Membership information +44 113 241 0727
Medicolegal advice +44 113 243 6436

A rash decision?

01 November 2005

Mrs R, a 45-year-old lecturer, became unwell with high fever and vomiting, taking to her bed. Her son rang Mrs R’s GP surgery to request a home visit. She was seen by Dr T in the early evening. Dr T noted a history of fever, shivering, vomiting and generalised aches and pains.

Mrs R’s symptoms had settled somewhat by the time of Dr T’s visit and she was able to get out of bed. Mrs R had a rash on her anterior thighs. Dr T documented that the rash was pale pink and macular. Her clinical impression was of a viral illness, possibly flu, and she advised bed rest, fluids and paracetamol. Dr T advised Mrs R and her son to seek further medical advice if her symptoms worsened.

Two and a half hours later Mrs R seemed much worse. She was unable to keep any fluids down and no longer ambulant. Her son was very concerned and he rang the out-of-hours GP co-operative now covering for Dr T’s patients. He explained that his mother had been seen that day, but appeared to be much weaker, severely aching with a very high temperature and recurrent vomiting. The call was taken by Dr F who advised giving ice cubes for hydration and contacting the GP surgery in the morning for alternative analgesia, if the aches and pains had not settled.

Mrs R was desperately ill by the next morning and her son took her to the emergency department of the nearest hospital. Mrs R was agitated, confused, had neck stiffness and photophobia and a widespread non-blanching purpuric rash over both her lower limbs.

She was treated as a suspected case of meningococcal meningitis and septicaemia. The diagnosis was later confirmed on blood culture. Mrs R was treated with high-dose intravenous antibiotics in the ITU and made a full recovery, but was unfortunately left profoundly deaf.

Mrs R sued Dr T alleging that her treatment had been negligent. She alleged that Dr F had made an insufficient assessment, resulting in the deafness.

Expert opinion

We asked a GP expert to examine the transcript of the phone call between Mrs R’s son and Dr F. In the context of a patient with fever, vomiting and generalised aches, visited that day by a GP, with a reported significant worsening of her condition, the expert felt that ‘the appropriate thing for Dr F to have done would have been to make arrangements for either Dr F or a colleague to visit the patient and reassess them’.

Regarding Dr T’s initial assessment, the GP expert felt that her actions were defensible and that Mrs R’s presentation was not atypical for flu. The rash, as it had been documented by Dr T, was not thought to be typical of meningococcal disease. An expert in infectious diseases concurred, stating that although in retrospect it was clearly an early meningococcal rash, ‘the macular rash described by Dr T could also have indicated a common viral illness’.

The same expert advised that had Mrs R been assessed and referred when her son had telephoned Dr F, she would have made a more rapid recovery from her illness and, although some degree of hearing loss was probably inevitable, she would probably have retained about 50% of her auditory function.

We settled the case for a sum equivalent to £60,000 (US$105,000) plus costs.

Learning points

  • Telephone assessment – You must put yourself in a position to accurately and objectively assess a patient and this is more easily done face-to-face rather than on the end of a phone line. Telephone assessment is increasingly being used by healthcare professionals to assess or triage patients with acute illness. Research has shown it is a very difficult art to perfect, even with the benefit of experience. Where possible, it should be done according to an evidence-based protocol, erring on the side of caution. Unfortunately, there is little evidence about how this can be done safely. A patient’s condition can change rapidly and this must always be borne in mind. The fact that an earlier assessment gave no cause for concern does not mean that reassessment is not necessary.
  • Non-specific rashes and meningococci – The classical non-blanching purpuric rash of meningococcal disease is often a late and ominous sign. It is not the only skin sign of meningococcal disease, as this case shows. Maculopapular rashes due to vasculitis also occur, as well as bruising and septic embolic lesions.