GP Clinical: A GP's doubts over a child's death

An emergency call ends with a child's death. What should you do?

THE DILEMMA

Recently, while on call for our rural out-of-hours service, I visited a five-year-old girl who had, over a few hours, gone from having the symptoms of a mild viral illness to being severely breathless, with a high fever and prostration.

When I examined her she was semi-comatose, peripherally shut down, and appeared dehydrated. I therefore put up a saline infusion and arranged her immediate transfer to hospital, where she died from heart failure the following day. A post-mortem examination showed that the underlying disease had been viral myocarditis. The parents have written to thank me for my efforts to save their daughter's life. However, I suspect that the litre of saline I gave probably contributed to her cardiac failure and, therefore, her death. Should I tell the family the truth?

A GP's VIEW - Dr Ben Gowrie, salaried GP in Maidenhead, Berkshire

You may not be under any specific legal obligation to mention your fears regarding the administration of saline. However, it would probably be wrong not to do so.

Once you have decided to tell the family the truth, you should contact the chief executive of the out-of-hours service, who will probably be aware of the situation. He might have already instigated an investigation into the death.

You might wish to discuss it with your GP partners and ensure you have their backing, and also mention it to your medical defence organisation.

Finally, you should contact the paediatric consultant to find out exactly what happened to the child once she was admitted to hospital. This information will be helpful when dealing with the family.

Any investigation will almost certainly exonerate you as the most important thing (admitting the child to hospital) was done and the child might not have survived anyway.

However, by keeping quiet until the inquiry, you will look like you have something to hide. Once you receive the letter from the family, you should arrange to meet them face-to-face. By discussing it in a non-confrontational environment, you are far less likely to antagonise them and might therefore avoid any further legal action.

A MEDICO-LEGAL OPINION - Dr David Stewart, medico-legal advisor, Medical Protection Society

It is always sad to lose a patient unexpectedly following sudden illness, and more so when it is a child. The clinical picture with which you were presented led you to admit the child as an emergency, and because of signs of dehydration, you decided to set up an IV infusion of saline.

Having now been informed of the cause of death from heart failure due to viral myocarditis, you have concerns that the IV infusion could have contributed to this outcome. Your feelings of guilt might have been made worse by the letter of thanks you have received from the child's parents.

A critical incident discussion should take place, and I would advise not only involving your partners within the practice, but also suggest that you discuss your clinical decision making with the consultant at the hospital and clarify if your concerns are justified.

It is important to remember your actions are judged in the light of the information available to you at the time and not in hindsight, after the post-mortem. Obtaining independent, objective advice is very important.You should offer support and help to the parents as you would any bereaved family. It would be much better for the parents to hear about your worries from you as opposed to a third party such as the hospital, or possibly the coroner.

A PATIENT'S VIEW - Trevor Seeman is a member of the Patient Partnership Group

The death of a five-year-old child will give rise to the usual platitudes relating to our sadness and regret for the family, and they inevitably have the effect of each of us questioning our own actions.

From my perspective you have acted in good faith with the uppermost professionalism. As a lay person, I could not possibly say that your prognosis that the saline drip contributed to this girls' cardiac failure is either right or wrong. You might possibly be correct in your assumption, but hindsight is by its nature retrospective.

On a balance of probabilities the action you took on this occasion will save more lives than those lost.

To tell the parents that you might have inadvertently contributed to their daughter's death would undoubtedly cause them considerable distress which is totally unnecessary and will serve no good to anybody concerned.

Also, the personal worry it would cause you as well as possibly damaging your reputation and trust among your other patients is also unnecessary.

You talk of telling the family the truth, and this is to your great credit, but the real truth is you do not and cannot know that your actions were a contributing factor any more than you could know if, had you treated her differently, she could have survived.

You must not reproach yourself, but accept that perfection is an ambition, never a reality.

Your patients need you to be confident under pressure in an emergency - they do not expect a miracle worker.

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