Case 13 A flu-like illness

Shaun Jones is a 34-year-old flight lieutenant in the Royal Air Force. He is generally fit and well. He is brought to the Emergency Department by his girlfriend one evening because he is pyrexial (39.2 °C) and drowsy. There are no localizing signs in respect of the fever. Mr Jones’s Glasgow Coma Score is 13/15 but there is no focal neurology. His girlfriend says that he has been complaining of a flu-like illness with prominent headache that has been progressing over the last 24 hours. He has appeared confused during the course of the afternoon. Mr Jones is seen initially by Dr Smethwick, the duty consultant.

What diagnoses should occur to Dr Smethwick?

Dr Smethwick instantly recognizes that Mr Jones is unwell and considers the diagnosis of meningitis. In addition to the fever, Mr Jones has a tachycardia and his initial blood pressure is 94 mmHg systolic. However, there is no history of photophobia or neck stiffness, and in the absence of any rash, Dr Smethwick feels an encephalitic process is more likely. In any event, Dr Smethwick sends bloods (including for culture) and immediately institutes appropriate antibiotics for meningitis, intravenous aciclovir and aggressive fluid resuscitation. He requests a CT examination of the head and refers Mr Jones on to the medical team for further management and consideration of a lumbar puncture.

Should any other treatments have been instigated?

Mr Jones’s initial treatments are commenced whilst he awaits review by the medical team. His blood pressure remains low but the nursing staff are able to maintain a systolic over 90 mmHg with liberal use of colloid. Initial blood tests from haematology show a platelet count of 43 000. Dr Smethwick (who is now busy with a trauma call) writes an entry in Mr Jones’s notes cautioning against lumbar puncture until the full blood count has been repeated. He also checks with Mr Jones’s nurse that the antibiotics have been administered.

Is there anything else that you would do?

An hour later, whilst in the CT scanner, Mr Jones has a grand mal seizure. The seizure appears to respond to intravenous lorazepam but soon recurs. Mr Jones is given further lorazepam and a phenytoin infusion is commenced. The fits continue. He is paralysed, anaesthetized and given phenobarbital before being taken to the intensive care unit. His blood pressure falls and metaraminol is administered. The effect is short-lived. Mr Jones’s blood pressure continues to fall, he suffers a cardiac arrest and resuscitation attempts are unsuccessful.

Dr Smethwick and the intensive-care team discuss the cause of Mr Jones’s death, and consider viral encephalitis as the most likely aetiology. Mr Jones’s death is discussed with the coroner’s officer and a medical certificate of cause of death (MCCD) is issued.

Five days later, Mr Jones’s case is discussed at the hospital’s postgraduate medical meeting. One of the consultants present suggests the diagnosis of cerebral malaria and there is a general consensus that this is a likely diagnosis.

What should the hospital do at this stage?

The hospital contacts the coroner’s office and explains the developments in relation to Mr Jones’s case. The coroner opens an Inquest and orders a post-mortem examination which delays the funeral, arranged for the next day, and causes much upset to Mr Jones’s family. Cerebral malaria is confirmed at post mortem.

Expert opinion

Mr Jones was clearly extremely ill at presentation. The prominent issues were fever, confusion and headache. Whilst a travel history was not offered, Mr Jones’s occupation is a clear risk marker in relation to malaria. Falciparum malaria should have been high up in Dr Smethwick’s differential diagnosis. Profound thrombocytopenia should also have set alarm bells ringing. Although a rare diagnosis in the United Kingdom, malaria should have been considered in the Emergency Department.

From the time of presentation to death, Mr Jones was in the hospital for only three hours. It is likely that recognition and treatment of malaria would not have altered outcome.

Dr Smethwick and the intensivists should not have completed an MCCD given that the diagnosis of encephalitis was entirely speculative. The coroner’s officer should not have sanctioned certification but does not have sufficient experience or medical knowledge to realize that the explanation put forward by the clinical team was not plausible.

The hospital should count itself lucky that the coroner did not issue a Rule 43 letter criticizing their death certification processes. From April 2013, the role of Medical Examiner will be introduced across England to standardize and quality assure the death certification process. Scrutiny by a medical examiner may have been of assistance in this case.

Legal comment

In this case, it was possible to arrange a post mortem despite the unusual circumstances. Had the patient’s body been buried, the coroner may have considered the unusual step of ordering exhumation.

According to section 23 of the Coroner’s Act 1998, a coroner may order by warrant the exhumation of a body if it appears that an examination of the body is necessary for the purpose of the coroner’s own functions in holding an inquest or inquiring into a person’s death. Such exhumations are extremely rare, with nine being ordered by coroners in England and Wales between 2006 and 2010.

Proceedings in the coroner’s court are governed by The Coroner’s Act 1998, supplemented by The Coroner’s Rules 1984. The duty of the coroner is to investigate certain deaths when informed that the body of a person is lying in his jurisdiction and there is reasonable cause to suspect that the death:

• was violent or unnatural;
  
• was sudden and of unknown cause;
  
• occurred in prison; or
  
• occurred in such a place or circumstances to require a inquest.

Doctors frequently sign a ‘death certificate’ and this only certifies the cause of death. The legal death certificate is issued by the Registrar of Births and Deaths. There is no obligation on a doctor to report deaths to the coroner that lie within the above criteria, but it is sensible, wise and courteous to do so. The Registrar will report the death to the coroner if he is not prepared to issue a formal death certificate on the information received.

A patient’s death should be reported to the coroner in the following situations:

• The cause of death is unknown.
  
• The doctor has not attended the patient during his last illness.
  
• The doctor did not attend the patient during the last 14 days of life and did not see the body after death.
  
• Death occurred during an operation or before recovery from the effects of the anaesthetic.
  
• Death was caused by an industrial disease or poisoning.
  
• Death is believed to be unnatural or caused by violence, neglect or abortion.

Rule 43 of the Coroner’s Rules 1984 states that a coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the ‘person of authority’ who may have such power to take such action. In the context of the NHS, this is the Chief Executive of the NHS Trust.

The Coroner’s (Amendment) Rules 2008 introduced a new statutory duty for organizations to respond to a Rule 43 letter sent to them by a coroner. The recipient must provide a response within 56 days and this should contain details of any actions which have been or will be taken, or provide an explanation when no action is deemed necessary or appropriate.

All Rule 43 letters issued by coroners in England and Wales since 1 October 2010 have been reported to the Ministry of Justice and where the Rule 43 letter concerns a NHS public authority this has been notified to the Care Quality Commission. The first Ministry of Justice Summary Report was published in September 2011. Rule 43 letters were issued in relation to 189 inquests, relating to 86 NHS hospitals and Trusts. An analysis in relation to hospital deaths showed that Rule 43 letters were most often issued in relation to staff training, procedures and protocols not being followed, poor documentation, record-keeping and communication.

Communication concerns are highlighted in a number of areas:

• Between different hospital departments or specialties, including referrals for out patient appointments following a stay in hospital or visit to ED.
  
• Between different staff involved in patient care, including where they change shift.
  
• With patients and their families.
  
• With community healthcare providers about follow-up treatment and after the discharge of patients from hospital.

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