Migraine misdiagnosis in child leads to claim

By Dr Gabrielle Pendlebury, Medicolegal Consultant, and Ceylan Simsek, Case Manager, Medical Protection.

Master J, an eight-year-old boy, was referred to the Emergency Department by his GP with a three-month history of headaches. The headaches were occipital and frontal and relieved by paracetamol, and the referral indicated that on examination the optic discs were red with a blurred disc margin.

Dr P examined Master J, noting that the headaches occurred in the mornings and after lunch, with no vomiting. Dr P documented that the pupils were equal and reactive, fundoscopy was normal and no abnormality was detected on examination of the central nervous system. Dr P’s impression was of occipital headaches without vomiting or photophobia.

Dr P discussed the case with the consultant paediatrician, Master J was admitted overnight for observation and Dr P believed that she had asked the consultant to re-examine the optic discs. Dr P’s entry in the medical records following this was: “Discussed with consultant – review – normal discs – observe overnight.”
Master J woke repeatedly in the night complaining of headache, which was relieved with paracetamol. Master J was reviewed by the consultant in the morning and diagnosed with migraine.

Master J was discharged home and advised to stop eating chocolate, cheese, peanuts and monosodium glutamate, with review in clinic in one month. Unfortunately, this appointment was missed as symptoms had improved with the change in diet.
Two months later Master J was again urgently referred to the Emergency Department by his GP due to a very severe headache accompanied by nausea and vomiting. Examination was unremarkable, fundoscopy was normal and the previous diagnosis of migraine was confirmed. 
Master J was reviewed by the consultant paediatrician the following week, who noted that Master J was suffering from persistent symptoms of headaches every day and buzzing in the ears. A CT scan was arranged and it revealed a large medulloblastoma. Master J underwent posterior fossa craniotomy for removal of the tumour, which was successful. Master J also underwent a course of radiotherapy. 

Four years later, a claim was made

Mrs J pursued a claim against Dr P and the hospital. It was alleged that Dr P had failed to adequately examine the patient and had misdiagnosed migraine. The consultant paediatrician that Dr P had discussed Master J with said that he had not examined the fundi. 

Dr P contacted Medical Protection for assistance after being served with the formal letter of claim; the public hospital legal department dealt with the claim but the matter was still passed to a medicolegal consultant to advise. 

Dr P was devastated; Master J had been left with some residual disability after the treatment. Dr P found it difficult to come to terms with the possibility that there was a delay in his diagnosis.

The outcome 

The claim against Dr P and the hospital was settled by the hospital, in respect of the three-month delay in diagnosis. 

Learning points

Unfortunately, to err is human. This can be uncomfortable to acknowledge within healthcare, as errors, whether individual or systemic, can lead to patient harm. However, mistakes provide an opportunity to learn, and prevent similar mistakes from happening again. Errors are not marks of indifference or intolerance, but a vital part of how we learn and change. Errors allow us to alter our perspective and understanding of systems and events. A culture that inhibits transparency around errors and mistakes reduces our capacity to learn and improve patient care.

Dr P’s medicolegal consultant at Medical Protection was able to reflect on the care with Dr P and help her identify areas for targeted professional development. Fundoscopy is a difficult skill and given the time elapsed it was impossible to determine if the consultant had viewed the fundi. Continuing professional development therefore not only focused on refreshing clinical skills such as fundoscopy and history taking around headache and raised intracranial pressure, but it also looked at documentation. The entry related to review by the consultant was ambiguous: “Discussed with consultant – review – normal discs – observe overnight.”

This could be interpreted in a number of ways. Dr P changed her practice by making more detailed entries to reduce the risk of multiple interpretations.

Medical Protection was also able to support Dr P by advising her of the process and supporting her with writing a statement. This support was invaluable; Dr P had moved hospitals and did not understand the process; she felt alone and was frightened, so having an allocated medicolegal consultant made the situation understandable and manageable.