3. Mr I complains the Trust) did not diagnose and treat meningitis on 4, 5, and 6 September 2021.
4. Mr I says this delayed his care, resulted in a more painful experience and a poorer quality of life and caused him and his partner distress. It also had a negative effect on him.
5. As an outcome, he wants a compensation payment as the delay in diagnosis affected his recovery.
6. On 4 September 2021, Mr I went to the emergency department (ED) of the Trust. After an examination, the Trust diagnosed him with viral upper respiratory tract infection (an infection of the nasal passages and throat caused by a virus) and discharged him to follow up with his GP.
7. On 5 September 2021, Mr I went back to the ED by ambulance as he was still feeling unwell. After the ED examined him, it discharged him and told him if he remained unwell he should take regular pain relief and ask his GP to look at his symptoms and rash.
8. On the morning of 6 September 2021, Mr I went to see his GP and sent the GP pictures of his rash. The GP diagnosed him with shingles. In answer to a request from Mr I, the GP saw him in a car later that evening. The GP noted Mr I was lying in the car with his eyes closed, alert and answering questions correctly. He complained of neck pain but was able to put his chin to his chest. The GP told him to go to the ED.
9. At the ED, a doctor diagnosed Mr I with shingles and meningitis and admitted him to a ward until his discharge on 9 September 2021.
4 September 2021- diagnosis
13. Mr I complains there was a delay in his receiving diagnosis and treatment for meningitis. The Trust disagrees with this, saying its approach was appropriate and viral illness was a reasonable conclusion.
14. Having looked at the GP records and the ED records from September 2021, we can see a consistent presentation. For our investigation, we are focusing on Mr I's visit to the ED on 4 September. Both sets of records showed that by 4 September, Mr I had been suffering with a headache behind his eyes for four days and was feeling sore and achy. The ED records also say he was suffering with chills and rises in temperature at night, and a sore neck and back.
15. Our adviser confirmed there is no national standard or guidance covering non-specific presentations (symptoms such as headache and muscle aching, which may be caused by many different illnesses, in particular viral illnesses) to the emergency department.
16. The GMC guidelines of 2014, ‘Good medical practice’ (paragraph 15), say doctors must:
· ‘adequately assess the patient’s conditions, taking account of their history (including symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient · promptly provide or arrange suitable advice, investigations, or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs’
17. The Trust’s records show it looked into Mr I’s condition, history and symptoms. The records show Mr I’s NEWS score (which shows the degree of illness) was zero at this point. The doctor noted his lungs were clear, he was lethargic, had aches in his neck and shoulders, chills with a rise in temperature at night, no abdominal pain (pain in his belly), no diarrhoea, and no flank tenderness. Mr I did a urine dip test and blood test, and staff told him to follow up with his GP once he was better to get another urine dip test.
18. We can see the Trust concluded there was ‘no meningism’, which is where symptoms look like meningitis but are not caused by meningitis. We can see the Trust was thinking about this possibility when looking at Mr I's symptoms and did an appropriate assessment.
19. We took advice from our clinical adviser, who noted that, at this appointment, Mr I did not complain of photophobia (discomfort when looking at bright lights) or a rash, which are typical signs of meningitis in line with the BMJ guidelines on viral meningitis. We have seen he had a sore neck and shoulder, however, our adviser explained when looking for meningitis, you would be looking for neck stiffness. The medical records also show that during his examination, Mr I was able to bend his neck so that his chin touched his chest.
20. Therefore, our adviser said the doctor’s working diagnosis of a respiratory infection (which can be a result of a viral illness) can be justified given Mr I’s non-specific symptoms, the lack of symptoms or signs suggesting meningitis and Mr I’s normal vital signs (including a normal temperature).
21. The clinical adviser also noted when a patient goes to the emergency department, it can happen that the symptoms suggesting a serious cause for their problem are not present at that time and only develop after the patient has left the emergency department.
22. Given the above information, we think the Trust’s decision to diagnose Mr I with a respiratory infection and discharge him home was in line with the guidelines set out in ‘General medical practice’.
5 September 2021- diagnosis
23. Mr I complains there was a delay in his receiving diagnosis and treatment for meningitis. The Trust says its approach on this occasion was correct. It says the attending clinician did a full examination. It says they noted a painless itchy rash on the left side, and Mr I had blood tests done. After getting the results, the clinician decided to discharge Mr I home, telling him to return if he remained unwell.
24. The medical records show on 5 September 2021, Mr I called the ambulance service. The ambulance service noted he was complaining of having felt generally unwell for one week, with a frontal headache (for four days in a row), a rash on his left side and back, and that on the day he had been feeling nauseous with one episode of vomiting and upper body, neck and back ache.
25. At 8.51pm, Mr I went to the ED at the Trust and the following tests were carried out: urea (a substance formed by the breakdown of protein in the liver) and electrolytes (salts and minerals found in the blood), liver function test, amylase (a digestive enzyme), C-reactive protein (a protein made by the liver), full blood count. The ED’s working diagnosis was migraine.
26. We can see Mr I was described as having had a headache for five days with sensitivity to noise and light, nausea and vomiting that got better with pain killers, and a painless itchy rash. The results of his neurological exam (exam of his nervous system) were normal, as was his pupillary reflex (the pupil’s response to light), his vital signs, VBG (venous blood gas, a type of blood test), ECG (electrocardiogram, a test for checking the heart's rhythm and electrical activity) and bloods.
27. The ED discharged Mr I home and told him to take good painkillers regularly. His GP should look at his symptoms again and prescribe him sumatriptan (a migraine medication) if needed. The GP should again look at Mr I’s rash and take further action if needed.
28. We can see from the information above that on this occasion, Mr I was bothered by bright light (photophobia) and had a rash on his back and chest. On this occasion, Mr I had different symptoms from the ones he had had before. Our clinical adviser said the doctor’s working diagnosis of a migraine was not reasonable on this occasion when keeping in mind the BMJ guidelines on viral meningitis, which state key diagnostic factors. We think that on this occasion, the Trust failed to identify meningitis.
29. The adviser also noted the national guidance from the Royal College of Emergency Medicine states that a consultant or senior doctor should look at any patient who goes to the emergency department within 72 hours of having gone there with the same problem before discharging them. There is nothing in the clinical records that shows a senior review took place on this occasion.
30. We can see a failing on the Trust’s part here. The Trust told us a locum doctor was on duty in the ED, and that this is not what they would expect. We can see that as a result of the failings here there was a delay in diagnosis and treatment that resulted in distress and worry.
31. A doctor saw Mr I at 2.00am on 6 September. His GP saw him at 11.57am the same day and started him on antiviral treatment. Mr I’s GP referred him to the on-call medical team at 18.38pm, where he had further tests and got intravenous treatment (medicine given directly into a vein through a needle or tube) later that evening. It therefore seems there was a delay of about ten hours between the 2am review (where meningitis should have been the working diagnosis) and the time Mr I started treatment after a further review by his GP. It was a further six hours before Mr I started intravenous treatment.
32. We first looked into whether it is likely this had any impact on Mr I’s condition or prognosis. Mr I says the Trust’s failure to diagnose meningitis delayed his care and caused him to have a more painful experience and a poorer quality of life, as well as distress and a financial impact.
33. We cannot say whether Mr I’s recovery period would have been any different if he had been diagnosed a day earlier. We know Mr I was eventually diagnosed with viral meningitis and shingles. Although we can see there was a failing in diagnosing Mr I during his second visit to the ED, we can see antibiotics were given by his GP.
34. Mr I then had intravenous treatment while he was in hospital, which is what we would expect in more serious cases. We can see when the Trust started treatment, it wrote in its medication plan that Mr I had had medication before being admitted and their plan was to provide the next dose intravenously when it was due.
6 September- diagnosis
35. Mr I complains there was a delay in his receiving appropriate diagnosis and treatment for meningitis. The Trust accepts that it should have identified meningitis during Mr I’s visit to the ED on 5 or 6 September and started treatment sooner.
36. When Mr I went to the emergency department, his GP referred him directly to the on-call medical team, and he was not seen by an emergency department clinician. Our clinical adviser said this was normal practice in the UK, as it avoids emergency doctors unnecessarily reviewing patients who have already been seen by their GPs.
37. Our clinical adviser has confirmed the GP had already started Mr I on the correct antiviral treatment earlier in the day and the medical team continued this treatment. The medical notes for 6 September 2021 state, ‘already taken 800mg Aciclovir (anti-viral medication) will give next dose as IV.’ We therefore believe there was a continuation of treatment.
38. We therefore have found no failings in the Trust’s actions during this admission.
Summary
39. We can see there was a failing on 5 September, but we have no concerns about the treatment on 4 or 6 September. We can see there was a delay in diagnosis. It is difficult for us to say whether earlier intravenous treatment would have helped. We accept this should have happened, but we are unable to know now whether it would have changed the length of Mr I’s recovery or changed the length of time he needed to stay in hospital.
40. It is clear Mr I was already quite unwell by the time he went to hospital on the night from 5 to 6 September. Our adviser said it is rare to get shingles and meningitis at the same time, and Mr I’s recovery time was likely to be longer even without the Trust’s failing. We are therefore unable to say whether having had a diagnosis earlier would have changed his recovery time or his ability to work.
41. We are unable to say whether the failing had a financial impact on Mr I over and above what it would have been simply because of his illnesses. However, we can say that the failing did cause an avoidable longer period of distress and worry that would not have happened if he had been diagnosed in the early hours of 6 September. As stated above, this delay was about ten hours.
42. We looked at what the Trust has already done to acknowledge and put right the impact on Mr I. The Trust has already apologised for the distress its failing caused and given feedback to the agency about the locum doctor. This is what we would expect them to do.
43. We looked into the possibility of a compensation payment, which Mr I also wants, using our scale of injustice. We feel Mr I’s case fits into our understanding of injustices such as annoyance, frustration, worry or inconvenience, typically arising from a single incident of service failure, where the effect is short-term, and where there are no other negative effects or ongoing wider impact. This most closely fits with level one on our scale. We would generally consider an apology to be enough for putting right a level one injustice.
44. We thank Mr I and his partner for telling us about their concerns and hope our statement clearly explains how we dealt with Mr I's complaint.
1. The Parliamentary and Health Service Ombudsman has carefully considered Mr I’s complaint about Hampshire Hospitals NHS Foundation Trust (the Trust). We understand this was a difficult time for Mr I and his partner and we are sorry to hear about their experience.
2. We have found a failing in a ten-hour delay in diagnosing that Mr I had meningitis (an inflammation of the tissues around the brain and spinal cord). We have seen that this caused worry and distress for Mr I and his partner. In considering what has been done to deal with this, we have seen the Trust has apologised for the distress and has given feedback about the delay to the locum doctor’s agency to keep this from happening to anyone else. We do not think any further action is needed to put this right.