Neutral Citation Number: [2010] EWHC 1827 (QB)
Case No: 8LS90181
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
LEEDS DISTRICT REGISTRY
Royal Courts of Justice
Strand, London, WC2A 2LL

Date: 22/07/2010

Before :

THE HON. MRS JUSTICE NICOLA DAVIES DBE
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Between :

	Rachael Elizabeth Knott	Claimant	
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	Dr Alan D Leading	Defendant	

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Mr Robin Oppenheim QC (instructed by Irwin Mitchell) for the Claimant
Mr George Hugh-Jones QC (instructed by Medical Protection Society) for the Defendant

Hearing dates: 20th, 21st, 24th, 25th, 26th May & 29th June 2010
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Judgment

Mrs Justice Nicola Davies : 

1.	This claim is brought by Rachael Knott, now aged 20, arising from the allegedly negligent medical care provided to her by Dr Alan Leading, her general practitioner, on 19 April 2000. It is alleged that on that day Dr Leading visited the claimant at her home and failed to act upon the presence of three petechial spots on her neck. On 20 April 2000 the claimant was admitted to Pinderfields Hospital where investigations revealed that she was suffering from meningococcal disease. As a result of the disease the claimant developed profound deafness in her right ear, severe hearing loss in her left ear together with tinnitus and vestibular dysfunction. The claimant’s case is that on 19 April Dr Leading failed to note, detect or recognise that she had three non-blanching petechiae on her neck, failed to recognise and act upon the fact that meningococcal disease could not be excluded and failed to urgently refer her to hospital. As a result of the defendant’s failure the claimant has suffered injury with consequent loss and damage.
2.	The defence case is that on 19 April 2000 only one spot was present on the claimant’s neck, it was non-petechial, urgent referral was not required.  It is agreed that if the three spots were petechial and the claimant had fever or some other systemic sign on 19 April 2000, the differential diagnosis should have included meningococcal disease and the claimant should have been referred to hospital.  There is a conflict of evidence as between the claimant’s parents and the defendant and one of his colleagues, Dr Taylor, as to the number and nature of spots which it is alleged were present on the claimant’s neck on 19 and 20 April.  The resolution of this issue is central to the allegation of breach of duty.
Factual Evidence - Mrs Karen Knott 
3.	Mrs Knott is the mother of the claimant who was born on 26 August 1989. Mrs Knott and her family were patients of the Crofton Health Centre, Crofton Village, Wakefield. On 12 April 2000 Mrs Knott took Rachael to Crofton Surgery for what was diagnosed as an infection in her right ear. A five day course of antibiotics was prescribed. By the time of completion of the antibiotics Rachael’s pain had disappeared, she felt fine. On 18 April 2000 Rachael went to school. On 19 April Rachael woke up between 7.30am and 8.00am and complained of feeling ill. Mrs Knott said she had a high temperature and was vomiting. Mrs Knott described Rachael as being “red hot” over her body, she moved Rachael to her own bed to provide more space and to better care for her. It was the opinion of her mother that Rachael was too unwell to be taken to the surgery, she could hardly stand up. Mrs Knott told her husband that she was going to telephone for a doctor’s visit.  Mr Knott left for work. Using the home landline telephone or a mobile telephone, Mrs Knott spoke to a receptionist at the surgery between 8.30am and 9.30am. She told the receptionist that Rachael had a temperature and had been vomiting. The receptionist asked Mrs Knott if she could take Rachael around to the surgery as it was only a few minutes from the house, Mrs Knott said that Rachael was not well enough. 
4.	The note made by the receptionist records: “high temperature – sick half an hour ago. On neck + down chest – rash…”  In her witness statement dated 30 November 2009 Mrs Knott stated: “It is possible that I told her that Rachael’s chest was pink or flushed. But I don’t remember that clearly”. In the same statement it is recorded: “Rachael was very hot but the only thing approaching a rash that I was aware of were those spots on her neck. Her chest might have been a bit pink but I wouldn’t describe that as a rash. If she had had a proper rash, it would have been obvious to me, as she wasn’t wearing her top, due to her high temperature and the bedding was folded back”. In her evidence to the court, Mrs Knott said of Rachael’s chest “It’s not what I would call a rash…it was not a rash in my mind”.
5.	Having telephoned the surgery, Mrs Knott rang her husband.  Her witness statement records: “After calling the doctor’s surgery, I spoke to Malcolm to update him.  Again, I cannot recall if I would have telephoned him with my landline or mobile phone or if he phoned me.”
6.	During the course of the morning Rachael continued vomiting. Her mother described her as being very lethargic, exhausted, she could not be bothered, she was not Rachael. Mrs Knott said that she tried to talk to her daughter but Rachael was not responsive. She did not want to take any paracetamol or water. Rachael was very pale, odd looking, when sick her face would flush up but for the remainder of the time her face was a waxy colour. Rachael spent the morning dozing between bouts of vomiting. Mrs Knott recalls that when Rachael said she needed to go to the toilet, Mrs Knott almost had to carry her there. Rachael complained that she ached all over her body and her mother noted that in spite of her having a high temperature she had very cold hands and feet. 
7.	Mrs Knott had seen items about meningitis on television. She specifically recalled Dr Hilary Jones on GMTV, he had given advice as to what to do if meningitis was suspected. Mrs Knott was concerned that Rachael could be suffering from meningitis as Rachael was waiting for her meningitis vaccine. Mrs Knott was aware that a high temperature, vomiting, stiff neck, spots or a rash, dislike of bright lights are all signs of meningitis. She knew the test was to press the spots to see if they faded under pressure. As a result, Mrs Knott said she was constantly looking all over Rachael’s skin.
8.	During the course of the morning Mrs Knott found three tiny red or purple spots between Rachael’s ear and collar bone. The spots were on the left side of her neck.  In her evidence she said they were like pin pricks.  Mrs Knott said she was constantly touching and pressing on the skin to see if the spots would disappear.  In her witness statement Mrs Knott said “I pressed on them with my fingers and a glass but they would not go away. I kept pressing on them, really hoping they would go white, disappear or fade, but they just stayed the same red/purple colour”. When cross-examined Mrs Knott said that she used her thumbs to press the spots, she used opposing thumbs one after the other.  Mrs Knott demonstrated the actions to the court, it was clear she was using opposing thumbs in sequence. In re-examination Mrs Knott said she tested using fingers and thumbs, the spots did not fade, they stayed the same size, they did not change or go white.
Dr Leading’s visit
9.	In her witness statement Mrs Knott recalled “Dr Leading called at the house at about lunchtime. I can’t say for certain what time he attended but my understanding was that morning surgery had finished at about 12.30pm and that he came straight after that”. In her oral evidence Mrs Knott said that Dr Leading opened the front door, shouted up to her and came up to the bedroom. Rachael was lying down and when Mrs Knott heard the doctor come in she went over, sat Rachael up and supported her with her arms. Rachael was wearing just her pants as she was too hot. She was not perky. Mrs Knott told Dr Leading that Rachael had been vomiting, she had had a high temperature since waking, she had had a course of antibiotics the previous week. 
10.	Dr Leading examined Rachael’s ears and throat. Mrs Knott pointed out the three spots on Rachael’s neck and said “She has got three spots on her neck and I’m worried about them”. Mrs Knott said that she pushed the spots on Rachael’s neck. Dr Leading then took hold of Rachael’s neck, he pushed her head back and then tried to pull it down, Rachael winced. Dr Leading said to Mrs Knott “It’s not what you’re thinking”. Mrs Knott said she was glad, “I thought it was not meningitis and so I was relieved, I did not press him about it”. She said that Dr Leading did not examine the spots; he did not look all over Rachael’s body for spots. Dr Leading thought it was a viral infection and told Mrs Knott to give Rachael plenty of fluids and a cool bath to try and keep her temperature down. Mrs Knott could not remember if Dr Leading had examined Rachael’s chest but accepted that he might have done so. She said that once she had been told “It’s not what you’re thinking” she could not really focus.  At the time of Dr Leading’s visit, the bedroom curtains were open and the room was fairly bright.
11.	In her witness statement Mrs Knott states: “I remember that after Dr Leading left, I spoke to Malcolm. My recollection is that he was on his lunch break, which was from 12.30pm to 1.00pm. I told him that the doctor had been and what he had said”. In her oral evidence Mrs Knott said that she spoke to her husband after Dr Leading’s visit and told him what had occurred.  Mrs Knott gave Rachael a cool bath, she had to carry her to the bath. Even after the bath Rachael’s temperature did not come down, she was “red hot”. Mrs Knott continued to try to give Rachael fluids, she also tried to give her a piece of toast but Rachael was unable to keep anything down.  During the day of 19 April Mrs Knott noticed that Rachael had a horrible smell on her breath; it was a sweet sickly smell. 
12.	Mr Knott arrived home from work between 5.00pm and 5.15pm. He went straight to the bedroom.  Mrs Knott showed him the spots on Rachael which she said were unchanged since Dr Leading’s visit. That evening Rachael stayed in her parent’s bed. During the course of the evening Rachael was sleeping heavily, she just wanted to be left alone. Mrs Knott slept with Rachael that night.  A bucket was at the side of the bed. Mrs Knott said she was checking Rachael throughout the night, looking at her, feeling how hot she was. During the night Rachael started to talk rubbish. She said “If you put me in a box in the corner I’ll be fine”. 
13.	In the morning Rachael was no better.  In her witness statement her mother said “Rachael still had a temperature and was being sick frequently. She wasn’t tolerating fluids and had had nothing to eat. I was worried that she would become dehydrated. I rang the GP surgery at 8.30am to ask for another home visit…I asked if I could have another home visit, as Rachael was no better. I said that Rachael was burning up”. The record of the call taken at the surgery records: “No better, burning up”.
14.	In her witness statement Mrs Knott records “During the morning, Rachael carried on muttering and she was very limp and floppy. She kept falling asleep and if I asked her something, I had to give her a little prod to get a response. She was also moaning and whimpering but wasn’t able to explain how she felt. She only spoke very quietly and I had to get very close to her to be able to hear”. In her oral evidence Mrs Knott said that by the time of the telephone call on the morning of 20 April Rachael was unable to stand up, she had no strength, she said that Rachael opened her eyes but was looking at her mother as though she did not know her. 
15.	Mrs Knott’s witness statement continues: 
“At some point in the morning, I noticed some more spots, which hadn’t been there the day before. They were between her fingers and down the outside of her hand. On the same side of her hand as her little finger. There was nothing on the palms or the backs of the hands or down the finger itself, nor did the spots go up the wrists. There were no marks on her arm. I can’t remember if it was equal on both hands but the spots were exactly the same purple pin pricks as the ones that Rachael had on her neck. There were about 4 to 6 on each hand side and 1 or 2 between her fingers. They were still quite widely spaced, like the ones on her neck”. 
In her oral evidence Mrs Knott said that she checked Rachael all over during the morning to see if the spots were still there. The spots on her neck were exactly the same and there were now spots on the outside of both hands and between Rachael’s fingers on both hands, the spots were red/purple in colour.
Dr Taylor’s visit
16.	Mrs Knott said that Dr Taylor arrived between 12 noon and 1.00pm. In her witness statement Mrs Knott said “I told Dr Taylor that I was concerned about Rachael’s vomiting and possible dehydration, because she wasn’t keeping any fluids down. Rachael was still hot and lethargic. When Dr Taylor examined Rachael, I told her about the nonsense she had been saying in the night”.
17.	In her oral evidence Mrs Knott said that she took Dr Taylor up to her bedroom and Dr Taylor sat on the bed with Mrs Knott. Mrs Knott told Dr Taylor that on the previous day Rachael had spots on her neck, a high temperature and vomiting.  She had been hallucinating during the night, Mrs Knott could not get anything into her and she thought Rachael might be dehydrated. Rachael was lying on the bed, Dr Taylor pinched Rachael’s tummy and then helped Mrs Knott to sit Rachael up. Dr Taylor examined Rachael’s ears, nose and throat. Mrs Knott could not remember if Dr Taylor had examined Rachael’s chest. Dr Taylor placed her fingers in and around Rachael’s neck and said the glands in Rachael’s neck were swollen. When she was doing that, she put her hands behind Rachael’s head and pulled it down. Dr Taylor held Rachael’s hands and as she did so Mrs Knott pressed the spots on Rachael’s hands to demonstrate that they were not going away. Dr Taylor told Mrs Knott not to worry because the spots were not raised. Dr Taylor agreed with Dr Leading that Rachael had a viral infection. When Dr Taylor finished her examination Rachael was laid back down. Dr Taylor told Mrs Knott that if she was not happy, she should ring the surgery at Shaftston as there was a surgery there in the afternoon.
18.	After Dr Taylor’s visit, Mr Knott returned home, it was noted that there were now spots on Rachael’s legs. The spots were exactly the same as on her neck. In her statement Mrs Knott records the spots being on the front of Rachel’s thighs. In the afternoon Rachael slept, her sleep was very heavy and she was very hot. 
19.	In the evening, shortly after 7.00pm, Mrs Knott was watching television, Rachael was in her arms. Rachael woke up with a start and said “Mummy, I can’t hear you”. As a result of Rachael’s comment, Mrs Knott telephoned the out of hours GP service and spoke to a call handler. The call was logged at 20.06hrs. By the time Mrs Knott received a return phone call from the out of hours service, Rachael had vomited a small amount of blood. She vomited into a metal bin and her parents took it with them when they went to the out of hours surgery and to the hospital. Mrs Knott was asked by a doctor in the out of hours service if they could take Rachael to the surgery right away. Rachael was taken by her parents, accompanied by her brother, to an out of hours surgery. Their arrival is timed at 21.26hrs on the out of hours service records. At the surgery Mr and Mrs Knott saw Dr Arjun, who having heard Mrs Knott’s account, told her to take Rachael to Pinderfields Hospital immediately. The doctor said that it was quicker to go by car and he gave them a letter to take to the hospital.
Out of hours service records
20.	Mrs Knott’s telephone call is recorded as follows: “PT started with sickness yesterday am and high temp with rash – GP visited and dx viral infection – visited again this am with same symptoms – advised paracetamol and fluids – tonight still being sick and mum said gone deaf – mum worried about dehydration”.
The doctor’s note timed 21.39hrs reads:
“h/o sickness for the last two days no diarrhoea
o/e temp 38C unable to hear properly
pulse 160 per minutes
cvs nad chest clear git nad
admitted in ward a pgh”.
The admission letter written by Dr Arjun records, inter alia,
‘Sickness for the last two days c̀ temp & rash on……legs taking paracetamol.’
The computer records maintained by the service record the doctor’s hospital
admission form as including the following information:
History
History of sickness for last 2 days.  Temp 38C.  
Rash on leg
Taken paracetamol.
On Examination
Temp 38C
Rash on leg
Loss of hearing
Pulse 160
CVA normal

Pinderfields Hospital
21.	Mrs Knott said that they arrived at about 10.00pm and went straight to A ward.  Mr Knott carried Rachael in.  Two nurses were waiting for the family and one of them asked Mrs Knott what had been going on. Mrs Knott told the nurse that Rachael had been vomiting; there were spots on her neck. The nurse wrote it down and examined Rachael. Mrs Knott said that at the hospital the spots were still on Rachael’s neck, the sides of her hands and in between her fingers. She could not remember whether there were any spots on Rachael’s legs because by that stage she was frantic.  On ward A they were seen by a doctor and Mrs Knott told him the history of the past two days. The doctor would have been Dr North.  Mrs Knott said she could not remember whether or not the doctor checked for neck stiffness but she definitely pointed the spots out to the doctor.  It was her memory that he pressed on them to show that they did not go away. Mrs Knott said that the junior doctor did not seem too worried about Rachael’s condition and said that he would do a blood test. A couple of hours later Rachael was seen by Dr Bishop who wanted to carry out a lumbar puncture, he said Rachael should have antibiotics right away. A lumbar puncture was performed and Dr Bishop said that the fluid extracted was cloudy; Dr Bishop said they did not really need to send it off to know that Rachael had meningitis. Dr Khan took over in the early hours of Friday morning, 20 April.  Rachael got better quite quickly and went home on the following Tuesday.
Mr Malcolm Knott
22.	On the morning of 19 April 2000 Mr Knott recalled Rachael being very poorly, she had a high temperature and was sick before he went to work. He left for work at around 7.45am. In his witness statement he records: “At about 9.00am, I recall Karen and I spoke.  She told me very briefly that she had asked one of the GPs to come and see Rachael at home….My usual  lunch break is from 12.30pm to 1.00pm…... my recollection is that Karen called me while I was on my break, so this would be normally between 12.30pm and 1.00pm. She told me that Dr Leading had seen Rachael and had just left. He thought Rachael had a virus”.  In his oral evidence Mr Knott’s understanding was that on the first occasion that his wife called the doctor, he did not think she suspected meningitis, if she had done, that would have caused alarm bells.  In the phone call following Dr Leading’s visit, Mrs Knott did not mention to her husband that Rachael had spots.
23.	Mr Knott returned home from work shortly after 5.00pm and went to see his daughter. In his statement he records: 
“I went upstairs and Rachael was in mine and Karen’s bedroom, in the double bed. I think she was asleep. She looked very poorly indeed – she was very pale and her skin had a waxy look to it. Karen pointed out three spots on her neck and said she was worried about them. They were red or purple, quite tiny and about one centimetre apart. She said she had pressed on them and they didn’t go away but Dr Leading wasn’t concerned about them…Karen continued to worry that Rachael might have meningitis. There had been a lot in the news about the illness and lots of other parents were worried about it. I tried my best to reassure Karen…I reminded her that Dr Leading had checked Rachael; had looked at these spots; and he didn’t think Rachael had meningitis”. 
In his oral evidence Mr Knott described the spots as three pin pricks.  He also said that in his presence, his wife pushed on the spots and they did not fade.  The spots stayed in exactly the same place and remained the same until Rachael went into hospital.   Mr Knott described the spots as being half way down the right side of Rachael’s neck.  Mr Knott said that he could not remember if he and his wife had discussed what the spots might mean. As to the spots on Rachael’s neck, Mr Knott said that his wife had never mentioned a rash and had never talked about a rash.  In his opinion, the spots on Rachael’s neck were a rash.  In the witness statement of Mr Knott there is no reference to his being aware of the existence of any spots until he arrived home after 5.00pm on 19 April.
20 April
24.	Before leaving for work Mr Knott briefly saw Rachael. She was not any better. She was very pale, waxy, there was no life in her. His wife told him that during the night Rachael had been saying “silly things”. Mr Knott was aware that his wife was going to call the surgery again for a home visit. He returned home during his lunch break because he was so concerned about his daughter. Mr Knott arrived shortly after Dr Taylor left.  His wife told him that Dr Taylor had reached the same conclusion as Dr Leading. Mr Knott in his statement stated: “Karen said to me ‘Look, there are more spots on Rachael’s leg’. Karen was pressing the spots and they would not go away. The spots were just like those on her neck, which were still there. Karen was really upset and I was trying to calm her down. She was almost frantic”. In his oral evidence Mr Knott said that when he went upstairs, his wife “had Rachael sat on her”, she was supporting her. He described Rachael as being like a rag doll, there was no life in her. Mr Knott said that he did not know who first noticed the spots on Rachael’s legs, the same as on her neck.  They were dark, red, purple and small.  They did not fade under pressure.  There were also spots on the side of her hands and in between her fingers.  Mr Knott accepted that nowhere in his witness statement was there mention of spots on Rachael’s hands.
25.	When Mr Knott returned home at the end of his working day Rachael was asleep, he did not want to disturb her. Later, he was downstairs with his son when his wife called saying that Rachael could not hear her. Mr Knott took his wife, Rachael and son to the out of hours surgery. Mr Knott carried Rachael towards the surgery and then handed her to his wife who carried her in.   They went from the surgery to the hospital.  At the hospital Mr Knott said that Rachael had three spots on her neck, there were also spots on her hands and legs.  Mr Knott said that to a parent Rachael was very poorly, she was prodded about a bit and that made her more alert. He did not remember her talking in hospital.
26.	Following Rachael’s diagnosis, Mr and Mrs Knott, their son and Mrs Knott’s aunt had to be given antibiotics because they had been in close contact with her. Mr Knott was at Crofton Health Centre waiting for the antibiotics.  He described what occurred in his statement: “Although I was not there to see Dr Leading, he asked to see me between his patients. He was very distressed and upset. He said that he had thought about meningitis but he did not think that Rachael had meningeal signs. He said he was very sorry and he had tears in his eyes during this discussion”.
Dr Alan Leading
27.	Dr Leading obtained his primary medical qualifications in 1974. He holds the further qualifications DFFP and diploma in advanced general practice. He is a member of the Royal College of General Practitioners. He has been a GP principal in his current practice at the Crofton Health Centre, since completion of his GP training in 1979.
Background
28.	The family of Rachael Knott had been registered with the practice for many years. Dr Leading said he had always enjoyed a good relationship with Karen Knott, her husband and children and had seen them on a regular basis over the years. He had been involved in Mrs Knott’s care during her pregnancies.  He described them as a pleasant family to deal with. On reviewing the medical records, Dr Leading noted that Rachael had suffered from fairly regular upper respiratory tract infections with associated ear ache through childhood. On 14 January 2000 she was seen in the surgery with a complaint of ear ache.  On 12 April 2000 she was again seen complaining of ear ache and a sore throat. In the right ear otitus media was diagnosed and she was prescribed with a five day course of erythromycin. It appeared to have been the recurring problem of upper respiratory tract infection with associated ear infection.
29.	Dr Leading said that a few weeks prior to 19 April 2000 as a course trainer and course organiser in the Wakefield district, he had been involved in an educational day along with other GPs and hospital doctors. During the day, considerable time and discussion was given to the diagnosis and treatment of meningitis, the signs and symptoms, specifically distinguishing between blanching and non-blanching spots.
19 April 2000
30.	In April 2000 calls to the surgery requesting home visits were received by the receptionist who contemporaneously noted the content of the call and its time in a visit book. Morning surgery would commence at 8.30am and end between 10.30am and 11.00am. All calls for home visits taken during morning surgery would be allocated to the doctors on duty at its conclusion. There is no morning call from Mrs Knott recorded in the visit book.  On 19 April 2000, the latest morning call is timed at 10.20am.  The allocation of the morning visits to the doctors is shown on an adjoining page.  An audit trail of the surgery’s computerised notes demonstrates that the morning calls received were entered into the computerised record at 12.36 or 12.37hrs.  There is no entry for Mrs Knott.  The call from Mrs Knott is noted in the visit book as being received at 2.10pm.  A further call from another patient is timed at 4.30pm.  Both these calls were transferred to the computerised record at 16.36hrs.   
31.	Dr Leading said that on 19 April 2000 he was on the on call duty doctor. Following morning surgery the home visits were allocated to the doctors on duty. After those visits had been done Dr Leading was responsible for home visits until later in the day. Dr Leading was in the surgery when Mrs Knott’s request was received. Dr Leading read the entry in the visit book. Taking Rachael’s notes with him, he went to her home, a matter of minutes from the surgery. At the house Dr Leading opened the door, entered and called out. Karen Knott indicated that she was upstairs, he followed her voice to the bedroom. 
32.	When Dr Leading walked into the bedroom he saw Rachael on the bed, sitting upright in the centre with her legs crossed. She appeared alert, she was not distressed. It was a sunny spring day, the curtains were open and the lighting was bright.  In his witness statement Dr Leading said that he asked Mrs Knott to tell him about Rachael’s condition. Mrs Knott explained that Rachael had been sick a number of times and had been running a temperature. Dr Leading noted that there was a bucket on the bedroom floor. He said that Mrs Knott was obviously concerned about her daughter but she was not frantic or panicking. Mrs Knott raised the possibility of meningitis early in the consultation.  In his statement Dr Leading recorded that meningitis is always a potential diagnosis which is at the forefront of his mind when examining a child with generalised symptoms.  Dr Leading told the court that he could not remember whether it was Rachael or her mother who was responding to his questions. He said that when examining, Rachael was able to follow his requests without difficulty.
Dr Leading’s examination of Rachael Knott
33.	In his witness statement Dr Leading recorded: 
“My examination of Rachael is obviously central to this case and I will comment on it in detail. Her temperature was raised. She had a rash which I have described as “urticarial”. By this I mean a rash in which the skin is slightly raised, like a nettle rash or hives. The rash was present across her upper chest and neck. The rash looked quite different to the petechial or purpuric rash which is associated with meningitis. I am familiar with the typical appearance of a meningeal rash having seen cases on several occasions during my twenty years in general practice. Petechial rash associated with meningitis does not blanch on the application of pressure. The urticarial rash on the chest was totally different from the haemorrhagic or petechial rash which is typical of meningococcal disease. I did not apply pressure to this area of urticarial rash on the chest in order to assess whether it blanched on the application of pressure or not as I was entirely happy that this was not meningococcal in origin, having seen similar urticarial rashes of viral origin on a great many occasions during my career as a general practitioner up to that date and since”.  
As to the lesion on the neck, in his statement Dr Leading said: 
“It was of a slightly different appearance to a generalised rash. I looked at it carefully, and found that it blanched completely on the application of pressure, and I consider this was also a small urticarial lesion”.
34.	In his evidence to the court, Dr Leading said that he examined Rachael’s chest for signs of infection and observed her. Rachael had a rash across the upper part of her chest. It was slightly raised, several centimetres across, it was a pinkish red. In Dr Leading’s opinion the rash had the appearance of an urticarial rash which is commonly seen in viral infections. Dr Leading said he did not apply pressure to the rash because it was so typical of an urticarial rash which he had seen many times before. It did not have the appearance of a meningeal rash; there were no petechial spots present. 
35.	Karen Knott did point out a spot on the base of the left side of Rachael’s neck, she said she was worried about it. The spot was one millimetre in diameter; it was pink, flat and oval in outline. It was larger than a pin prick. In the opinion of Dr Leading it had more of a macular appearance, a flat skin lesion. Dr Leading applied pressure to the spot and it blanched. He said he applied pressure mainly because of Mrs Knott’s concern. Dr Leading agreed that he did say to Mrs Knott “It isn’t what you think”; he said he did that after he had assessed the spot, when re-examined he could not recall exactly when he said it.  Dr Leading said he examined Rachael’s skin by observation to see if there was a rash at any other points on the back, buttock and thighs. There was no rash. 
36.	Dr Leading accepted that in his oral evidence he had described the lesion as a macule and not a small urticarial lesion. He said he had thought about it afterwards and it was the difference between a rash and a spot. He said the separate lesion was a macule. He accepted there was no description of the macule in his note of the examination, in his letter of response to the claimant’s solicitor’s original letter or his witness statement. He said that is in fact what he saw.
37.	Dr Leading said that he was aware that a maculopapular rash can appear in the early stages of meningococcal disease and in a number of other conditions. He said that an identification of maculopapular rash does not exclude meningococcal disease if other symptoms and signs are present. Dr Leading accepted that he did not identify in his note where the rash was. He said the bigger part of the examination is visual, he did not need to physically examine from what he had already seen. The rash did not contain any macular elements in the main part of the rash. He accepted that if the hospital was correct that the spot on the neck was petechial, he had made a mistake in assessment.
38.	In order to examine Rachael’s neck movements, Dr Leading put his hand on her head and asked her to extend it by bringing her head forward from her chin to touch her chest. He was using his hand to steady Rachael’s head, he was not forcing it. Rachael was able to bring her chin onto her chest. Dr Leading also asked Rachael to move her head from side to side. There was no restriction of movement. Rachael showed no sign of discomfort when asked to perform the manoeuvre.  She was able to comply with Dr Leading’s request without complaint or difficulty. Dr Leading said that if there had been any discomfort he would have moved to Kernig’s test.  He did not want to disturb Rachael unnecessarily by performing the test and as he was fully satisfied as a result of his examination that she had a full range of movement without discomfort, there were no symptoms of meningitis apparent. No photophobia was present as Rachael was quite happily sitting in a room brightly lit by daylight.  Dr Leading said that he was told that Rachael had been suffering from a headache but he was not told she was suffering from pain which he would have regarded as myalgic pain.  At no time did Rachael moan when being examined.  In Dr Leading’s opinion, the potential diagnoses were infection or allergy.  
39.	Dr Leading examined Rachael’s ears and throat.  He found inflammation in one ear and in her throat, this assisted him in making a diagnosis of viral upper respiratory tract infection. If a bacterial infection of the ears and throat had been present he would have expected the appearance to be angry and red, in this case it was pink. Further he would have expected to see ulceration or exudate at the back of the throat. They were absent. In examining the ears Dr Leading used an otoscope. The chest was clear with no sign of congestion which also supported his view that a viral infection was present.
40.	Dr Leading said he was told by Karen Knott that Rachael had vomited on a number of occasions during the morning; he said he would be concerned about vomiting, he would want to know how often she had been vomiting and if she was tolerating fluids. He would have enquired about her fluid intake and would have wanted to know if there were any signs of dehydration from vomiting. He made no note of the vomiting. As to dehydration he said he would have checked her mucus membranes when he checked Rachael’s mouth, he accepted that there was no mention of this in his statement.
41.	A patient presenting as unwell with vomiting and a rash was something Dr Leading had encountered fairly frequently as a presentation of illness. He quite frequently encountered blanching and white spots and it was the level of frequency which gave him the confidence to move to a diagnosis of viral illness although it did not allow him to completely eliminate differential diagnoses.
42.	Dr Leading said that having completed his examination he spoke to Karen Knott about the possibility of meningitis and told her he could find no evidence to suggest it in this case. Rachael had just completed a course of erythromycin and he did not consider it appropriate to prescribe further antibiotics. He informed Karen Knott of his diagnosis of a viral infection and advised her that Rachael’s raised temperature was likely to continue for between 24 and 48 hours and this may be accompanied by continued vomiting for a while. He explained that it was important to control Rachael’s temperature by taking paracetamol which would serve to reduce temperature and act as a painkiller, Rachael should be given plenty of fluids at regular intervals.  If there was no improvement in Rachael’s condition in the next 24 to 48 hours then Karen Knott should contact the surgery again for further advice and if she was concerned about the progression of any symptoms then she should contact the surgery. The note made by Dr Leading was wrongly dated 18 April 2000 and it read:
“viral URTI
Temp. Urticarial rash
Throat + ear inflamed.
Chest clear. No meningeal signs. Advice”

As to the mistake of the date Dr Leading said that he realised that when first 
informed of the claim around August 2000. He made the entry above “was in 
fact 19.4.2000 at 2.10pm” at that time. The timing came from the entry in the 
visit book.
43.	In cross-examination, Dr Leading accepted that if he had suspected meningococcal disease on clinical examination he would have referred Rachael urgently to hospital, the threshold of suspicion is a low one, the consequence of a mis-diagnosis can be dire, one needs to be confident and exclude on clinical grounds before deciding not to refer. He also accepted that the diagnosis of meningococcal disease in its early stages can be very difficult, the symptoms and signs being non-specific. He agreed that as between viral and meningococcal disease there can be common symptoms.  There is a need to take a thorough history and carry out a thorough examination which includes engaging with the child.  Dr Leading agreed that for the purposes of this potential diagnosis there were two “red flag” signs: photophobia and neck stiffness.  It was suggested to Dr Leading that he had determined early on in Rachael’s examination that she had a viral infection as a result of that he did not do a careful assessment. Dr Leading did not accept that proposition.
44.	After Rachael was admitted to hospital Dr Leading said he wanted to make contact with the family to find out how she was getting on. He was concerned as to how it was he could have missed meningococcal disease. He agreed that he spoke to Mr Knott in his consultation room, he said he was upset but he could not recall being in tears. The point he was seeking to make to Mr Knott was that he had considered meningitis when examining Rachael but had come to the conclusion that she did not have it. He said that he was sorry. Dr Leading said it was an adverse outcome, that he wished there had been signs to guide him to a diagnosis at the time.
Dr Joanne Taylor
45.	Dr Taylor graduated in 1993 with the degrees of MBChB.  She holds the further qualifications of DFFP and DRCOG and is a member of the Royal College of General Practitioners. Dr Taylor commenced her general practice training in August 1994, she held a post in paediatrics at Pinderfields General Hospital from February to August 1996, she completed her vocational training in August 1997.  Dr Taylor became a partner in the practice at the Crofton Health Centre in February 1998 and has remained as a partner at the practice.
20 April 2000
46.	Dr Taylor was performing morning surgery at Crofton Health Centre. A call is recorded from Rachael Knott’s mother at 9.17am. Following morning surgery Dr Taylor was allocated a visit to the Knotts’ home. Dr Taylor said that she had Rachael’s notes, she also read the entry in the visit book. She saw that her partner Dr Leading had diagnosed Rachael as suffering from a viral upper respiratory infection. Dr Taylor believed that she would have arrived at the Knotts’ home between 12.30pm and 1.30pm. When in the bedroom with Mrs Knott and Rachael, Dr Taylor asked Mrs Knott to recount the history. Dr Taylor was sitting on the bed in front of Rachael.  Mrs Knott said that Rachael had woken up with a temperature, begun vomiting in the morning, she had been seen by Dr Leading.  After Dr Leading left, Rachael continued to have a temperature that went up and down, she vomited on a number of occasions. During the night Rachael had become somewhat disorientated, was hallucinating but had settled down by the following morning. Dr Taylor asked Mrs Knott if Rachael was taking fluids and was told she was. She also asked if Rachael had been to the toilet and was told she had passed urine and was not suffering from diarrhoea. Mrs Knott said that the spots on Rachael’s arms and leg had appeared the previous day but not when seen by Dr Leading. At the time of Dr Taylor’s visit, Rachael was sitting up in bed, she was alert and taking notice.  In asking Rachael to move during the examination, Dr Taylor did not have to repeat herself. Rachael was socially responsive. Dr Taylor said she had spoken to Rachael but she could not recall if she spoke directly back. It was Mrs Knott who gave the history.  When examining Rachael, Dr Taylor was standing in front of her, an arm’s length away.  It was a bright day, the room was well lit by daylight.
Dr Taylor’s examination of Rachael Knott
47.	In her statement Dr Taylor records: 
“On examination Rachael did have a rash on her hands and arms. Karen was naturally concerned about the possibility of meningitis, and my first consideration on checking the rash was to decide whether it could be a symptom of meningitis. The rash did not have the reddish/purplish haemorrhagical appearance which is associated with meningococcal rashes. I checked the rash on her arms and hands to ensure that it blanched on the application of pressure. I do this test by applying pressure to the lesion and to ensure that it fades and then refills with blood. I performed this test on Rachael’s spots and was satisfied that they blanched on the application of pressure.” 
48.	In her evidence to the court, Dr Taylor said she tested all the spots on the hands and both arms. She did not count how many but there were not so many that she could not test them all. It was important to do that in order to assess the significance of these spots. Dr Taylor accepted that Mrs Knott showed her the spots but it was Dr Taylor who took Rachael’s hands in her own.  Rachael’s hands were warm and this is when Dr Taylor checked the spots. Dr Taylor did not recall Mrs Knott pressing the spots on Rachael’s hands, she said that even if Mrs Knott had done so, she would have checked them herself. 
49.	The spots were pinkish in colour, about one millimetre in size, larger than a pin prick.  Within the rash, Dr Taylor saw a mixture of macular (raised) and papular (flat) spots.  There was no rash on Rachael’s chest.  Dr Taylor did not recall Mrs Knott pointing out three spots on Rachael’s neck.  Dr Taylor was aware that Mrs Knott was very concerned as to what the rash might signify. Dr Taylor did not say it is ok, they are not raised, it is not something she would have said as it would not have made sense.   Petechiae are flat, if a spot is raised it is more likely to be reassuring.  If the spots had not blanched Dr Taylor would have admitted Rachael to hospital. Dr Taylor said she was familiar with the rash of meningococcal disease. She had seen it when doing a six month paediatric attachment in hospital.  When in general practice she had queried meningococcal rash in several patients, given antibiotics and admitted the patients but none developed meningococcal disease.  Dr Taylor said that she would not have hesitated to refer Rachael immediately to hospital if she had suspected meningococcal disease.  The importance of excluding meningitis in children is stressed in GP training.
50.	In examining Rachael, Dr Taylor also felt around her neck, in doing so she flexed Rachael’s neck forward, her chin reached her chest, Rachael was able to do that without any pain in the neck.   To test for hydration Dr Taylor checked Rachael’s mouth, it was wet.  She pinched the skin to ensure elasticity, she was happy that Rachael was not clinically dehydrated. Rachael’s temperature was 37.6o C, moderately raised, but not sufficiently to cause concern.  
51.	Dr Taylor checked Rachael all over.  Dr Taylor examined Rachael’s chest with a stethoscope, examined her abdomen which was soft and non-tender.  When Rachael lay down Dr Taylor examined her legs, the back of her legs and lower buttock. She listened to the back of her chest when Rachael was sitting up.  She was able to check the back and her upper buttocks. No spots were present.  Dr Taylor noted that Rachael had continued vomiting overnight.  The vomiting was on and off, it was not continuous.
52.	Dr Taylor could not recall what questions she had asked about Rachael’s activity levels.  As to her mother’s contention that she had to prod Rachael to rouse her, Dr Taylor said that was not the case at the time of her visit. Dr Taylor was aware that Rachael had been up in order to go to the toilet, she said she may have been told that she had to be carried there. Dr Taylor did not accept that when Rachael was sitting up she was supported by Mrs Knott.  It was suggested to her that she was told that although Rachael was taking fluids she was not keeping them down. Dr Taylor said that was not the information she was given when she asked about fluids.  Dr Taylor did not recall being told Rachael was in pain.  As Rachael moved about there was nothing to indicate that she was in pain. She said she could not recall if she asked about a headache but there was no evidence of a headache when she was there. 
53.	Dr Taylor diagnosed a viral upper respiratory tract infection and told Mrs Knott of her diagnosis.  Dr Taylor advised Mrs Knott to give Rachael plenty of fluids and paracetamol.  In her notes, she recorded “RBIN this pm if not happy” (Ring Back If Necessary).  Dr Taylor explained to Mrs Knott that she would be at Sharlston surgery that afternoon.  If Rachael’s condition gave any further cause for concern, she should not hesitate to contact Dr Taylor. 
Dr Taylor’s note of the consultation
54.	“Cont vomiting O/N.  Temp still up + down.  Taking fluids.  Still some rash on arms, blanching, nil else.  O/E ENT red.  No meningism.  Hydn √.  T37.6.     Chest clear.  Abdo soft, non-tender.  Adv cont fluids/Paracetamol.  RBIN this pm if not  happy.  PU √ BO √”.
Pinderfields Hospital
55.	The medical and nursing records of Rachael Knott were produced.  The relevant entries are below:
Triage Admission Form
56.	A triage admission form timed at 22.05 on 20.4.00 was completed.

Nursing Note
57.	Timed at 22.00 hours on 20.4.00, this records:
“Acute admission via on call GP with a 48 hour history of vomiting and pyrexia, recently treated for an ear infection with a course of erythromycin.  Over the past two hours has complained of deafness.  On warding accompanied by both parents temp 37.2oC pulse rate 158 very reluctant to stay.  Unable to hear at present.  Has small non blanching area around right arm and hand x2 small to neck.  Ametop applied.  2230hrs seen by Dr North – no complaints of neck stiffness Kernigs sign – negative, urine sample obtained and urinalysis performed.  Protein, ketones and blood present.  Discussed with Dr Bishop ? urinary tract infection.  Bloods obtained canula sited.  Has vomited ++ at home to commence intravenous infusion of dextrose saline.”
Doctor North’s note
58.	Dr North was the doctor who saw and examined Rachael upon admission.  His is a lengthy and detailed note, dated 20.04.00.
It records, inter alia,

“……Started vomiting yesterday and retching…...Vomited x 4 today.  Not tolerating fluids….Mum noticed Rachael deaf later..not responding to her → called GP….Immunisation| Up to date – Awaiting meningitis….Not responding to voice…..cvs – no neck stiffness although not quite full flexion….No photphobia Kernigs – ve Few petechiae arms + neck (Present – 24 hours…IMP → ? UTI causing vomiting deafness 2o to ? sinusitis ?? cause of petechiae”
Doctor Bishop’s note
59.	This is likely to have been completed prior to 01.00 on 21.4.00, it records inter alia:
“24 hr hx of vomiting and pyrexia……?  Delirious at times Mum noticed a rash on her arms last pm  No definitive change Not keeping anything down…?  Having difficulty hearing this pm.  Not as responsive to mum as normal.  C/O Headache yesterday.  None today…O/E Temp 37.9oC Flushed…..CNS Glazed expression Awake…..No photophobia ?.....Minimal neck stiffness on extreme flexion Kernig’s – ve.  Skin – Non blanching purpuric rash over both arms.  Few spots over lower limbs + on back…Imp??  Viral illness ?? Meningococcal meningitis (? partially treated)”
Expert Evidence
60.	For the purpose of assessing breach of duty, the following experts were instructed, produced reports, attended meetings and produced joint statements.
Claimant
Dr Nigel Ineson – General medical practitioner
Dr Alastair Thomson – Paediatrician
Professor Nigel Klein – Professor of infectious diseases and immunology
Defendant
Dr Ian Isaac – General medical practitioner
Dr Stephen Conway – Paediatrician
Professor Keith Cartwright – Clinical microbiologist

Meningococcal disease
61.	Meningococcal disease is an infection caused by a gram-negative bacterium, neisseria meningitidis (the meningococcus).  The normal habitat of this microbe is the back of the human throat, though carriage of meningococci is comparatively common.  Once in the bloodstream the meningococci may be cleared spontaneously by the body’s natural defence mechanisms.  If this does not happen, they may begin to multiply and/or migrate to and invade the meninges, the linings of the brain.  As meningococci multiply in the bloodstream, they produce and shed amounts of cell-borne substance, rich in endotoxin and this is released into the circulation by bacteria.  It is endotoxin and the body’s damaging inflammatory response to it that cause the symptoms that characterise systemic meningococcal disease – fever and skin rash.
62.	The classical skin rash of meningococcal infection comprises petechiae or purpura.  Petechiae are pinhead-sized, red-purple spots that are caused by small haemorrhages into the skin.  The bleeding results primarily from the damage from the walls of small blood vessels and capillaries in the skin, augmented in some cases by a disturbance in blood clotting mechanisms, both precipitated by meningococcal bacteria and the release by them of endotoxin.  Purpura are larger areas of haemorrhage into the skin.  They resemble bruises, but as they develop, they may darken, spread to involve wider areas of body surface, extending into the underlying tissues.
63.	Meningococcal disease can be meningitis, septicaemia or a combination of the two.  Meningitis is an infection of the meninges, which develops after the bacteria has spread there via the blood stream.  Septicaemia, in which the spread through the blood stream results in overwhelming infection, is a more dangerous form of the disease.  Meningococcal disease can begin insidiously and then develop very rapidly.  It may often follow a viral or other infection.  Unfortunately for clinicians and their patients, the early symptoms and signs of meningococcal disease are non-specific and are common to other minor or viral infections.  They often do not allow for early suspicion that a serious illness is developing nor lead to an early diagnosis.  Even when there is no viral infection, the first symptoms of meningitis are non-specific and so similar to those of viral infections that no distinction can be made between the two.
64.	The specific diagnosis of meningococcal disease can be made in three ways:
i)	Septicaemia is generally only suspected when the characteristic petechial or purpuric rash develops in a feverish, ill child;
ii)	Meningitis may be suspected when a child presents with suspicious symptoms and, in addition, is found to have a stiff neck and/or a positive Kernig’s sign (pain in the neck, when a child with hips and knees flexed has the knee extended).  The initial symptoms of meningitis are non-specific, as the condition progresses, the child may develop a constellation of symptoms.  The typical symptoms of meningitis include fever, vomiting, headache, lethargy, drowsiness, neck stiffness and dislike of bright lights (photophobia) and eventually coma.  Symptoms such as neck stiffness and photophobia, as described by the patient, are highly subjective and may be difficult to interpret.  On examination, the main signs to seek are neck stiffness and Kernig’s signs.
iii)	Children may present with a combination of the above.
65.	The diagnosis of meningococcal disease is made even more complex because one in three children can develop an early rash which is not typical of the petechial or pupuric rash.  Maculopapular spots or rash consist of flat altered skin (macule) together with raised altered skin (papule).  It is usually pinkish in colour and blanches under pressure.  The macular rash is not diagnostic and often leads to a mis-diagnosis of viral infection which can only be corrected when petechial and purpuric rash presents.  
66.	At the time of admission to hospital on 20 April 2000, Rachael Knott had bacterial meningitis caused by meningococcus serogroup C.  As between the experts, the likely formulation of events is:
i)	Meningococcal infection probably began with invasion of the bloodstream by meningococci very late on 18 April 2000 or in the early hours of 19 April followed by;
ii)	Development of non-specific symptomatology in the morning of 19 April;
iii)	The meninges were breached 12 to 24 hours after invasion of the bloodstream, during the night of 19/20 April so that by morning of 20 April, there were organisms already in the cerebrospinal fluid and white blood cells were about to follow in response to the presence of these organisms i.e. meningitis evolved overnight between 19/20 April;
iv)	Signs of meningitis probably take at least 12 to 24 hours to develop after invasion of the meninges by organisms spreading from the blood stream.  Acute infection in the meninges evolves slowly at first and then more rapidly.  The growth of the infecting bacteria is exponential; this is because the bacteria which have settled in the meninges multiply by doubling.  While the bacteria are multiplying, they begin to stimulate an inflammatory response.  There is a lag phase between the multiplication of the organisms and the inflammatory response;
v)	There were no clear signs of meningitis, neck stiffness or Kernig’s sign during the day of 20 April because these were found to be subtle even when Rachael was later admitted to hospital;
vi)	Rachael developed sensorineural deafness as a result of meningitis.  Treatment with antibiotics at any time on 19 April or in the early hours of 20 April would have preserved Rachael’s hearing.
Paediatric Experts
67.	The following summary represents the agreed evidence of the paediatricians, save where otherwise stated.  The classic rash of invasive meningococcal infection is one of petechiae progressing to purpura, it will be seen in the large majority of these infections.  The non-petechial maculopapular rash may be the early presenting lesion in about 20% of cases and is usually superseded by the haemorrhagic rash.  The two types of rash may co-exist for a time as the maculopapular element subsides and the petechial element increases.  By the time the meningitis is established, the petechial rash is much more commonly present than the maculopapular rash.  Dr Thomson said that whilst all of this is true, individuals can respond with a wide spectrum of clinical features in meningococcal disease.  
68.	In the timeframe of this case, approximately 48 hours, it would be unlikely for petechial spots to disappear without treatment.  Maculopapular spots may commonly disappear without treatment during the course of the evolution of meningococcal disease.  It is reasonably common in cases which have a maculopapular element to have a skin rash which consists of both petechial and non-petechial spots.  Petechial spots do not tend to evolve at exactly the same site as maculopapular spots, though they may be very near or adjacent to the site and occasionally a petechial spot may coincidentally develop in an area where a maculopapular spot has faded.  Dr Conway said that a maculopapular spot may evolve/develop into a petechial spot (the centre of the spot becoming petechial) but more usually the maculopapular lesion will fade and petechial lesions will develop around the same area.  A petechial spot can quite commonly emerge at the same site, broadly in the same area, of a maculopapular spot which has recently disappeared.
69.	If there were no neck spots at 12.30pm to 13.30pm on 20 April (Dr Taylor’s examination), petechial spots could have emerged by 22.00hrs on admission to hospital.  Petechial spots can develop “in front of one’s eyes” within minutes.  A maculopapular blanching rash can disappear within an hour or up to several hours.  If there was a maculopapular blanching rash/spots on Rachael’s hand or arm at 12.30pm to 13.30pm on 20 April, that could have disappeared and been replaced by a petechial rash at or near the same or similar sites before 22.00hrs on the same day.  Dr Thomson said that petechial spots may appear in a similar site to the disappearing maculopapular spots but tend not to do so in exactly the same location.
70.	If Mrs Knott’s account is correct, Dr Conway said in the following 32 hours the number of petechiae would be likely to have increased, not necessarily confined to the neck.  It would be very unusual for a proliferation of petechiae to slow or become static.  Dr Thomson said it is possible but for the court to decide what happened.  Non-proliferation of isolated petechiae over 24 to 32 hours is uncommon.  Dr Thomson said it is possible.  In his oral evidence, Dr Conway said he could never say never but it would be very unusual.  Dr Conway and Dr Thomson were of the view that the group of spots described by Mrs Knott belonged to the same type as opposed to a mixed group of petechial and non-petechial spots.  
71.	On Mrs Knott’s account, namely that Rachael had three petechial spots which would have been a specific diagnostic clue as to the presence of meningococcal disease as well as several non-specific features – high temperature, vomiting, rash, pain on neck movement, aching all over, very cold hands and feet, very pale, mumbling speech, all these would make the diagnosis of meningococcal disease likely.  
72.	On Dr Leading and Dr Taylor’s account, no meningeal signs – neck stiffness, photophobia and Kernig’s sign - were present at the time of Dr Leading’s examination of Rachael.  Based on the hospital records, including the blood results and the overall chronology provided by such records, meningeal signs would not be likely to be present at the time of Dr Leading’s examination.  Further, if neck stiffness had been present on the early afternoon of 19 April, it would have been marked on the evening of 20 April.  Both experts were agreed that an ability to walk unaided, altered consciousness or lack of responsiveness together with incoherent or mumbling speech were unlikely to be present at the time of Dr Leading’s examination.  This is because the symptoms suggest significant disease.
Causation Experts
73.	Professor Klein and Professor Cartwright agreed that petechial spots occur in over 80% of cases of invasive meningococcal infection at some stage in the illness, Professor Cartwright put that figure at over 90%.  The petechial spots may be preceded in up to 20-30% of cases by a transient blanching rash that may be macular or maculopapular and that usually disappears around the time the classical petechiae and/or purpura appear.
74.	The experts were asked within the timeframe of this case, how common or uncommon it would be for:
i)	Petechial spots/rash to disappear without treatment: very unusual;
ii)	Maculopapular spots/rash to disappear without treatment: very common, Professor Cartwrights says almost universal;
iii)	A skin rash to consist of petechial and non-petechial rash: quite common, though blanching rashes only occur at all in up to 30% of cases;
iv)	A maculopapular spot to evolve and to develop or evolve at the same site into a petechial spot: Professor Cartwright said quite common, Professor Klein said they can occur in the vicinity but do not directly go from one to another.  In his oral evidence, Professor Klein said “It is possible to have a petechial spot merging within a maculopapular rash.”
75.	If Mrs Knott’s account is correct, in the period leading up to admission to hospital, the emergence of further petechiae would be likely.  Further spots would not necessarily be on the neck.  Cases do occur when spots remain limited but Professor Cartwright said this is very unusual.  In many cases of meningococcal disease, as the organisms and the host response increase, petechial spots along with other manifestations of the disease increase or change.  More petechiae are then highly likely.  As to the possibility of isolated petechiae not proliferating over 24 to 32 hours, in cases of bacterial meningitis, Professor Cartwright said it is not common,  Professor Klein said he could not estimate how common it is but it does occur.  Both experts agreed that on Mrs Knott’s account, the group of spots which she first detected would be likely to belong to the same type if they looked the same.
Professor Klein
76.	Professor Klein said that the description of Rachael, as given by Mrs Knott, could have been interpreted as an indication of meningitis or an unwell child in the bacteraemic stage of the illness.  If Rachael was suffering from a stiff neck at the time of Dr Leading’s examination, which was due to meningitis, then without antibiotic treatment it is highly likely that meningeal signs would have worsened materially over the course of the next 30 plus hours.  As to Rachael’s response to the neck examination, Professor Klein was of the opinion that it could indicate that Rachael simply did not want to be touched or moved.  It did not indicate that the problem was meningeal.  This opinion was shared by all the experts.  Professor Klein thought it unlikely that an inability to walk unaided, altered consciousness or lack of responsiveness together with incoherent or mumbling speech was present at the time of Dr Leading’s examination even if Rachael had meningitis because if present, they would worsened markedly in the absence of treatment.  He said that from his reading of the documents in the case, Rachael did not have meningitis when seen by Dr Leading.
77.	Professor Klein said that within a rash, it is easy to miss spots as the doctor may not be looking for the individual spot or may not examine properly to see if it is blanching.  Parents are good at picking up rashes.  Reliance was placed upon a paper published in the British Medical Journal in November 1996, written by Riordan et al where the point made was that delays in the treatment of meningococcal disease occur when doctors do not recognise the rash that is typical of meningococcal septicaemia, particularly the less well recognised maculopapular rash.
Professor Cartwright
78.	A summary of Professor Cartwright’s evidence is set out at paragraph 86.
General Practitioner Evidence
79.	There was broad agreement between the two doctors, neither gave evidence at trial.  In an unwell febrile child, the diagnosis of meningococcal disease should always be considered and if suspected an urgent referral to hospital should take place.  A general practitioner was required to confidently exclude on clinical grounds the possibility of meningococcal disease before deciding not to refer to hospital.  In 2000, a reasonably competent general practitioner who suspected meningococcal disease should carefully examine the child’s entire body for petechiae.   If three red/purple non-blanching spots were present in an unwell child, this should lead to mandatory urgent referral to hospital.  If the child was unwell and vomiting but without such a rash, this would not necessarily require referral to hospital.  It is the character of the rash which makes urgent referral mandatory.  
80.	The following questions were posed to the experts at their meeting, their response is recorded as follows: 
“Q:  If the court finds that at the time of the attendance of Dr Leading on 19 April 2000 that the claimant was as described in Dr Leading’s note (mistakenly dated 18 April 2000) and did not have any petechiae, was it in accordance with a standard of reasonable care by a GP to diagnose a viral upper respiratory tract infection and not refer the claimant to hospital?
A:  We are agreed that this was, in such circumstances, a reasonable diagnosis to make, and most children in this situation do not require admission, subject to their other symptoms and signs.
Q:  If the court finds that at the time of the attendance of Dr Leading on 19 April 2000 the claimant was as described in Dr Leading’s witness statement at paragraphs 12-29 was it in accordance with a standard of reasonable care by a GP to diagnose a viral upper respiratory tract infection and not refer the claimant to hospital?
A:  The statement describes a thorough and competent examination and assessment by Dr Leading and if accepted by the Court we are agreed that his assessment and management were reasonable.
Q:  On the basis of the version in Mrs Knott’s witness statement, namely that on 19 April 2000 when Dr Leading attended at the Knotts’ home and 
(i) Rachael was exhibiting three small red/purple petechial      spots on her neck
(ii) The spots were non-blanching under pressure
Was it mandatory for Dr Leading to refer Rachael to hospital for investigation of potential meningococcal disease?
A:  We are agreed that it was, as discussed above.
Q:  On the basis of the version contained in Dr Leading’s witness statement that on 19 April 2000 when he attended at the Knotts’ home and
(i) Rachael was exhibiting an urticarial type of rash on her chest and one small pink lesion on her neck
(ii) The small lesion on the neck blanched under pressure
Was it within the range of responsible practice for Dr Leading to assess the condition as viral and not refer Rachael to hospital?
A:  We are agreed that referral was not mandatory, as discussed above.”
Resolution of evidence
81.	As between the evidence of Mr and Mrs Knott and that of Dr Leading and Dr Taylor, there is no middle ground.  Both accounts present difficulties: Mr and Mrs Knott in their evidence of the phone call at 8.30am on 19 April and their description of the gross signs and symptoms exhibited by Rachael.  Dr Leading, in his oral evidence, described the single lesion on Rachael’s neck as a macule, a description not found in his letter of response nor in his witness statement.  Resolution depends in part upon my assessment of the witnesses and also upon how their evidence corresponds with other evidence in the case.  
82.	Mrs Knott is a loving, caring mother, who feels that she should have done more for Rachael, she wishes she had taken Rachael to hospital earlier.  Mr Knott is a caring, loving father who wishes to support his daughter and his wife.  There is no evidence to support their contention that at or around 8.30am on 19 April 2000, Mrs Knott telephoned Dr Leading’s surgery to request a home visit.  The Knott’s home telephone landline records for 19 April 2000 show only the afternoon call to the surgery.  No records were produced for Mrs Knott’s mobile telephone.  The handwritten and computerised surgery records record one call: at 2.10pm on 19 April 2000, this was transferred to the computerised records shortly after 4.30pm.  The note made by the receptionist refers to a rash.  On Mrs Knott’s account, spots did not begin to appear until later in the morning.  In his closing submissions, Mr Oppenheim QC, on behalf of the claimant, all but conceded this point.  
83.	The evidence of Mr and Mrs Knott goes beyond the initial telephone call.  Mrs Knott spoke of a telephone call to her husband following the 8.30am phone call, and a later phone call to her husband during his lunch break (12.30pm to 1.00pm) to inform him of Dr Leading’s visit.  Such a phone call could not have been made at that time as Dr Leading had not visited.  Mrs Knott cannot be right.  Mr Knott gave evidence consistent with that of his wife.  I find as a fact that Mrs Knott did not make a morning phone call to the surgery at or around 8.30am, the first phone call she made was at 2.10pm. Of itself this finding is not sufficient to undermine the entirety of Mr and Mrs Knott’s evidence.  However, if Mr and Mrs Knott are able to give clear evidence as to three phone calls, specifically their timing and content which, in the presence of documentary evidence, is demonstrated to be wrong, it is difficult to regard either witness as wholly reliable.  
84.	One further matter significantly calls into question the reliability of their evidence.  It is the description given by Mrs Knott, and to a lesser extent, by her husband, of Rachael’s general condition from the morning of 19 April to her admission to hospital on 20 April.  On Mrs Knott’s account, Rachael was being continually sick, she could keep nothing down, she barely had the strength to stand, she was very pale, her skin had a “waxy” look.  At the time of Dr Leading’s examination, Rachael was pale, lethargic, very drowsy and tired, she was not speaking clearly but mumbling.  From the evening of 19 April, Rachael did not say much, she just moaned.  By the morning of 20 April, Rachael was very limp and floppy, she kept falling asleep, her mother had to prod her to obtain a response to a question, she was moaning and whimpering and was not able to explain how she felt.
85.	It was the opinion of the paediatric experts that Mrs Knott was describing a very sick child.  This contrasts not only with the description of Rachael by Dr Leading and Dr Taylor, it is inconsistent with the triage note made at Rachael’s admission to hospital.  The description contained in the note is not accepted by Mr and Mrs Knott.  The note records Rachael’s colour as “normal”, her response to social overtures as “chats or smiles”, hydration is normal, Rachael is described as “alert” and the assessment is that she is “mildly ill”.  By this time Rachael was suffering from meningitis, she could not have been mildly ill, but it was her presenting state which is of note.  It does not fit with the description of her parents, even allowing for the stimuli presented by an admission to hospital.  Further, following her admission, blood tests were carried out.  A urea reading of 4.2 and a creatinine reading of 52 indicate that Rachael’s hydration was normal.  
86.	Professor Cartwright said that if Mrs Knott’s account is correct, he would have expected significant worsening over 24 hours although he accepted that within the bacteraemic phase, there would be an equilibrium but he said it can be a short one.  Professor Cartwright said that it is highly likely that Rachael would have been severely unwell and would have obtained a different triage score and different clinical findings on admission to hospital.  The capillary return rate noted at hospital did not demonstrate any evidence of poor circulation at the peripheries, inconsistent with Mrs Knott’s evidence of finding cold hands and feet.  Mrs Knott maintained that Rachael had not taken fluids, Professor Cartwright said that in those circumstances, Rachael would be clinically dehydrated on admission with lax skin and raised urea.  These were not the findings at hospital.  As to Mrs Knott’s evidence that Rachael was pale or a waxy colour, Professor Cartwright pointed to the normal capillary return and the noting of normal pallor on admission.  
87.	Dr Conway, the paediatrician instructed on behalf of the defendant, said that Mrs Knott’s description of Rachael on 19 April was that of a sick child likely to progress to significant septicaemia.  Of the description, he said “It doesn’t hang together for me as a clinician”.  Of Mrs Knott’s description, that in the evening of 20 April, Rachael suddenly awoke and said “Mummy I can’t hear you”.  Dr Conway had difficulty with this, he said “It does not fit together”.  I share Dr Conway’s concerns.  
88.	The description given by Mrs Knott and her husband, is not only inconsistent with the findings of the doctors who saw Rachael on 19 April or 20 April and the content of the triage note, it is difficult to reconcile this picture of a very sick child with the formulation of the development of bacterial meningitis as described by the experts.  It is not without significance that the description by Mrs Knott of all of these gross signs and symptoms is not included in the letters written in August 2000 and March 2003 by solicitors acting on behalf of the claimant to both Dr Leading and Dr Taylor.  I do not consider that either Mr or Mrs Knott was deliberately attempting to mislead the court.  Having seen and heard them give evidence, I regard the description of gross signs and symptoms as a reflection of their efforts to do all they believed they could for Rachael.  On separate matters of reliability; Mrs Knott was adamant that there were no spots on Rachael’s arms.  This is inconsistent with the evidence of Dr Taylor who specifically examined the arms and the clinical notes made by Dr North and Dr Bishop who record being told this.  Mrs Knott said the spots were on the right side of Rachael’s neck, Mr Knott said they were on the left side.
89.	On Mrs Knott’s account, the three spots on Rachael’s neck were present by lunchtime on 19 April and were still present at the time of Rachael’s admission to hospital at or around 10.00pm on 20 April.  It is not suggested by Mrs Knott that any other spots developed on Rachael’s neck.  Dr Leading found one spot on Rachael’s neck, Dr Taylor found none, Dr Arjun found none, at the hospital the nurse who examined Rachael found two non-blanching spots on her neck.  Dr North records: “Few petechiae arms + neck”.  I regard the note made by the nurse as significant.  When examining Rachael’s neck, she was testing and counting.   Mrs Knott said that the nurse was examining in a poor light.  I treat that observation with some caution, the nurse was on notice of the need to distinguish between blanching or non-blanching spots, the significance was such that she thought it was necessary to count the exact number on Rachael’s neck.  It was the uncontroverted evidence of the experts that had petechial spots been present on 19 April, they would have remained until Rachael’s admission to hospital on 20 April.
90.	In the context of the development of Rachael’s illness, how likely is it that three petechial spots present on 19 April, remained as isolated spots on Rachael’s neck until her admission to hospital?  The evidence of the experts is that the usual course would be for the petechiae to proliferate.  It is not impossible for the three spots to remain as isolated spots but it is uncommon.  It is not uncommon for a macular spot to develop, disappear and be replaced in the same area though not on exactly the same spot by a petechial spot, this would be consistent with the findings of Dr Leading.
91.	Dr Leading’s description of the lesion found on Rachael’s neck as a macule conflicts with the description in his written statement.  The description is important and the change in evidence, concerning.   In giving evidence, Dr Leading did not attempt to justify the change, he simply said “That is what I saw”.  That was consistent with the whole tenor of his oral evidence which was modest and understated.  
92.	The change from the description of an urticarial lesion to a macule could only cause difficulties for Dr Leading.  Whether it was an uritcarial lesion or a macule, one point is to be made, it was not petechial.  The rash on the chest and the lesion on the neck found by Dr Leading were not present when Dr Taylor saw Rachael.  It is accepted by the experts that such a course is consistent with the development of meningococcal disease.  Petechial spots had developed by the time of admission of hospital.  The development of petechiae after Dr Taylor’s visit, prior to admission to hospital and when at hospital, is consistent with the evidence of the experts, in particular the evidence of the paediatricians.
93.	When Dr Leading and Dr Taylor visited and examined Rachael, each was aware that Mrs Knott was concerned that Rachael might have meningitis.  That each doctor had in mind the possibility of meningococcal disease is demonstrated by specific entries in their notes:  Dr Leading ‘No meningeal signs’; Dr Taylor ‘No meningism’.  Neither doctor was sanguine as to Rachael’s condition.  Both informed Mrs Knott that she could call if there were further concerns.  That two doctors who had knowledge of the signs and symptoms of meningitis, were on notice of the possible diagnosis and of mother’s concern, would thereafter ignore three petechial spots on the neck of a child, which were pointed out to them by the mother is a high evidential hurdle for the claimant to surmount.  
94.	I am unable to find that Mr and Mrs Knott are wholly reliable witnesses.  They are wrong as to the phone calls made on 19 April, their evidence of the gross signs and symptoms displayed by Rachael does not fit with the progress of the disease in this case, it is inconsistent with the findings made upon admission to hospital.  Their evidence as to the presence of three petechial spots on the neck which could not disappear is not supported by the findings of health care professionals who examined Rachael on 19 or 20 April.  The highest this aspect of the case could be put is the note of Dr North, part of which is disputed by Mrs Knott.  By the time of his examination, it is likely that petechiae would have in any event developed, consistent with the progress of meningitis.
95.	I prefer the account given by Dr Leading as to Rachael Knott’s condition when he saw and examined her on 19 April 2000.  Specifically, that at the time of examination no petechiae were present on Rachael’s neck.  The account is consistent with the progress of meningococcal disease generally and with the development of the disease in this case.  It is consistent with the conduct of a doctor who is aware of the possibility of meningococcal disease but does not find the symptoms present to warrant referral to hospital.  
96.	For the reasons given, this claim is dismissed.