Australia: Public hospital doctor kills because he failed to recognize or consider a fully symptomatic meningococcal case

A doctor made a serious error of judgment in ordering a lumbar puncture for a boy, 11, infected with meningococcal disease, a coroner has found. Coroner Dyson Hore-Lacy yesterday recommended that all hospitals review their guidelines in the light of Ryan Fitch's tragic death. And he expressed concern that the Frankston Hospital had not been prepared to admit a mistake was made.

Ryan, of Chelsea, died on August 5, 2005, from respiratory arrest as a result of a lumbar puncture. The sports-mad boy told his mum he loved her shortly before having a seizure at Frankston Hospital. He was put in an induced coma and flown to the Royal Children's Hospital, where he was declared brain-dead.

Ryan's devastated parents said yesterday they were pleased with the coroner's recommendations. "If it helps the next person, then that has to be a good thing," mum Robyn Fitch said. "There's comfort in the fact that if they adopt the recommendations, at least someone else will have the benefit of having antibiotics before they have a lumbar puncture." She said the family were yet to decide if they would take further action.

Dad Ron Fitch said he'd the highest respect for the doctor who performed the lumbar puncture, Dr Ted Lowther. "He was man enough to get up (at the inquest) and say 'I'm sorry for what I've done'." Mrs Fitch said Ryan's death must have affected Dr Lowther as well. "I know it wasn't his intention to come to work and have something like this happen. Unfortunately, it did happen. "And there are consequences, and we live with those consequences every day," Mrs Fitch said.

She said the family were upset with the way the hospital had handled the matter. At the inquest, Dr James Tibballs, of the RCH, took issue with the decision to perform the spinal tap. He said a patient suspected of having meningococcal should be given antibiotics, and doctors should then await the results of blood tests.

Mrs Fitch rushed Ryan to the Frankston Hospital's emergency department when she found him sick, vomiting and writhing with back pain. In the hours after he was admitted on August 3, staff investigated whether he was suffering pneumonia, a kidney infection and gastro. Mr Hore-Lacy said every one of Ryan's symptoms was consistent with meningococcal disease, and he was concerned that no one suspected it for 13 hours. By that stage, Ryan had developed a rash on his legs and one of his eyes.

The hospital's guidelines recommend that meningococcal disease be treated with antibiotics as soon as it is suspected, and that a lumbar puncture is usually not necessary and involves an increased risk in some patients. It can be performed when the patient is stable, but the coroner said Ryan shouldn't have been considered stable. "No doctor could give a (substantial) reason why a lumbar puncture had to be performed, let alone conducted before antibiotics had a chance to take effect. "This may bring back to clinicians the danger of lumbar puncture where there is so little to gain and so much to lose," Mr Hore-Lacy said. He said Dr Lowther now waited until the day after administering antibiotics to perform any lumbar puncture, which was a recognition that he'd made a mistake.

Frankston Hospital, part of Peninsula Health, said it would not comment until it had reviewed the findings.

Source