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The Clinical Communiqué is an electronic publication containing narrative case reports about lessons learned from Coroners’ investigations into preventable deaths in acute hospital and community settings. The Clinical Communiqué is written by clinicians, for clinicians. The Clinical Communiqué was first published in 2003.
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We go to work each day and strive to do our best and care for our patients. Most of the time, we succeed, however, sometimes we don’t and the systems fail us and our patients. The Victorian Institute of Forensic Medicine has recently published a poignant article including coroner findings which is enclosed  and highlights the tragic results of poor communication.

Case Number: 24/2016 SA Case Précis Author: Dr. Raymun Ghumman BA, BSc, GCertIntl&CommDev, MBBS, DCH, FRACGP

CLINICAL SUMMARY

BK was a previously well 10 year old girl with a past history of a tonsillectomy. One afternoon, BK became unwell and went to bed early. The following day she stayed in bed with a fever, vomiting, headache and a sore throat for which her mother gave her paracetamol. The next day, BK’s mother took her to the local general practitioners’ (GP) clinic where she was diagnosed with a viral infection.

A script for antibiotics was also provided, which BK’s mother was instructed to commence if she felt them necessary. The script was filled immediately. Over the course of the day, BK did not eat or drink, and reported an unremitting sore throat. Her mother decided to take her to a major metropolitan hospital, some distance from their home. There she was assessed by a paediatric registrar, and reviewed by a paediatric emergency medicine consultant. A number of painful lesions were observed on the back of her throat.

The lesions were swabbed and tested for respiratory viral PCR, general microbiology, and Bordetella PCR. Although BK was deemed well enough to go home, a period of observation in hospital was also offered. BK’s mother chose to return home with her. At discharge, BK’s mother was advised to return to the hospital or see their GP if BK became worse. BK continued to experience throat pain and malaise. The day after the hospital visit, BK’s mother took her to the local hospital where she was seen by a GP, Dr S, who noted her temperature was 38.8 degrees Celsius, pulse rate was 115 beats per minute (bpm), and oxygen saturations were 94% on room air. Dr S also noted multiple small ulcers at the back of her throat and diagnosed a viral infection, most likely glandular fever.Dr S recommended a course of prednisolone (a corticosteroid) to relieve the sore throat, and requested that BK return for a review the next day.

The following day, Dr S deemed BK to be marginally better, her temperature was 37.6 degrees Celsius, pulse rate 95 bpm, and oxygen saturations 98% on room air. Dr S advised BK’s mother to continue with the medications and fluids. BK’s mother did not think that BK had improved though, as she was still listless and not interested in eating or drinking. Dr H called BK’s mother that afternoon saying that the blood results were unusual and that he would seek further advice from the laboratory, which he did in a discussion with Dr M, a chemical pathologist.

Five days after BK first became unwell, her mother remained concerned and arranged for BK to see her parent’s GP, Dr H. BK required support to walk into the clinic for her appointment. Dr H noted that the throat swab results were negative, and diagnosed her with possible glandular fever for which urgent blood tests were taken. She was administered a dose of intramuscular ceftriaxone (an antibiotic) and sent home.

Dr H called BK’s mother that afternoon saying that the blood results were unusual and that he would seek further advice from the laboratory, which he did in a discussion with Dr M, a chemical pathologist. The next morning Dr H called to check on BK’s progress. BK’s mother called him back after the initial conversation, reporting that BK had developed the urge to urinate but was unable to, and she seemed to be getting worse. Dr H told BK’s mother to take her daughter to hospital immediately.

On arriving at the hospital, BK collapsed outside the emergency department and had a seizure. A code blue was called. BK was admitted to the Paediatric Intensive Care Unit with multi-organ failure and was intubated, ventilated and dialysed. Despite maximal therapies she died in the early hours of the following morning, a week after she first became unwell.

PATHOLOGY

An autopsy was performed and the cause of death given as multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection.

INVESTIGATION

At inquest, the coroner heard from BK’s mother and the doctors involved in BK’s care. An expert opinion was provided by a microbiology and infectious disease specialist. The expert witness explained to the court that the transaminase levels in the liver function tests were markedly elevated (AST ~ 5300 U/L, ALT ~ 4000 U/L), and close to 200 times and 100 times the upper normal limit in a child respectively. BK’s mother stated that she had felt reassured by the doctors that she could take BK home, but would have stayed if they had communicated to her that she should. She explained that she did not return to the major hospital with BK because she did not feel that BK was getting worse, as per the instructions, but instead she was just not getting better.

She believed that the local hospital would direct them back to the major hospital if needed, which would give them the authority to justify their return. Similarly, BK’s mother described how although she did not agree with Dr S that BK was a little better on review, she wanted to believe it was true and therefore accepted the plan to return home and continue with the prescribed treatment. Dr H and Dr M gave conflicting accounts at inquest as to the nature of the conversation between them about the blood test results. Dr M recalled indicating that BK needed intravenous fluids for rehydration. Dr H could not recall such words, and instead had been focussed on whether the results were consistent with glandular fever. The expert witness explained to the court that the transaminase levels in the liver function tests were markedly elevated (AST ~ 5300 U/L, ALT ~ 4000 U/L), and close to 200 times and 100 times the upper normal limit in a child respectively.

The expert witness stated that regardless of the nature of the conversation, given the degree of abnormality on the blood tests, “…it was inconceivable that [BK] was not immediately referred…” Nevertheless, it was his opinion that even if BK had been referred to the major metropolitan hospital as soon as the results were known “…it would have been too late to avoid her death”. The expert witness suggested that had BK stayed in hospital initially and had blood tests taken at the time, it was possible that an evolving liver dysfunction may have been identified.

CORONER’S FINDINGS

The coroner observed that there was a lack of continuity of care for BK over the course of her illness in the week preceding her death. The coroner considered whether the outcome would have changed had BK represented at the major metropolitan hospital instead of the local hospital. If this had occurred, it may have permitted a better comparison of the progression of her illness or at least precipitated a degree of caution given the re-presentation within 24 hours. It is critical that patients and their carers understand in what circumstances they should seek review even if only for non-specific concern.
The coroner felt it pertinent to consider how best to encourage parents of sick children and their treating medical practitioners to make every effort to maintain continuity of care. He recommended that the major metropolitan hospital undertake a campaign to educate parents about the importance of continuity of care. As such, parents should not hesitate to attend hospital for re-assessment for any concern.

AUTHOR’S COMMENTS

This case highlights the importance of continuity of care, which is not widely appreciated in the community. It also demonstrates the significance of clear communication: between clinicians; clinicians and patients; and clinicians and the patients’ carers. Doctors in outpatient or ambulatory care settings must make an assessment based on one point of contact in time. As such, it is critical that patients and their carers understand in what circumstances they should seek review even if only for non-specific concern. Ideally, re-assessment should be with the clinician who performed the initial assessment or at least at the same service so that disease progression and its complications may be appreciated, as well as to ensure prompt follow-up of results

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