Abstract
Background
S, a 14-year-old girl at the time, initially attended her GP surgery on 30 November 1998 with a four-day history of headaches, which seemed to worsen in the mornings, together with dizzy spells upon standing. She was also noted to have inflammation of the throat and cervical lymph nodes. Neurological examination was normal.
S returned to the surgery on 16 October 2000 with a two-week history of headaches, which again appeared worse in the mornings, improving towards the early evening. On this occasion, she was seen by Dr C who noted that she had a rare type of migraine, but instigated no further investigations.
On 11 January 2001, S was reviewed by Dr C who noted occasional visual disturbance and dizziness, associated with the persistent headaches. Dr C prescribed Propranolol Hydrochloride 10 mg.
On 19 February 2001, S returned to the surgery after still waking early with the headaches and experiencing dizzy spells. She was seen by Dr R, who considered the possibility of postural hypotension. S explained that she had passed out on three occasions and that the headaches had failed to improve despite the medication. Dr R noted the absence of epilepsy in the family and advised S to see Dr C on her next visit.
On 26 February 2001, S was reviewed by Dr C as planned and reported that her headaches had become less frequent and less severe, although the dizzy spells persisted. She also described a particular dizzy episode the previous week when she had passed out and started nodding her head involuntarily. Dr C considered that this was suggestive of faints, with possibly suffering a fit secondary to fainting. S was to return in four weeks' time for a review and to report any further blackouts or faints.
On 19 March 2001, S was reviewed by Dr C as scheduled and was prescribed Ibuprofen 200 mg as the headaches continued.
S did not seek further medical advice until 11 November 2002, at which stage she was continuing to experience headaches, and attended her GP as a result of a five-day history of pain in her forehead. She was reported as being otherwise well. She had no neck stiffness, although was noted to have swollen tonsils and mild cervical adenopathy. She was also tender over the ethmoid and frontal sinuses. She was prescribed a further course of Ibuprofen 200 mg and advised to return to the GP in the event of deterioration.
S returned on 18 November 2002, her headaches having failed to improve. She advised that analgesia failed to help. It was noted that the optic discs were clear and the headaches were considered to be stress related. She was advised to use a relaxation tape and to return in 10 days for review. It was noted that should there be no improvement, a paediatric referral should be considered.
On 28 November 2002, S returned and stated that the relaxation tape had been of little help. She was advised to take paracetamol as well as her regular dose of brufen and return the following week.
On 2 December 2002, the Claimant (S's mother) telephoned the surgery and reported that S had been unwell over the weekend. She had also experienced an occasional buzzing in her right ear associated with the headaches, together with occasional blurring of vision. S was then referred to the paediatric team at the Royal United Hospital, Bath, noting a four-week history of almost continuous headaches.
On 3 February 2003, S was assessed by a consultant paediatrician. The consultant paediatrician noted that she had actually been troubled with these headaches for the past three years, each episode running for around 3–4 weeks at a time. He noted that she also experienced blurred vision and flashing lights upon moving her head. On examination, the consultant could find no evidence to suggest raised intracranial pressure or any other significant pathology. S was advised to modify her diet and return in six weeks for review.
On 17 March 2003, S was reviewed by a senior SHO to the consultant paediatrician, who noted that she continued to have these headaches despite modifying her diet as advised. On examination, she seemed well and comfortable. Neurological examination confirmed no abnormalities and fundoscopy showed normal discs, and as the modified diet seemed to have had little effect, she was prescribed Pizotifen 1.5 mg nocte. The diagnosis was a migraine and S was to return to be reviewed in 4–6 weeks' time.
On 21 April 2003, S became suddenly unwell. She was admitted to the Royal United Hospital but emergency attempts to resuscitate her failed, and tragically she died.
The postmortem examination on 25 April 2003 concluded the cause of death to have been by way of a haemorrhage into a vascular malformation of the cerebellum.
Claimant's case
A letter of claim was sent to the MDU on behalf of the Defendants on 17 March 2004.
Breach of duty
It was the Claimant's case on breach of duty that S had received negligent treatment. The principal allegations of negligence were that the Defendants had:
failed to investigate properly S's symptoms between October 2000 and December 2002; failed to refer S to the hospital on 19 February 2001 following a history of persistent severe headaches and three episodes of loss of consciousness; failed to refer S to a paediatrician on 26 February 2001 following a fourth consultation and at least four episodes of passing out and two possible fits; failed to review S and again refer her on 19 March 2001 and failure to request a computerized tomography (CT) scan or other investigation within a reasonable time.
Causation
It was the Claimant's case on causation that as a result of the above negligence S was deprived of hospital treatment that would have led to the diagnosis of her vascular malformation and would have resulted in treatment, which would have prevented a haemorrhage occurring. It is likely that earlier prognosis and treatment would have prevented S's death.
Defendant's case
In the Defendants' letters of response dated 9 July 2004, the MDU stated that they were not prepared to admit there had been a breach of duty, and indicated that they wished to obtain their own expert evidence. In a letter dated 22 March 2005, the Defendants argued that the treatment and diagnosis received by S was not unreasonable and that given there was no change in her signs and symptoms, there was no reason for a referral to the hospital or to a paediatrician.
The Defendants admitted that many paediatricians would have requested a CT scan in March 2002, but stated that in the ‘absence of signs of raised intracranial pressure, this would not have been arranged urgently and in most (if not all centres) this would not have been performed prior to her sad death’.
Claimant's expert opinion
Dr Nicholas Kearsley—GP and expert witness
Dr Kearsley identified two incidents which, in his opinion, constituted a level of care which fell below an acceptable and reasonable standard. He considered that a referral should have been made on 19 February 2001 when S presented to Dr R with a history of three episodes of loss of consciousness, together with a history of frequent and persistent headaches.
A further consultation on 26 February 2001 following a similar episode was also considered by Dr Kearsley to amount to negligence.
Dr Ben Lloyd—Consultant Paediatrician
Dr Lloyd was of the view that had S been referred to the hospital when she should have been by the GP that she would, after some investigation, have been referred to a neurosurgeon.
Mr Peter Richards—Consultant Neurosurgeon
Mr Richards expressed the opinion that the lesion would have shown as an abnormality if a CT scan had been taken. The abnormal CT scan would have led to a referral to a neurosurgeon and any neurosurgeon would have treated the referral with urgency. The most probable treatment of choice would have been embolization of anterial feeders and protection against haemorrhage would thereby have been achieved.
Defendants' expert opinion
The Defendants' experts could see no reason for an earlier referral and considered that the diagnosis of postural hypotension caused by propranolol was not unreasonable. Furthermore, they did not consider that the delay between the consultation on the 18 November 2002 and the referral letter written on 9 December was a significant delay.
The Defendants' experts concluded that management was reasonable and although it was admitted that most paediatricians would have requested a CT scan on 17 March 2002, they argued that in the absence of raised intracranial pressure this would not have been arranged urgently and it was not likely to have been performed prior to S's death.
Settlement
On 24 April 2006, the Defendant made a Part 36 Offer in full and final settlement of the claim in the sum of £10,000 plus reasonable funeral expenses. This offer was subsequently accepted by the Claimant on 14 June 2006. The funeral expenses being £1866.15 and interest of £352.17, the total offer was accepted as £12,218.32. Dr C and Dr R did provide a joint personal letter of apology to S's family as requested by the Claimant.