Baby O, the son of a European mother and North African father, was born at term in the early 1990s and had his first vaccinations at three months old; the health visitor left the section dealing with TB and BCG tests blank on the vaccination card.
A month later, Baby O had his third triple and polio and first Hib injection. The health visitor noted that the baby was going to North Africa for two months, but did not comply with accepted practice by administering a BCG vaccination.
Following the visit abroad, Mrs O brought her now seven-month-old son to see their GP, Dr S; he noted the boy’s extended family’s smoking in the home and recorded Baby O’s scattered coarse transmitted sounds and asthmatic tendencies. He prescribed a course of amoxicillin and a salbutamol inhaler.
Three weeks later, Dr S noted that Mrs O felt the salbutamol had helped her son, so continued the prescription. However, he also wrote to the local housing authority to ask for Baby O’s family to be rehoused away from the smoking, which exacerbated his ‘tendency to asthma’.
At nine months old, Baby O was seen by an out-of-hours GP, Dr W, suffering from vomiting, high temperature and listlessness. The next day, he was brought to see Dr S, as he was still vomiting. Dr S noted coarse transmitted sound at the lung bases. He diagnosed ‘gastric and chest infection’ and prescribed amoxicillin.
Two days later, Baby O was brought to see Dr S again, having vomited three times in the past 24 hours. Dr S made a diagnosis of ‘gastro’ and prescribed Dioralyte. He noted that the boy had recently undergone chest and abdominal x-rays while abroad; he did not repeat these investigations.
That evening, Mrs O became particularly concerned about her son’s projectile vomiting, so she took him to A&E. The SHO, Dr K, noted that Baby O was apyrexial, not dehydrated and that his general condition was fair. He recommended clear fluids for the next two days, Dioralyte and to finish the amoxicillin course. He also noted, ‘nature of emergency situation – seen your GP three times this week’.
Mrs O was reassured by this consultation, so it was five days later when she brought Baby O back to her GP; he was still vomiting, had been staring blankly and was not moving his right arm. He was admitted to hospital, where the consultant paediatrician found that he had a right-sided flaccid paralysis and a blurred right disc margin on fundoscopy.
Baby O was referred to the local neurological surgical centre and treated for a cavitating left anterior cerebral lesion and hydrocephalus due to tuberculosis. He was left with limited motor activity and unintelligible speech.
The case against the general practice comprised:
- Their failure to deliver BCG in the neonatal period when Baby O was at increased risk of contracting TB.
- Their failure to administer a BCG vaccination knowing that Baby O was to go to North Africa.
- Their failure to refer to hospital on Baby O’s third attendance within four days.
Delayed diagnosis – Tuberculous meningitis is tricky to diagnose, and Baby O’s GPs would not be criticised for failing to make such a diagnosis on history and examination alone, especially in the earlier stages when the symptoms are non-specific.
However, when Baby O’s parents returned for the third time in four days, Dr S’s suspicions should have been raised. He knew that the baby had spent time in North Africa, but he did not examine for neck stiffness or for an abnormal fontanelle; nor did he consider alternative explanations for the patient’s four days of continuous vomiting with constipation and irritability without fever. This clinical picture would not be suggestive of gastroenteritis; further help should have been sought at this point. Expert opinion was that the majority of GPs would have arranged for paediatric advice within 48 hours.
Vaccination – Baby O did not receive BCG even though he was in a high-risk group. This was a failure by the hospital where he was delivered, by his health visitor and by the GP. Dr S missed a further opportunity to administer BCG prior to Baby O’s visit to North Africa.
Current recommendations for BCG vaccination in the UK include:
- infants whose parents or grandparents were born in a country with a TB incidence of 40/100,000 or higher;
- all infants living in areas where the incidence of TB is 40/100,000 or greater;
- previously unvaccinated new immigrants from high prevalence countries for TB; and
- children who would otherwise have been offered BCG through the schools’ programme will be screened for risks factors, tested and vaccinated as appropriate. www.gov.uk/government/organisations/department-of-health