Failings in the assessment and care of a patient with meningitis delayed his diagnosis and treatment but did not result in an unavoidable death

What happened

Mr J was in his thirties. He lived with his mother, who he cared for, and he was due to start an alcohol rehabilitation programme two days after he went to A&E. On the day he went to A&E, Mr J's sister found him in his bedroom suffering from the aftermath of a fit. She noted that he had a high temperature, was unable to stand unaided, was audibly chesty and had a superficial injury to his head. She called an ambulance.

In the ambulance Mr J was given paracetamol and arrived at A&E at about midday. Mr J's family say that from the outset they heard staff imply in their comments that his condition was probably related to alcohol use.

At triage Mr J's diagnosis was alcohol withdrawal and a head injury with confusion. The confusion was thought to be the result of the head injury, infection or alcohol withdrawal. He was started on the alcohol abuse care pathway and referred for a CT scan of his head which returned a normal result. He was given medication for symptoms of alcohol withdrawal and referred to the medical team. His condition continued to deteriorate. In the evening he was diagnosed with a possible chest infection and possible encephalitis and started on antibiotics.

Later that night, Mr J was transferred to the high dependency unit, placed in an induced coma and diagnosed with bacterial meningitis. The next day Mr J's sedation was withdrawn but he failed to improve. A CT brain scan showed extensive, irreparable brain damage. On the following day Mr J's respirator was switched off and he was declared dead.

The Trust acknowledged and apologised for delays in initial triage and medical assessment due to high demand in A&E that day. However it denied that Mr J suffered as a consequence.

The Trust accepted no failing in the triage rating or any unreasonable delay in reaching the correct diagnosis. It stated that there was no obvious sign of infection and no indication to start antibiotic treatment at an earlier stage.

What we found

There were delays in triage, and lost opportunities in A&E for earlier medical review and possibly earlier medical intervention.

There were a number of missed opportunities to identify the seriousness of Mr J's condition that were not acknowledged by the Trust. Earlier triage and an earlier initial assessment by an A&E doctor should have prompted an earlier review by a senior doctor. Indications that Mr J needed to be seen by a senior doctor in the afternoon and evening were missed.

If a more experienced doctor had seen Mr J earlier, and particularly in the afternoon when CT and blood test results were available, it is possible that the diagnosis would have included a central nervous system infection. This may have resulted in the earlier use of antibiotics and referral to the critical care team.

Although we agreed with the Trust that Mr J's death was probably unavoidable, there were significant failings in his care in A&E which the Trust had not addressed in its response to this complaint. We therefore made recommendations for systemic improvement.

We partly upheld this complaint.

Putting it right

We asked the Trust to prepare an action plan describing what it had done or planned to do to address the failings we had identified.