Hydrocephalus

hydroAn interesting and tragic case came before the High Court recently involving a young lady, Ava, who was represented by her mother in the proceedings. The Decision in the case was handed down by Mr. Justice Cross on the 4th of March 2015.

Significant in this Decision is that the case related to the negligence of a Public Health Nurse and her failure to properly record the outcome of various check-ups on baby Ava and to have due regard to the concerns of the child’s mother.

The Court heard that the birth of Ava herself was uneventful. It would appear, however, that serious Neurological symptoms subsequently developed attributable to Hydrocephalus.   Within the brain there are a number of chambers that contain cerebral fluid which is constantly produced and reabsorbed. Where difficulties result in reabsorption chambers enlarge and brain damage can occur.

The Court heard evidence that brain damage occurs in an exponential manner as the head expands. In order to relieve the pressure, where such condition arises, a shunt is placed in the brain which drains the fluid into the abdomen cavity.   If the shunt is placed early in the process significant brain damage can be avoided and the result can be benign.In the case of baby, Ava, by the time the shunt was inserted the damage had already been done.

The evidence of the case turned primarily on the role of the Public Health Nurse and the conduct of post-natal check-ups and the completion of a Chart known as the “3 Centile Chart”.

The Court held that the Public Health Nurse should have been sufficiently alerted by the factual information provided to her on measuring baby Ava’s head and based on the concerns raised by her mother to refer the child for full medical examination.   This was not done.   The contents of the Chart maintained by the Public Health Nurse were also thought to be inadequate.

To say the least the note taking and recording was entirely unsatisfactory and below the expected standard of care, as any amendments to the Chart should have been recorded and the reasons for the amendments given but naturally that, of itself, is not causative of any injuries sustained by the Plaintiff”.

In essence the Judge criticised the record keeping but stated that it was not of itself the cause of the injury to the child.

In relation to the information gleaned from the examinations, however, it would appear that, if the measurements at the various checkups fell between certain “centiles”, then a Public Health Nurse exercising the appropriate level of care would have been more vigilant in following up on the baby or would have  referred the child for further medical examination.

Mr. Justice Cross held that the Public Health Nurse was acting in or capacity as a Professional Public Health Nurse and that she had professional standards to maintain and her obligations were to perform to those standards.   She was required to exercise the appropriate level of skill and judgement that could be expected from a person in her position.

The Judge focused on the examination by the Public Health Nurse of baby Ava after nine months and also on the one just after twelve months.   At the nine month examination the child’s mother expressed a concern that the baby was not able to hold her bottle.   While clearly there can be many innocent explanations for this and, indeed, simple developmental aspects the Judge held that the fact of that concern being raised by the mother combined with the measurement of the child’s head on the occasion would have recommended to a Public Health Nurse acting in her Professional capacity that the child should at least be referred for medical examination.  In such circumstances a Pediatrician would have carried out an Ultrasound Scan or CT which would have shown the progressing hydrocephalus.

In relation to the final examination after the twelve month period, it was conceded at the Hearing by the HSE as Defendant that there had been negligence on the part of the Public Health Nurse in this particular examination though it attempted to argue that the damage was already done to the child and that this negligence did not cause any damage.    The HSE further argued that there had been no negligence in the nine month examination.   It would appear that, at the examination just beyond the twelve month period, there was an error in the actual measurement of the head and rate of change.   A Public Health Nurse professionally performing her duties would have immediately sent the child for further medical examination had there not been negligence. This referral should have been immediate.

Mr. Justice Cross held that the negligence in that particular examination was not just in recording an incorrect measurement but in ignoring specific serious developmental concerns expressed by Ava’s mother indicative of a certain amount of regression on the part of Ava.    It was not sufficient to simply reassure Ava’s mother at that meeting.

Mr. Justice Cross further disputed the HSE’s contention that only a short delay existed between the treatment of the child and her attendance in hospital. In this respect, Mr. Justice Cross commented that baby Ava was examined on the 16th of September 2008 by the Public Health Nurse who simply reassured the mother and took no further steps. Such was the mother’s concerns subsequently that she brought Ava to her GP who had to see the child without the benefit of the Charts which were kept by the Public Health Nurse. He did refer the child to Our Lady of Lourde’s Hospital where she was again seen by the Doctors there.

Mr. Justice Cross commented that both the GP and the examining Doctors were all handicapped and delayed in their diagnosis by not having these Charts available to them at the time. The Judge concluded that there was a delay of at least two weeks if not two and half weeks from the examination by the Public Health Nurse to the actual treatment of the Hydrocephalus by the insertion of shunt.  Had the diagnosis been made by the Public Health Nurse on the 16th of September 2008 Mr. Justice Cross believed that Ava would not have been left in as bad a position as she was at the time of the hearing.

This is a sad and tragic case and, indeed, on a human level, one must have considerable sympathy for the Public Health Nurse.   The fact of the matter is that medical errors of this nature result from human frailty, errors in Judgement, pressures of work and absence of diligence. This case was a most unfortunate and life changing experience for all involved.

In the event, Mr. Justice Cross found that Ava was entitled to be compensated and referred the matter of compensation to separate treatment on another date.

 

 

 

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