A.B     V   CRUMLIN HOSPITAL

Note that to protect the plaintiff from suffering further possible distress by reason of his injuries and condition the High Court made an order pursuant to Section 27 (1) of the Civil Law (Miscellaneous Provisions) Act 2008 that the publication or broadcast of any matter relating to these proceedings which would or would be likely to identify Minor Plaintiff as a person having  a medical condition be prohibited. Therefore, key details and dates of the below report have been changed to ensure the identity of the plaintiff remains anonymous.

A.B was born on April 6th, 2012 at 41 weeks of gestation by normal vaginal delivery. His birth weight was 3990 grams, head circumference 34 centimetres and Apgar scores were 9 and 9 at one and five minutes respectively. He fed well and there were no neonatal problems and he was discharged home on Apri7 13th. His examination at that time was normal.

On March 16th, 2013 at the age of 11½ months, A.B was seen by his general practitioner because of a periorbital swelling and fever and he was treated with antibiotic medication (Augmentin). Although he improved initially, a few days later, he had an increase in temperature and he was seen in Emergency Department of his local hospital. Two days previously, he had developed diarrhea and vomiting, and, on examination, he had a temperature of 39 degrees. This fell to 36.8 degrees by the time he was discharged, and the plan was to continue antibiotic treatment. On March 30th, 2013, he was taken back to the Emergency Department of his local hospital because of recurring vomiting, diarrhea and fever. On examination at that time, he was pale and lethargic and had an increased respiratory rate. There was no meningism’s. His CRP was increased at 44 mg/L.

He was admitted to hospital and there were continued spikes in his temperature. His CRP rose to 182 and blood cultures grew streptococcus. He was treated with Ceftriaxone.

The CSF analysis demonstrated 1730 white blood cells. Penicillin was added to the antibiotic regimen. It was then considered that he likely had pneumococcal meningitis and he was treated with Vancomycin. He continued to be lethargic and drowsy. A CT scan of the head on April 2nd was correctly interpreted as normal.

On April 6th, the Ceftriaxone was discontinued and vancomycin was continued. He improved over the next few days and on examination, he was alert, responsive and feeding well. Although his neurological examination was normal, examination of his chest revealed a systolic murmur and so he was referred to the cardiologist.

On April 14th, a lumbar puncture produced CSF with a white blood cell count of 25 which was decreased and no bacteria was found on gram stain. However, the pneumococcal antigen test was positive.

On April 19th A.B was discharged on. From the care of his local hospital.

On April 20th, He was seen by the cardiologists at Crumlin Hospital. His temperature was 38.4° and an echocardiogram demonstrated a cleft mitral valve. He was immediately admitted to hospital and a lumbar puncture was performed. A CSF specimen had 229 white blood cells and a glucose level of 2.7. The blood culture indicated pneumococcus and treatment with vancomycin and cefotaxime were continued.

On April 22nd, A repeat echocardiogram had demonstrated the cleft in the mitral valve but no vegetations were present

On April  23rd, he was still having spikes in temperature.

 On April 26th  However, a subsequent echocardiogram demonstrated vegetations on the mitral valve (strongly suggestive of infective endocarditis).

 On April 27th a CT scan of the head was wrongly reported as normal when in fact it demonstrated the presence of a mycotic aneurism which is a known complication of infective endocarditis

On May 8th, his temperature was again increased and he became irritable. The CRP was increased.

 On May 10th, he was noted to be holding his head intermittently.

On May 12th, A.B was upset and irritable and was still holding his head.

On May13th An urgent MRI scan was performed which was reported and demonstrated hemorrhage in the right hemisphere of the brain. The findings were considered to be most in keeping with rupture of a mycotic aneurism arising from right middle cerebral artery.

A.B was transferred to the nearest tertiary Centre for endovascular coiling treatment by an interventional neuroradiologist in an attempt to stop the bleeding from the mycotic aneurysm in the right middle cerebral artery. He was then transferred to another specialist hospital for surgical decompression with right craniectomy and the evacuation of blood.

On May 22nd, the bone flap was replaced and on May 28th, he was discharged. At the time of discharge, he had a dense left hemiparesis secondary to brain injury from the intracranial hemorrhage which, in turn, had been caused by the mycotic aneurism rupture. There was no further leakage form the aneurism.

SUBSEQUENT PROGRESS

The following year in May of 2014, he attended the National Rehabilitation Hospital (NRH) where he had 10 weeks of multidisciplinary rehabilitation. He subsequently received physiotherapy, occupational therapy and speech/language therapy. Following that time, he has had ongoing therapy. A.B attends main stream primary school and has a full-time special needs assistant. He also has fatigue breaks. He had difficulties with reading, writing and maths. He had no fine motor skills with the left hand he but may use his left elbow to stabilize things on the table e.g., paper if he was writing. His left leg was weak and he had a foot drop and at time he hyperextended his left leg. He often tripped and fell and he walks with a limp. He has a left ankle foot orthosis (AFO) and a hand splint. Because of the left visual field defect, he often bumps into things on his left side, e.g., doorways.

Outside the home, when the family go for a walk, A.B can walk for up to 1 kilometre before complaining that he is getting tired. He does not use walking aids and he does not use a wheelchair.

A.B began to have seizures in 2018 and they were described as absences. The seizure consists of his eyes turning to one side followed by unsteadiness, although he would not necessarily fall. His level of alertness was diminished. The duration of the seizure was around a minute or less. The alteration in conscious level would be associated with some twitching of the limbs. He has been taking the anticonvulsant medication Trileptal, which seems to be achieving reasonable control. He has been assessed a the consultant pediatric neurologist for the management of the seizures.

He is a safe feeder. The parents may help by cutting up the food, e.g., meat, in small portions following which he will use his right hand with a spoon and will swallow satisfactorily. He does not choke or aspirate and there is no history of aspiration or chest infections. He is able to drink from a cup.

Overall, he is a healthy boy and has not required hospitalization for anything other than his motor problems. He is followed on an annual basis by a neurologist and has repeat MRI scans of his head on a yearly basis. He is also followed by a consultant ophthalmologist and by the local branch of the Central Remedial Clinic.

 

 LEGAL PROCEEDINGS; (the plaintiff’s case)

Our firm was tasked with investigating the care provided by two hospitals. It required a complex detailed forensic investigation into the management of the patient’s initial meningitis at his local hospital, his subsequent development of infective endocarditis and lastly the mycotic aneurism which ruptured in his brain. Our investigations required us to instruct an A+E consultant, a microbiologist, a paediatric intensivist, an interventional neuroradiologist, a paediatric neurologist and a paediatric neurosurgeon to enable us to make out a strong case on A. B’s behalf.

In summary the essence of the plaintiff’s case was that he developed infective endocarditis as a secondary consequence of the same pathogen that had caused his earlier meningitis. Once he was diagnosed with infective endocarditis (following presence of vegetations on heart valve seen on echocardiogram) he was then at risk of infective cardiac emboli breaking off, travelling in the bloodstream to the brain and forming mycotic aneurisms. This was the precise reason the clinicians at the Defendant hospital ordered a repeat urgent CT scan on 26 April to out rule this potentially lethal condition. Most unfortunately the CT scan of the 26 April was incorrectly read as normal. It was the plaintiff’s case, that had the CT scan been properly interpretated, then coiling of the aneurism would have occurred before it ruptured and as a matter of high probability the plaintiff would have made a full recovery and avoided all his long term brain injuries.

DEFENCE- Somewhat remarkably the defendant hospital initially disputed liability in full and then just before trial admitted negligence in misreading the CT scan. However, they then adduced expert evidence that suggested that even had the mycotic aneurism been correctly diagnosed by the earlier CT scan there was a body of medical opinion that would have adopted a conservative approach and would not have offered coiling surgery before the aneurism had ruptured 16 days post CT scan.

 SETTLEMENT DISCUSSIONS –

On the eve of trial the Defendant finally conceded liability and requested mediation talks, this firm instructed senior counsel to who had been briefed for the trial to assist and conduct the mediation talks. As the future prognosis for the plaintiff was so uncertain and because of his young age, this firm strongly recommended that the plaintiffs family elect for an interim settlement. This would allow time to ascertain how the plaintiff progressed through primary and secondary school. Thus items of damages such s the claim for specially adapted housing and for the plaintiffs future loss of earnings were adjourned for assessment in six years’ time. After a full day of mediation talks an Interim Settlement and an agreed award of interim damages of € 1.3m plus legal costs to cover care for the next 6 years was reached with an admission of Liability subject to the approval of the Court. The case will return to Court again in 2028 when all of the remaining heads of claim and all the future care needs of the Plaintiff will again be assessed by the Court. The High Court subsequently approved of the Settlement upon the recommendation of the entire legal team and with the full support of the parents. The precise breakdown of the interim award of damages was made up as follows;

i)                   General Damages                               €550,000

ii)                 Retrospective Care                             €210,000

iii)                Past Specials                                       €37,859.67

The Plaintiff’s claims in respect of the following heads of loss for the next 6 years only

i)                   Future Care                                         €271,110

ii)                 Aids and Appliances                           €100,000

iii)               Assistive Technology                      €35,000

iv)               Educational and Neuropsychology€31,400

v)                Speech and Language                      €22,292

vi)               Orthotics                                            €21,513

vii)             Physiotherapy                                       €20,826

viii)           Stamp Duty Allowance                        €12,100

TOTAL   AWARD                         €1,320 000

SHOULD YOU REQUIRE ANY FURTHER INFORMATION OR ADVICE CONTACT-

Gillian O’Connor, Managing Partner at gillian@michaelboylan.com Michael Boylan at michael@michaelboylan.com; Ciara McPhillips at ciara@michaelboylan.com