dr X took a history over the telephone and diagnosed a “viral illness”. The mother assumed Dr X would have seen Z’s records and be aware of her underlying condition so did not mention the hydrocephalus or the shunt during the telephone consultation. Dr X did not ask about Z’s past medical history. He advised regular paracetamol and fluids.

Z was no better the following day. She was vomiting more frequently and was unusually quiet. She did not want to play and was not interested in eating or drinking. Her mother was worried that her shunt may be malfunctioning again and so she rang the surgery to speak to a doctor. A receptionist dealt with the call. She disregarded Z’s mother’s concerns and told her that “she had already spoken with one of the doctors yesterday”, adding that all the clinics were full for the next five days.

Z’s mother felt powerless but tried to carry on with Dr X’s advice giving paracetemol and fluids. Later that day, Z collapsed and was admitted to hospital, where she suffered a cardiac arrest and the ventriculo-peritoneal shunt was found to be malfunctioning. Z recovered but was left with long-term brain damage and was unable to function in the same way as she used to. A claim was made against the surgery.

Learning points

  • Exercising clinical judgment based on a telephone consultation can be challenging, but even more so with children. Taking a good past medical history is a crucial part of any telephone consultation, especially if the patient’s records are not available.
  • Parental concerns are a good indicator of something being wrong and should be taken seriously.
  • Non-clinical staff should not become a barrier between patients and doctors. Clear protocols should be applied, setting out what is expected of non-clinical staff in such situations.
  • Ensure that you are employing safety-netting procedures. In this case there was an omission to tell the mother under what circumstances she should have contacted the practice.