Case 6 An opportunity missed

Samantha Jenkins, 36, has been referred to the medical take by her GP with generalized fatigue, weakness and some lumbar pain. She last felt well four or five days ago. The GP’s working diagnosis is of pyelonephritis although Ms Jenkins is apyrexial and urinalysis is normal.

Dr Wilkins, the on-call registrar, takes a history from Ms Jenkins who works as a police officer and usually enjoys good health. She has a three-year-old daughter who is looked after by her mother-in-law when she is at work. Ms Jenkins has mild asthma which seems to be seasonal and she has not needed salbutamol at all in the last six months although has felt more short of breath over recent days. Ms Jenkins describes a deep aching sensation over her lumbar spine which has been present for 48 hours, and generalized weakness and lethargy. It has become a real effort to climb up and down the stairs at home, so much so that she has started to use the downstairs toilet even though her husband is in the middle of decorating the room.

Systems enquiry reveals a bout of diarrhoea ten days earlier which Ms Jenkins had put down to a take-away meal.

What is your differential diagnosis and how will you proceed?

Dr Wilkins examines Ms Jenkins. Her nursing observations are within normal limits apart from a respiratory rate of 24 per minute. Chest, cardiovascular and abdominal examination is unremarkable. Ms Jenkins is able to stand and walk unaided. The registrar makes a diagnosis of a nonspecific viral illness and sends routine blood tests. These demonstrate a sodium level of 128 mmol but are otherwise normal. Ms Jenkins is discharged home to rest with free oral fluids and regular paracetamol.

What are your thoughts?

Ms Jenkins represents to the Emergency Department 36 hours later, and is clerked in by Dr Al-Hamdi, a core medical trainee. Ms Jenkins states that she has become so weak that she can no longer get up from a chair. Her speech has become slurred over the last few hours. On examination, she has a respiratory rate of 30, a mild facial droop and is drooling saliva. Her chest is clear and she is generally weak although this seems most profound in the distal lower limbs. Dr Al-Hamdi is unable to elicit any deep tendon reflexes.

Dr Al-Hamdi considers the possibility of Guillain-Barré Syndrome and measures Ms Jenkins’s vital capacity with a handheld spirometer. It is 0.8 L. Dr Al-Hamdi seeks an intensive care opinion and Ms Jenkins is transferred to the intensive care unit for observation. Whilst there, a lumbar puncture is performed and intravenous immunoglobulin administered. Three hours after admission, Ms Jenkins is intubated because of a deterioration in vital capacity.

Ms Jenkins spends two weeks in the intensive care unit and requires a tracheostomy. She subsequently spends three months in neurological rehabilitation before discharge home. A year later, she continues to make progress, but to date she has only been able to undertake office-based duties for the police.

Expert opinion

Although the diagnosis of Guillain-Barré syndrome was eventually made and Ms Jenkins survived, it is possible that she may have followed a more benign course had her illness been recognized earlier and appropriate treatment (IVIG / plasma exchange) been instituted earlier. She might have avoided an ITU admission and her functional status at one year may have been better.

When a differential diagnosis is made always focus on those elements of the history or examination and investigations which don’t ‘fit’, So, why was a previously well 36-year-old woman with an adequate blood pressure tachypnoeic, hyponatraemic, and subsequently unable to walk? One wonders by what mechanism Dr Wilkins thought a nonspecific viral illness was causing these problems.

Guillain-Barré syndrome can present in a very nonspecific manner and it is sufficiently unusual that most receiving doctors in ED or emergency assessment units may not have it foremost in their minds. The average-sized hospital in the UK will deal with only around five cases a year.

Back pain is a feature of Guillain-Barré syndrome and reflects the presence of nerve root inflammation. The typical history is of ascending distal weakness with paraesthesiae and autonomic features are common. CSF examination usually reveals an elevated protein without a significant white cell count.

When Ms Jenkins was first seen, the assessment was incomplete and her classical symptoms (even though nonspecific) were not recognized for what they were. The clinical features may progress rapidly and lead to respiratory failure as respiratory muscles become affected.

Delayed treatment for Guillain-Barré syndrome is associated with a poor outcome. Ms Jenkins may have a case to seek financial recompense for any lost earnings.

Legal comment

Reimbursement of past and future loss of earnings would be included in the schedule of loss compiled by Ms Jenkins’s solicitors in any legal claim. If liability is admitted at an early stage of investigation by the NHS Litigation Authority on behalf of the Trust, an interim award of damages for immediate past loss of earnings may be made to ease the financial hardship in which Ms Jenkins and her family find themselves. Ms Jenkins will of course be entitled to statutory sick pay during the initial time she is in hospital, but full pay can continue for public sector workers up to a period of six months. It is now a year since the initial incident and she has not yet returned to active police duties.

The intention of compensation is to place the claimant, so far as money is able, back in the position she would have been in, but for the negligent act. Her significant compensation is divided into general damages and special damages. Her general damages are for her pain, suffering and loss of amenity attributable to the injury. Calculation is based on annual Judicial Studies Board Guidelines, which set out a range of settlements for different types of injuries, from within which awards for a particular injury are selected. In addition, case law is used to establish or refute a particular point within any guideline range.

Special damages are losses specific to the claimant which are directly attributable to the negligence. Past losses, such as loss of earnings, can be calculated accurately whereas future losses are hypothetical. Interest on past losses are recoverable from the date of injury to the date of settlement or trial. Significant injury will potentially impact upon a patient throughout her lifetime. Although the total amount of losses calculated at the time of settlement of the claim, the patient has immediate benefit of the compensation which, but for the injury, would have taken a life term to earn.

Although Ms Jenkins may have recovered from the immediate effects of her injury by the date of settlement she may still be at a disadvantage (i.e. she has not returned to full police duties and there is a partial continuing loss of earnings, for example, through loss of overtime work). She may well be disadvantaged if in the future she were to lose her current job and find herself on the open labour market. Damages may be recovered for the weakening of Ms Jenkins’s competitive position in the labour market, it does not matter that there is no immediate loss.

Ms Jenkins is also entitled to be compensated for her loss of capacity to undertake housework and to care for her child during the time when she was critically ill and for the fact that her mother-in-law looked after Ms Jenkins’s three-year-old daughter more than usual. During this same time period Ms Jenkins will not have been in a position to undertake the usual contribution to the family’s home life (for example, cooking and cleaning). These losses can be claimed by reference to what equivalent commercial costs would have been for a cleaner with a discount to acknowledge that these services were provided by Ms Jenkins to her close family. If Ms Jenkins’ husband, as a nonprofessional, has provided care, this can also be compensated under the principles established by the case of Housecroft v Burnett where the needs of an injured patient have been supplied by a relative without regard to monetary reward. In this case, the loss is calculated by either the market value to employ professional help or if Mr Jenkins has given up work to look after his wife, he would have incurred actual loss of earnings.

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