Scenario 1 - this patient is real, but names have been substituted.

 

 

At 11.15 the receptionist at the GP surgery receives a call. The mother of Naomi Phillips has phoned up asking for a GP to visit her 5 year old who is in bed with a fever. Putting the phone on hold, the receptionist asks one of the GPs, Dr Ball, what to do.

“There won’t be any time for that this afternoon, what with the audit meeting and the visits we already have – see if you can slot the child into Dr. Collier’s evening clinic.”

 

At 18.30 Dr Collier sees Naomi at the surgery. He finds out that she is normally well and has not been to the GP for a year. She developed a fever last night and has not been taking any food, just a little liquid for the last day. Mrs Phillips has been giving her regular paracetamol. This afternoon she has noticed a scanty widespread rash, which she says blanches using the ‘glass test’.

 

Dr Collier diagnoses a viral infection and suggests that she is given paracetamol at home as it will be 3-5 days before it improves.

 

At 22.45 Mrs Phillips becomes concerned because Naomi is now more drowsy. The rash too seems different, darker than before. She puts her in the car and takes her to the local emergency room.

 

By 23.15 Naomi has been triaged by the nurse and assigned to the “minors” area. After 3 hours she is seen by the A+E junior doctor, Dr Apple, as he is the only one free – the consultant and 2 registrars are attending to two road traffic accident casualties.

 

At 2.15 The Dr Apple has assessed the child. Although he thinks it is a virus causing the rash (almost all blanching), fever and drowsiness, he decides to check with his supervisor that it no further action is needed and the child can be sent home.

 

The registrar listens to Dr Apple’s account, and asks if there is any neck stiffness. Dr Apple does not think there was any. “In that case, its most likely to be a viral illness. Tell the mum to bring the child back if she gets worse and we’ll reassess” he says.

 

Mrs Phillips takes the child home at 02.30, mostly reassured.

 

At 06.30 Mrs Phillips check on her child in her bed at home. She is barely rousable, and has a widespread purpuric rash. She calls an ambulance and the child is taken to the local hospital where a diagnosis of meningococcal meningitis is made.

 

END