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Mother knows best

01 September 2011

Miss T was 17 years old and still at college when she became pregnant with her first child. She gave birth to a healthy baby boy at term, and was discharged the following day, with planned midwifery follow-up at home. At one month old, Miss T became concerned that her infant, baby T, appeared to be having occasional odd movements of his left hand. She contacted her community midwife, who advised her to take the infant straight to the Emergency Department (ED) of her local hospital.

At the ED, baby T was seen by the junior doctor on-call for paediatrics, Dr Y. Miss T told Dr Y that she had noticed a bit of twitching of baby T’s hand. She found it difficult to describe the twitching, and was unsure when it had first come on or how long it had lasted for, but she was sure that the infant had not had any movements like this when in hospital.

Dr Y examined the infant, and recorded a normal examination in the records. He advised a period of observation; Miss T and baby T remained in the observation area of the ED. An hour later, when no unusual episodes had been observed, they were discharged.

At home, Miss T continued to be concerned about her infant. She noticed that the twitching was more frequent, and that baby T did not wake for his 10pm feed as he usually did.

Unable to contact her midwife, she brought baby T back to the ED. Here, the infant was again seen and examined by Dr Y, this time attempting not to wake him since he was sound asleep. He noted the nursing observations of a slightly elevated temperature of 37.8° (route not documented), but that examination was otherwise unremarkable. Dr Y organised some blood tests and arranged for baby T to be brought back to the department’s Rapid Access Clinic in the morning.

Dr Y noted Miss T’s young age and her exhaustion, which he put down to caring for a new infant. He wrote in the record: “over-anxious mum – almost a child herself.”

The following morning, baby T was seen in the Rapid Access Clinic by a registrar, Dr B. She noted that the infant was hot, more sleepy than usual, and had not fed overnight. On examination, baby T was noted to be febrile and listless with a mottled appearance and a high-pitched cry when examined. Occasional brief twitches of the left arm and leg were observed. Dr B made a presumptive diagnosis of bacterial meningitis, arranged a full septic screen, and started baby T on intravenous antibiotics.

Shortly after commencing treatment, baby T’s condition deteriorated, necessitating resuscitation and ventilation. He was transferred to the regional Paediatric Intensive Care Unit where he spent a further two weeks recovering. The bacterial meningitis was confirmed and treated appropriately, but he was left with significant neurological impairment.

Baby T’s mother made a claim against Dr Y. Expert opinion was that the initial symptom of twitching should have prompted a full septic screen, including a lumbar puncture. The decision to discharge the infant after the second presentation to the ED was indefensible. Earlier treatment might have impacted on the outcome. The case was settled for a substantial sum.

Learning points:
  • Babies can be difficult to assess; seek senior advice if you are unsure.
  • Meningitis can present in a number of non-specific ways, including with twitching. Signs of meningitis should be actively looked for in any acutely unwell infant. Any infant presenting with symptoms where bacterial meningitis is a part of the differential diagnosis should have an immediate septic screen. This should include a lumbar puncture unless there are contraindications, such as evidence of raised intracranial pressure. See the NICE guidance on Feverish Illness in Children – Assessment and Initial Management in Children Younger than 5 Years
  • Listening to the parents is always the safest option. If a mother thinks that there is something not right with her baby, she may well be right.
  • If a patient re-presents to the ED shortly after discharge, they need to be re-assessed carefully, preferably involving a more senior or experienced colleague.
  • Patients don’t use textbook language to describe their concerns and may require further exploration; if you don’t fully understand what the patient is saying, let them explain in detail in their language.
  • Always write records with the expectation that patients, relatives or other third parties may read them. Remain professional in all that you write.
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