Infectious diseases (such as meningitis), and sepsis are terrifying. One of the very first clinical negligence inquests on which I was instructed involved a child who died from sepsis, with death occurring within a staggeringly short time of onset of symptoms.
In terms of breach of duty, such claims are simpler (though not always easier) than they once were, as there are well-known published standards and guidelines against which to benchmark care.
These claims are difficult on causation. The progress of infection or the sepsis (defined below) which is a consequence of serious infection may be such that by the time any breach occurred, it would have been too late to make much of a difference.
The microbiological evidence (or sometimes the evidence of acute physicians in adults or paediatricians in children, with an interest in infectious diseases) is frequently the battleground of the litigation.
It seemed to me that practitioners would benefit from a handbook which would summarise the medical background to sepsis, meningitis and meningococcal disease in some detail. The aim of the book (to be published later this month, details below) is to enable a lawyer to understand the background, including being able to analyse the medical notes when a claim is at an early stage, and an expert has not yet been instructed. There are also practical chapters on inquests, expert and non-expert evidence and lessons learnt from the reported cases.
In my experience, very few people know what is actually meant by ‘sepsis’. This is regrettable considering that sepsis is the most common cause of hospital death both in this country and worldwide. The Sepsis Trust has estimated that 52,000 in the UK die every year from this condition.
It is not an infection, although it arises from infection.
Properly defined, it is “life-threatening organ dysfunction caused by a dysregulated host response to infection”. In essence, in response to an infection, systemic inflammation occurs, which causes blood vessels to leak water and proteins into body tissue, which consequently reduces the blood circulating volume and lowers blood pressure (although a drop in blood pressure in children happens quite late in the process). Septic shock then occurs when the circulation is inadequate to meet the body’s needs. Organ failure occurs from decreased flow of blood and oxygen.
Meningitis is an infectious disease, predominantly caused by meningococcus or pneumococcus (although there are many meningitis-causing pathogens). This occurs when the relevant pathogen is able (whether due to impaired immunity or high virulence of the pathogen) to cross the blood-brain barrier and inoculate the cerebrospinal fluid (CSF).
Once this has occurred, this can cause inflammation of the meninges, which can have devastating complications including brain damage and death.
The only way to make a confirmed diagnosis of meningitis is to perform a lumbar puncture in which a CSF sample is taken. A positive sample is one containing increased white cells and proteins.
Signs and symptoms differ between children and adults, but as with sepsis, there are well-known published standards and guidelines.
In some cases (but not all), where the pathogen is meningococcus, the infection can also cause sepsis in the form of meningococcal septicaemia.
It is not well understood why, in some cases, the infection will develop into septicaemia rather than meningitis (it is uncommon to suffer from both).
In these patients, the bacteria will multiply within the blood, shedding ‘blebs’ from their outer coats, which contain a toxin. The presence of the toxin provokes a significant inflammatory response which leads to damage of the blood vessels, and in some cases, a clotting disturbance.
A non-blanching meningococcal rash will develop due to leaking capillaries, characterised first by pin-prick ‘petechiae’ and later by larger ‘purpura’. In many cases the rash will not develop until the latter stages by which time a poor outcome is unavoidable.
In some cases, widespread clotting in peripheries or limbs can lead to tissue hypoxia and necrosis, which may result in amputation. The process may also lead to organ failure or death.
The above is just a summary of the conditions examined within the book. The book sets out signs and symptoms, treatment and outcomes, and then considers the legal background.
It is my hope that there is a place for a practitioners’ guide to such claims, and that colleagues find the book useful.
It is being launched at a seminar hosted by my Chambers on 18th November 2019 at which Dr Nelly Ninis (Paediatrician) will speak on meningitis and meningococcal disease, and Dr Ron Daniels (Intensivist and CEO of the Sepsis Trust) will speak on sepsis. For all copies of the book ordered via the publisher’s website in November, 10% of sale price will go to the Sepsis Trust and the Meningitis Research Foundation. Details are available at http://www.12kbw.co.uk/events
Once launched, later this month, the book will be available at: http://www.lawbriefpublishing.com/product/sepsisandmeningitisclaims/
12 King’s Bench Walk
18th October 2019.