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A rash oversight

01 May 2013

Mrs B was a housewife with a four-year-old son. She had been trying to have a second child for some time and eventually conceived. She rang Dr L, senior partner at her practice, to inform him of her positive pregnancy test.

Her son developed chickenpox and seemed “under the weather” so Mrs B phoned her surgery to make an appointment with his GP. While she was talking to the receptionist she asked if she was at any risk from chickenpox since she was eight weeks pregnant. The receptionist tried to be reassuring and told Mrs B that there was no risk from chickenpox and that only German measles or rubella would cause concern.

Mrs B’s husband took their son to the appointment with GP Dr Y the next day. Dr Y confirmed the diagnosis of chickenpox by inspecting his widespread vesicles. He had noted that examination of his ears, nose and throat had been acceptable and that his chest was “fine”. His management notes were very minimal and just stated “advice given”.

On a separate occasion, Mrs B visited Dr Y to arrange antenatal care. She did not mention her son’s chickenpox because she had felt reassured by the advice he had given her husband when he had attended with their son. Dr Y made no notes of this consultation although he arranged a dating ultrasound scan and an appointment at the antenatal clinic.

Mrs B developed the same spots as her son and immediately panicked about her pregnancy. She became anxious that the baby could be harmed so rang her surgery to make an appointment with her GP. The receptionist informed her that only emergency appointments were available so she could not get an appointment that day. She also told Mrs B that “nothing could really be done for chickenpox”. Mrs B was still anxious so the receptionist agreed to put her through to the practice nurse. The nurse also tried to reassure her and reiterated the receptionist’s advice.

Mrs B, who had had two miscarriages in the past, still felt very anxious about her pregnancy. She felt upset and rang her husband at work. He rang the surgery and demanded that his wife should have an appointment with a GP that day. An appointment was eventually made with Dr L who made no notes of the consultation. Mrs B stated that Dr L said there was “no need to worry about any risks to her pregnancy with respect to her chickenpox”.

Mrs B went on to have a normal dating and 20 week scan. Her chickenpox was never discussed in her antenatal appointments. She had a normal delivery at term. Her baby, CB, was 4.54kg and breast fed well.

When CB was three months old, the health visitor noticed a squint and a referral was made to a paediatrician. At five months old it became evident that CB had an abnormal posture. Mrs B’s chickenpox at eight weeks gestation was noted by the paediatricians and congenital varicella syndrome (CVS) was diagnosed. CB had severe visual impairment, asymmetrical 4 limb motor disorder, scoliosis and learning difficulties.

Mrs B was completely devastated that her chickenpox had not been managed while she was pregnant and she made a claim against her GP, Dr L.

The opinion of a GP expert was sought. He thought the standard of care was indefensible because the receptionists had provided clinical advice without discussing it with a doctor first. He felt that Mrs B should have been able to speak to a doctor. Had a doctor seen Mrs B when she had the chickenpox contact, he stated that varicella antibody testing should have been arranged.

If varicella IgG had been negative then Mrs B should have been offered varicella zoster immune globulin (VZIG). It was his opinion that a “reasonable GP” would have concluded that there was no benefit in giving VZIG when Mrs B was seen with the rash. The claim was settled for a high amount. Dr L was criticised in his capacity as senior partner in the practice for allowing administrative and nursing staff to provide negligent medical advice.

It was also agreed that he had personally provided negligent advice to Mrs B concerning the risks to her and her unborn baby resulting from exposure to the varicella virus. He had also failed to test Mrs B for immunity to the varicella virus and administer VZIG once the results were known.

Learning points

  • Clear and accurate note-keeping is an important aspect of providing good clinical care. It is also vital when trying to defend a case. Dr Y’s records were very minimal and some consultation notes were completely missing. The case was consequently impossible to defend.
  • Reception staff should not provide medical advice. It could be easy for them to act outside their competence so clear roles and responsibilities should be set.
  • If a pregnant woman consults you worried about a chickenpox contact:
    • Define “contact”. Significant contact usually means face to face contact in the same room for 15 minutes or more.
    • Ask the woman if she has had chickenpox. If she has a negative history or is unsure, test for varicella zoster IgG urgently.
    • Consider her susceptible if IgG is not detected.
    • Post-exposure prophylaxis with VZIG can be given if susceptible within ten days of the exposure and may attenuate the disease in pregnant women.
    • If the woman is antibody negative with significant contact or if she has the vesicular rash then expert advice should be sought.