Failure to diagnose meningitis - a GP's duty

Posted by Malcolm Johnson on

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In the case of Coakley v Rose [2014] EWHC 1790 (QB), His Honour Judge Oliver-Jones QC found the Defendant GP, in breach of duty, for failing to diagnose a 42 year old woman with bacterial meningitis. 

On the 29th December 2007, whilst on a short visit with her husband to France the Claimant began to feel unwell with what, to her, felt like the first signs of flu. She came home and on the 7th January 2008 she felt much worse. She noticed she had a rash on the palm of her left hand, across both her lower arms and across her midriff. Her right arm was spotty and dark pink. The rash was spidering and the spidery parts were purple with gaps between the dots. The Claimant telephoned the surgery and arranged an appointment to see the Defendant at 5.20 p.m. The GP diagnosed her as suffering from respiratory infection and sent her home. However around five and a half hours later, the Claimant collapsed and an ambulance was called.  1.2 gm of Benzylpenicillin was administered intravenously and she was admitted to hospital.

It was this, the first dose of antibiotic, that the Claimant alleged should have been given by the Defendant some 5½ hours earlier when she saw the GP.

As a result of the infection she suffered total loss of her sight and substantial loss of hearing, with other significant neurological damage. She claimed that but for the negligence of her GP in failing to recognise or suspect, and consequently failing to treat, the infection, she would not have suffered the injurious sequelae. Further or in the alternative, she claimed that the Defendant's negligence materially contributed to the injury she sustained as a result of the bacterial infection.

Oliver-Jones J heard evidence from eleven expert witnesses representing six medical disciplines. There were substantial disputes of fact, as well as differences of medical opinion,

In relation to breach of duty, Oliver Jones J found:-

  • the Claimant presented to the Defendant with signs and symptoms of bacterial meningitis, including purpuric and petechial rashes on (at least) her lower arms, left hand and midriff, a severe 'pressure headache' and neck stiffness, which were characteristic and diagnostic of the bacterial (meningococcal) meningitis from which she was in fact suffering
  •  the Defendant failed to observe and examine the rashes thoroughly or more than superficially and mistakenly identified the rashes she did observe as being urticarial when they were neither raised nor itchy
  • the Defendant failed to examine the Claimant properly and, in particular, failed to examine the Claimant's neck for stiffness and to heed the Claimant's query about meningitis;
  • the Defendant failed to suspect, diagnose or exclude, and consequently failed to treat the Claimant for, bacterial meningitis when she should have done and when a reasonably competent GP would have done so

In relation to causation, the question that should be asked was whether the Claimant had established, on the balance of probabilities, that 'but for' the lack of penicillin at 5.30 p.m and hospital admission immediately thereafter, she would not have suffered blindness and other injury. Alternatively, relying upon Bailey v Ministry of Defence [2008] EWCA Civ 882 the Claimant further argued that she should succeed on causation if she could show that the Defendant's breach of duty materially contributed to her injuries, in other words, that but for the negligence she would have had a materially better outcome. Oliver Jones J also referred to the case of Pringle v Nestor Prime [2014] EWHC 1308 (QB) in which the court said that had it not found for the Claimant on the 'but for' test that it would have accepted her alternative argument based upon Bailey. This case involved very similar facts to the instant case.

Oliver Jones J said that there was no doubt in this case that but for the fact that the Claimant suffered bacterial meningitis she would not have suffered blindness, deafness and other neurological damage. There was no suggestion of any coincidental medical cause of any of these injuries. There was also no doubt that meningococcal meningitis was a treatable disease and that provided treatment is commenced early enough antimicrobial therapy was, in the case of an individual patient, more likely than not to be effective treatment whereby significant injury would be avoided. Consequently the “but for” test was satisfied. However Oliver Jones J said that that this was a case where Bailey would have allowed the Claimant to have succeeded on the basis that the delay in treatment made a material contribution to that damage. Thus the Claimant succeeded on the issues of liability in respect of both breach of duty and causation.

Contrast this case with the decision of the Court of Appeal in the case of Doy v Gunn [2013] EWCA Civ 547 where the Claimant was born prematurely in January 2002. He remained in hospital until 18 February. On 21 March he was admitted to hospital where he was found to have acute bacterial meningitis due to Group B streptococcus, and was treated with antibiotics. The meningitis left him with severe problems.

Proceedings were brought against a general practitioner who saw him on the evening of 19 March. She diagnosed colic and did not refer him to hospital. In essence, the allegation against the GP was that she ought to have referred him and that, if she had done so, antibiotics would have been prescribed immediately which would have had the effect of preventing the development of meningitis. The trial judge held that, if the Claimant had been referred to hospital on 19 March, he would have been prescribed antibiotics and this would have prevented the development of bacterial meningitis.

However, the claim failed because he went on to hold that the GP had not been negligent when she decided against a hospital referral. There was a dispute as to precisely what the GP had found on examination, and this was hampered by the fact that these were events that had occurred a decade before trial. The GP gave evidence that she had made a physical examination, and that she had made findings of abdominal softness, absence of a rash and ear infection. The trial judge accepted that evidence, even though it was  common ground that the note of the consultation was inadequate, and the Court of Appeal upheld that finding. This form of meningitis was very rare but the Claimant’s history of symptoms as presented to the GP was very common.  

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About the Author

Malcolm is an Senior Associate in our London office, with nearly twenty years' experience.

Malcolm Johnson
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