Treatment injury case study
March 2009
Sharing information to enhance patient safety
EVENT:
Failure to diagnose
varicella pneumonia
INJURY:
Death
Case study
Tom, a 28-year-old, became unwell a few months after starting a new job
as an early childhood teacher.
Initially, Tom experienced a fever,
which was soon followed by spots
over much of his body and inside his
mouth. As a number of children from
his kindergarten were suffering from
chickenpox, Tom went to see his GP.
The GP noted that Tom had extensive
vesicles and muscle aches, and was
off his food but drinking well. She
prescribed symptomatic treatment
Key points
• Adults with chickenpox may have,
or may develop, pneumonia
• Patients most at risk include
pregnant women, smokers, those
with impaired immune status,
chronic lung disease, severe rash or
persistent fever
• Physical signs may be minimal –
therefore an X-ray is essential if
symptoms suggest pneumonia
• Survival is improved by early antiviral
treatment for high-risk groups, and
hospitalisation of X-ray-proven cases.
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in the form of paracetamol and
ibuprofen, but didn’t make any
particular review arrangements.
Two days later Tom began vomiting,
was having trouble sleeping and still
had no appetite. He returned to his
GP and said he was feeling much
worse. The GP found that Tom’s
temperature was 38.1 degrees, but
she took no further action other than
to reassure Tom and send him home.
The following evening Tom presented
to the after-hours clinic with his
partner. He told the after-hours
doctor that he was exhausted, and his
partner mentioned that she was very
concerned about Tom’s condition.
The doctor noted that Tom was
distressed and took his temperature,
which showed 37.9 degrees. There
was no record of further examination,
and once again Tom was reassured
and sent home.
Sadly, Tom died in his sleep that
night. A Coroner’s post-mortem
examination established the cause of
death as varicella pneumonia.
09/03/2009 13:14:55
Case study
Expert commentary
Ian St George, General Practitioner, MD FRACP
FRNZCGP DipEd
GPs should be alert to the possibility of
pneumonitis in any patient with chickenpox.
Although difficult to diagnose, varicella pneumonia
progresses to fatal respiratory failure in 5-10% of
cases. This mortality can be considerably reduced
with aggressive treatment (respiratory support and
intravenous antiviral therapy) in hospital.
The incidence of adult chickenpox has doubled in
recent years, along with an increase in hospital
admissions and mortality. Varicella pneumonia
is the most common and serious complication of
chickenpox in adults, with an incidence 25 times
higher than in children.
Pregnant women, previous or current smokers,
and patients with impaired immune status or
chronic lung disease all have an increased risk of
developing pneumonia, as do those who have a
severe rash or persistent fever.
Varicella pneumonia usually presents one to
six days after the onset of the rash, and can be
associated with tachypnoea, chest tightness,
cough, dyspnoea, fever and occasionally with
pleuritic chest pain and haemoptysis – although
chest symptoms may start before the skin rash.
How ACC can help your patients following treatment injury
Many patients may not require assistance following their treatment injury.
However, for those who need help and have an accepted ACC claim for
treatment injury, a range of help is available.
This help will depend on the specific nature of the injury and the
applicant’s personal circumstances, but may include things like:
Physical findings are often minimal, but chest
X-rays typically reveal nodular or interstitial
pneumonitis. With the exception of hypoxia,
physical signs are a poor indication of severity.
The risk of developing respiratory failure requiring
artificial ventilation is difficult to predict early in the
disease. In one report, X-ray abnormalities were
detected in nearly 16% of enlisted military personnel
who developed varicella, yet only one-quarter of
these had a cough and only 10% of those with X-ray
abnormalities developed tachypnoea.
Acyclovir has become standard therapy for
patients with, or at risk of developing,
complications of varicella infection. Currently,
the consensus is to use acyclovir daily for 7-10
days, but this use should be tailored to each
patient’s clinical assessment.
References
1. Wilkins EGL, Leen CLS, McKendrick MW, Carrington D. Management of
chickenpox in the adult – a review prepared for the UK Advisory Group
on Chickenpox on behalf of the British Society for the Study of Infection.
J Infect 1998; 36 (Suppl 1): 49-58.
2. Mohsen AH, McKendrick M. Varicella pneumonia in adults. Eur Respir
J 2003 May;21(5):886-91. (http://erj.ersjournals.com/cgi/content/
full/21/5/886)
3. Shepherd J, Harris T, Harrison T and Hilton S. General practice survey
of the management of chickenpox: appropriate targeting of antiviral
therapy. Family Practice 2001; 18: 249–252.
Claims information
Between July 2005 and January 2009, ACC received 28
treatment injury claims relating to a delay or failure in
diagnosing or treating infections. Of these, 16 claims
(57.1%) were accepted.
Various types of infection were represented in the accepted
claims, including septicaemia, wound infection and septic
arthritis. Two accepted claims related to pneumonia.
The most common reasons for declining claims were that
the treatment (including diagnosis) was reasonable in the
circumstances, or that the perceived failure to diagnose or
treat, did not cause an injury.
•
a contribution towards treatment costs
•
weekly compensation for lost income (if there’s an inability to
work because of the injury)
•
help at home, with things like housekeeping and childcare
•
a contribution to the cost of travel to and from treatment
About this case study
•
changes to the home, such as the installation of rails and
wheelchair ramps
•
personal aids, such as crutches and wheelchairs.
This case study is based on information amalgamated from a
number of claims. The name given to the patient is therefore
not a real one.
No help can be given until a claim is accepted, but it’s a good idea
to keep receipts for any injury-related costs, as ACC may be able to
reimburse these.
It’s important to make a claim for a treatment injury as soon as
possible after the injury. This will ensure ACC is able to investigate,
make a decision and, if covered, help your patient with their recovery.
The case study has been produced by ACC’s Treatment
Injury Centre, to provide health professionals with:
•
•
an overview of the factors leading to treatment injury
expert commentary on how similar injuries might be
avoided in the future.
Send your feedback: AdminTeamTI&PS@acc.co.nz
ACC5080 Printed March 2009 ©ACC 2009
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