McDonnell v Holwerda

When assessing a young child with a high temperature and possible meningococcal infection, a general practitioner must assess the aggregate of the presenting symptoms and signs together with the child’s general condition. Referral should occur on the basis of a properly formed and carefully assessed suspicion, without waiting for fully developed diagnostic signs. A cursory examination, or reliance on one apparently reassuring feature such as a blanching rash or a temporary fall in temperature, is insufficient where other features materially increase the risk. The assessment must include appropriate inquiries and a sufficiently thorough examination, including investigation of irritability, sensitivity to light, vomiting and the whole-body distribution of any rash.

The claimant, aged four and a half, developed meningococcal septicaemia on Christmas Day 1997. The defendant, his general practitioner, visited him twice. On the first visit he had a high temperature, vomiting, headache and general aching, but the court found that the examination and decision not to refer were reasonable. On the second visit he had deteriorated, with repeated vomiting, reduced alertness, sensitivity to light, sensitivity to touch and a rash. The claim concerned whether the defendant’s assessment and examination on that second visit fell below the standard of a reasonably competent general practitioner and whether earlier referral would have led to earlier treatment.

1. First visit. The examination on the first occasion was not below the standard expected of a reasonably competent general practitioner. The diagnosis of gastroenteritis was reasonable, and advice to monitor the child for specified developments provided an appropriate short-term safety net.
2. Second visit. The defendant should have undertaken a more searching assessment. She should have asked about sensitivity to light, the frequency of vomiting, the child’s general condition and sensitivity to touch. She should have examined the limbs, neck and abdomen and fully undressed the child to examine the whole body for a rash.
3. A blanching portion of a rash did not justify excluding meningococcal infection. A rash may have different characteristics in different areas. Similarly, the absence of flinching when the light was turned on did not reliably exclude significant sensitivity to light. The defendant’s reliance on these limited observations was too dismissive and insufficiently investigative.
4. The proper approach was not to refer every child with a high temperature automatically, nor to wait for specific signs to develop. The general practitioner had to consider the totality of the symptoms and signs, the child’s general condition and the extent and depth of the resulting suspicion. The speed with which meningococcal infection can progress heightened the significance of the risk.
5. On the accepted evidence, the second assessment was inadequate and the defendant should have referred the claimant to hospital. Treatment would probably have commenced between 22.30 and 23.00. The court therefore found liability on the second visit and adjourned consequential orders and directions.