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01 May 2010

M was a previously healthy five-year-old girl who had been vomiting for two days. She was not keeping any fluids down, had stopped drinking much at all, and was not playing and chatting as usual. Her parents became concerned by the evening when symptoms persisted. They took her to the OOH GP at 11pm and expressed their concerns. They explained that M had “not been drinking, had been sick several times in the last two days with no diarrhoea, and had been much quieter than usual”.

Dr F, the OOH GP, asked how many times she had vomited and whether she had passed urine that day. Dr F examined her but only made brief notes, stating that dhe did not look unwell and that she was not dehydrated. There was no comment on her temperature or other observations. Dr F told her parents that the vomiting was due to a viral stomach upset and advised giving Dioralyte. Dr F did not advise the parents to seek further medical advice should she deteriorate or not improve.

M’s parents took her home that evening, feeling reassured by what Dr F had said. The next morning, however, they became very worried as M was confused and sleepy. They rushed her in to see her usual GP who noted a purpuric rash and a temperature of 39.4. She was also noted to be considerably dehydrated with a dry mouth, cool extremities and a capillary refill time of four seconds. An ambulance was called immediately and M was taken to hospital where a diagnosis of meningitis was confirmed and intravenous antibiotics started.

Unfortunately, M suffered long-term disabilities as a result, including profound deafness. Her parents were very upset and felt that Dr F should not have reassured them when he first saw M. They felt angry because they wished that they had been told what to look out for and made a claim against Dr F.

Experts found that the management of M’s case had been negligent, even though they agreed that the early signs of meningitis can be vague and non-specific, rendering an early diagnosis difficult. They thought Dr F’s management was negligent on two counts. Firstly, that Dr F’s history and examination concentrated only on whether M was dehydrated, rather than trying to elicit the cause of vomiting. Dr F’s notes did not include a record of her temperature, an examination of her abdomen, or the presence or absence of a rash, neck stiffness or photophobia that could have helped to elucidate the cause of vomiting.

Secondly, Dr F gave no “safety-netting” advice to the parents. They were not told to seek further medical advice should she deteriorate, or given signs to watch out for that should result in urgent reassessment.

Learning points

  • When assessing a vomiting child, it is essential to make a differential diagnosis, as many serious clinical conditions can present in this way. Document that the most serious possibilities have been considered and excluded for the time being. Assessing dehydration is only part of what needs doing and documenting in the consultation.
  • Take the time to explain to parents what symptoms and signs to look out for that could point to a serious condition and should trigger urgent re-assessment, and document this discussion. Explain clearly, in a way they can understand.