Meningitis – Timing is of the essence

Meningitis can be a very serious condition that is most common in babies, young children, teenagers and young adults. Whilst there is a vaccination programme in place for new born babies, this does not eliminate the risk.

Meningitis is an infection of the protective membranes that surround the brain and spinal cord. It can lead to septicaemia, which is blood poisoning caused by the same germs that can cause meningitis. It needs to be diagnosed and treated promptly so as to avoid death or serious permanent injury. The time-window for diagnosis of meningococcal disease or sepsis is limited. Children can have only non-specific symptoms in the first 4-6 hours, but a small number can advance very quickly and be close to death by 24 hours. Therefore it should be treated as a medical emergency.

Whilst most persons recover with no lasting effects, meningitis can lead to significant injuries such as deafness, sight loss and brain injury. Such injuries are particularly damaging to babies and young children as the disability occurs prior to them developing language skills. Often the problems can be difficult to identify until the child has developed and the problems become more obvious. This further compounds the problem. Such injuries very sadly lead to lifelong problems.

Being able to recognise the symptoms of meningitis and septicaemia is vital because early recognition and treatment provides the best chance of a good recovery. Such treatment can include the urgent administration of antibiotics.

There are sadly instances where medical professionals have missed the opportunity to appreciate the significance of the symptoms and the chance to diagnose and treat meningitis earlier. A delay can have a calamitous consequence, being responsible or contributing to the severity of any meningitis related injury. If such significant injuries have occurred and could have been prevented then it is important that the injured person can seek compensation so as to be able to get help and support they need so as to deal with the disability caused.

Symptoms of meningitis include a high temperature (fever) of 38C (100.4F) or above, being sick, a headache, a rash that does not fade when a glass is rolled over it (although this will not always occur), a stiff neck, a dislike of bright lights , drowsiness or unresponsiveness and fits (seizures).

Some of the symptoms detailed can be quite general and non-specific, such as lethargy and headaches. A symptom that is generally focused on is the non-blanching rash. However such a rash is not always present, might appear late or not be immediately recognisable. Other symptoms like a stiff neck and impaired consciousness develop late on in the disease. In contrast symptoms less well recognised, including limb pain, pale skin, and cold hands and feet often appear earlier.

To consider whether more could be done, the government established the Meningococcal Working Group in January 2018. This identified that more needed to be done to raise awareness of meningococcal disease among parents, young people and healthcare professionals. They published a report on 30 April 2018[1]. This in very brief summary recommended, amongst other things:

1. Approaches to the recognition, early diagnosis and treatment of meningococcal disease should be included under the umbrella of the cross-system Sepsis Board.
2. To identify and rule out sepsis there should be:
   1. A broader culture of routinely using structured observations and recording of physiological measurements such as respiratory rates, perfusion, level of consciousness in all tiers of medical practice, to guide recognition of possible sepsis;
   2. Implementation of the NICE fever guideline in children under five years of age, with evidence available in patient notes to demonstrate to CQC during inspections that this guideline was being systematically implemented by healthcare professionals in primary and secondary care.
3. Documentation (in addition to verbal instruction) should be given to any patient (particularly parents/carers of a child or teenager), who has been assessed because of concerns about infection and is being sent home. This information should: (1) set out what to look for in terms of deterioration or causes for concern for the child in question; (2) empower patients and carers with appropriate knowledge so they can seek further advice and assessment if concerned. It should be recorded in the patient’s notes that this information has been provided and there should be mechanisms in place to monitor and audit that this is taking place

The Group agreed that there was a need to increase awareness among healthcare professionals, particularly in Accident and Emergency and general practice but also for NHS 111 and paramedics, of the range of symptoms that can be associated with meningococcal disease and sepsis. Further, there should be timely availability of senior/experienced staff in hospital to support junior colleagues with diagnosis.

It was considered better for GPs to focus on recognition of a really sick child amongst all the children they see rather than specifically focus on meningococcal disease. However, rapidly recognising deteriorating health in a child should help identify those with meningococcal disease. The report also noted that children less than 5 years of age with a fever, or a history of recent fever, and who are considered at very low risk of serious bacterial infection needed a urine sample to exclude urine infection. This system should capture cases of meningococcal disease.

Sadly we do see instances where there was an opportunity to have diagnosed meningitis sooner, and this delay has led to significant injury. We have been able to secure the financial support that these people need to best help them get on with the rest of their lives as best they can.

[1] Raising awareness of the signs and symptoms, and ensuring early diagnosis and treatment of meningococcal disease.