Setting the Scene
The patient, a minor, had a history of a febrile illness with upper torso pain with shooting pains on inhalation. They felt short of breath. The patient was seen in ED, had a normal chest x-ray and was discharged. Their symptoms progressed and they re-presented with fever, tachycardia and tachypnoea. They were also found to have hypertension, blood and protein in the urine, high CRP (in excess of 150). The patient was discharged without treatment.
The patient reattended shortly after, antibiotics were given for a possible urine infection (although the microscopy was negative) but no other investigations undertaken. A chest x-ray was obtained some hours after admission. This had a widened mediastiunum, but there was no Senior input and no further investigations.
The patient then collapsed and died on the ward. The missed cause of death being mediastinitis secondary to staph aureus infection.
The main learning points from this review stem from the following events:
Abnormal physiology pointing toward a serious pathology not being investigated;
Unlikely diagnoses (given the clinical picture) were not discarded timeously;
Grossly abnormal blood results were not investigated and acted upon;
- Senior input is mandatory in all cases with grossly abnormal blood tests /when the diagnosis is not obvious/ the patient is unstable; all of which did not occur.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
1. Indications of a significant pathology must be investigated
Care should be taken if a diagnosis is made which is unusual in that age group, such as UTI in a teenager.
Patients with clinical features of infection or high inflammatory markers should be admitted and then further investigations undertaken (such as blood cultures, CT, USS, ECHO chest x-ray) to try and identify the source of the infection.
Immediate broad-spectrum antibiotics should also be instigated as early as possible to try and combat any underlying infection that has not yet been identified, if there are very high inflammatory markers or signs of sepsis.
2. Grossly abnormal clinical features require a response
In a patient with grossly abnormal clinical features or laboratory tests regardless of the suspected diagnosis, a response to these findings must be implemented.
If tests are undertaken and return abnormal results, there is no sense in not actioning these.
In this instance broad spectrum antibiotics were required to try and cover any underlying infection, and not doing this, directly contributed to the patient’s death.
3. Unlikely clinical diagnoses should be excluded timeously
If a diagnosis is not supported by the accompanying blood tests or radiology, then further investigations must be undertaken to get to the correct diagnosis.
Failing to appreciate this and continuing to treat the wrong diagnoses, causes delays to commencement of the correct treatment
Unlikely diagnoses in light of the clinical features should be discarded timeously to allow for the correct diagnosis to be identified.
4. Where a diagnosis is proving difficult to make Senior input is mandatory
When a minor is presenting with serious symptoms, alongside a long history of illness and no diagnosis has been reached, Senior input is mandatory.
A Senior clinician is more likely to be able to review the case as a whole, direct investigations and ask for second opinions from other teams, as required. Decisions as to commencement of empiric antibiotics often need to be made by a senior clinician.
Less experienced clinicians may lack the experience to manage complex cases and decide on the nature of the investigations required.
This is a case where a teenager presented with clinically significant and ominous features of an underlying infection that required urgent treatment.
They were however, routinely under-diagnosed and discharged, leading to their untimely death.
Action in cases such as this, needs to be prompt and effective with Senior input to ensure the best outcome for the patient, and this case is an example of that not occurring. Lessons can be learned as above to ensure further patients such as in this case, do not have the same tragic outcome.