Deceased
Rhys Andrew Rodger
Demographics
16y, male
Coroner
Coroner William P. Gibb
Date of death
2010-11-24
Finding date
2013-07-04
Cause of death
Bacterial meningitis
AI-generated summary
A 16-year-old previously healthy boy died from bacterial meningitis after being misdiagnosed with gastroenteritis at a general practice. He presented with a 3-day history of vomiting, severe headache, and fever. The GP recorded a borderline temperature (37°C) and concluded gastroenteritis, prescribing an antiemetic injection. Critical diagnostic failures included: inadequate history-taking; failure to communicate between nurse and doctor about symptoms; defective progress notes omitting the reported headache; and failure to consider meningitis despite overlapping symptoms with gastroenteritis. The nurse did not perform formal triage. The coroner found the symptoms were suggestive of meningitis such that it could not be ruled out. Systemic failures in the practice's triage documentation system were identified. The case highlights the diagnostic challenge of meningitis in general practice but identifies specific communication and documentation gaps that contributed to the fatal oversight.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: 4518/2010
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: Rhys Andrew RODGER
Delivered On: 4 July 2013
Delivered At: KYNETON
Hearing Dates: 6 September 2011
Findings of: Mr. William P. Gibb
Representation: Mr. S. Reid appeared on behalf of relatives of the deceased Mr. J.E. Goetz appeared on behalf of Dr. M. Kefford and Ms. A. Reaburn
*Police Coronial Support Unit Leading Senior Constable Snell
*Counsel Assisting the Coroner [name of barrister]
[name of solicitor]
Coroners Court (Amendment No. 1) Rules 2011 1
L, William P. Gibb, Coroner having investigated the death of Rhys Andrew RODGER
AND having held an inquest in relation to this death on 6 Septeniber 201 1 at KYNETON MAGISTRATES’ COURT
find that the identity of the deceased was Rhys Andrew RODGER
*born on 21 August 1994
and the death occurred between the hours of 1.00 a.m. and 1.10 p.m. on Wednesday 24 November 2010
at 7 Bennett Close, Lancefield from:
1 (a) Bacterial meningitis
in the following circumstances:
Rhys was a previously healthy 16 year old boy who resided with his father Andrew, mother Karen and two sisters Sarah and Hayley in the family home at Lanceficld. He was attending Kyneton Secondary College as a year ten student. His primary interest and passion was riding both BMX
bicycles and motor bikes with a close circle of friends.
On the evening of Saturday 20 November 2010 Rhys was seen by his mother to be getting a couple
of paracetamol tablets. When asked by her what was wrong he said he had a sore throat.
On the following morning of Sunday 21 November 2010, he was still in bed at 11.30 a.m. when other family members went out to a friends place. This raised no concerns with the family as it was not unusual for him to sleep in. Upon their return at about 1.00 p.m., Rhys was laying on the couch watching television. He was quiet and had not eaten anything. Shortly thereafter he took himself off to bed. Tt was then that Hayley asked her brother what was the matter, Rhys responded that he felt sick and was about to vomit. Hayley took a bucket to him and advised her mother that Rhys was unwell. Both Hayley and her mother continued to tends to his needs checking on him
frequently.
Coroners Court (Amendment No. 1) Rules 2011 2
Rhys vomited multiple times throughout the afternoon, evening and up until 3.00 a.m. on the Monday morning, He continued to feel ill and remained in bed during the day. In the afternoon when asked by his father how he was, Rhys said he didn’t feel too bad but had a headache. Family members encouraged Rhys to keep his fluids up offering him water, flat lemonade and Gatorade.
Rhy’s condition deteriorated to a point where he was unable to keep fluids down and his headache got worse. As a-consequence his mother gave him two paracetamol tablets. When Hayley got home from school, they put up dark curtains in Rhy’s room. As Rhys appeared hot and sweaty,
Hayley set up a fan for him in his room and he was given more Gatorade but couldn’t keep it down.
Hayley observed that Rhys “..was.a bit slow in his speech and was slurring his words. If I asked him a question he would just stare at me. He wasn’t eating anything and was complaining about his
headache.’ Ms. Moulin continued to monitor him until late on the Monday night.
On Tuesday Rhys was still sick. His mother rang the Lancefield Country Practice for a doctors
appointment but was told they were booked out, She rang back again at 3.50 pm. and asked to be put down in the event of a cancellation. At that stage she was told there was a cancellation at 4.20 p.m. so she took him straight down. Hayley accompanied them. Ms. Moulin says at that time her
son
*,...dooked like death. He was complaining of dizziness, his head was killing him and he
had a sore neck” Ms. Moulin goes on to say that she knew this (ie the sore neck) wasn’t a good sign.
“I was concerned it could be Meningitis.”
Itis noted that this concern was not recorded by Detective Grunden in his hand written notes of Ms.
Moulins statement made to him the day after Rhy’s death.
Ms. Moulin says this was an omission by the Detective. It is also conceded by Ms. Moulin that this
concern was not raised with Dr. Kefford.4
' Statement by Hayley Louise Rodger dated 30 August 2011. Page 1. para 5, ? Statement by Karen Elizabeth Moulin dated 27 March 2011. Page 2, para 7 3 ibid. Page 2 para 7
Coroners Court (Amendment No. 1) Rules 201 t 3
Upon arrival at the Practice they took a seat in the waiting room, Hayley says Rhys “was just slumped on the chair sitting back and drinking his water”, when Rhys looked like he was about to vomit, his mother asked for a sick bag. They were then invited by the office manager to go into the treatment room where Rhys was able to lay down on a bed. It was an adjustable bed that allowed
for the upper part of a patients body to be elevated.
Nurse Reaburn was passing the treatment room and noticed that there was someone inside. As a matter of courtesy she popped her head behind the curtain and introduced herself, She told the occupants that the Doctor wouldn’t be too much longer and asked what was wrong. She noticed
that Rhys was lying in a semi-Fowlers position at the time.°
In response to her inquiry, Ms. Reaburn says Ms. Moulin told her that Rhys had been vomiting since the previous Sunday and that he had a headache.® Ms, Reaburn further inquired whether Rhys
had any past history of migraines or whether he was sensitive to light and was told “No.” ’
As Ms. Reaburn was already in the middle of a consultation with another patient she didn’t formally assess (triage) him at the time.® Before returning to the patient she had been dealing with, Ms.
Reaburn told Dr. Kefford in a very brief exchange that there was a boy in the treatment room who was unwell. She can’t recall if she told Dr. Kefford that Rhys was suffering from “a headache and
vomiting” or whether she just said one or the other ie “headache” or “vomiting”.
The Practice did have a triage system in place which consisted of the Nurse recording her
observations on a white board after assessing a patient and before they were seen by the Doctor.
57 52: 28-30
® Statement by Amy Reaburn dated 24 November 2010 Page 1, para 5 7 Tid Page 1, para 5., T 38: 12-15
Coroners Court (Amendment No. [) Rules 2011 4
This did not occur on this occasion for as already mentioned, no assessment was made due to Ms.
Reaburn being busy with another patient. Rhys was to be her next patient. Before she could get to him Dr. Kefford had intervened."
Having been made aware by Ms, Reaburn that Rhys was in the treatment room, Dr. Kefford saw him as her next patient.” Her first observation of Rhys was that he looked tired but not terribly sick.'? Whilst accepting that such observations are subjective, Dr. Keffords view is not shared by several other people who saw Rhys that day."
After making her initial visual observations of Rhys, Dr. Kefford asked how she could help. She says Ms. Moulin responded by telling her that Rhys had been sick since Sunday, that he had a fever and had been vomiting. When asked how many times, Ms. Moulin said “a couple of times.” In response to a question “How many times today”, Ms. Moulin said “a few times,”"
Dr. Kefford then turned her attention to Rhys and asked him if he could tolerate fluids to which he answered ‘yes.” Ms, Moulin added “a bit, not much.?!°
Dr Kefford made ‘Progress Notes’ of her consultation with Rhys in which she recorded (inter alia) “Nausea, fever since Sunday” although she could not recall a conversation in relation to fever.!”
Dr. Kefford says she checked Rhys’ temperature with an car thermometer and recorded 37 degree which in evidence she said is borderline.'® As a result she didn’t take the issue of fever or his temperature any further. She checked for but didn’t see any signs of dehydration. This is not recorded in the Progress Notes.
4 Mir, Andrew Rodger saw his son just before he was taken to the Doctors for his appointment. He says “he looked really crook”, Statement 27 March 2011 Page 2, para 6
Ms. Moulin says her son “...looked like death” Statement 27 March 2011 Page 2 para7
Ms, Pollyanne Brown, receptionist at the Lancefield Country Practice says “he looked really pasty and unwell” statement 29 August 201] Page 1 para’s 4 & 5
Patient Ms. Rence L. Twining saw Rhys when she was seated in the waiting room. Her observations were that “...he seemed quite unwell, ..,too unwell to walk steadily on his own, the young male looked very sick he was slouching a bit and looked listless”. Statement 29 August 2011, Page 1, para’s 3,4 & 5
Nurse Reaburn said Rhys was pale and looked unwell, T 40: L 1 &2 5 Statement by Dr. Kefford (supra) Page 1 para 5, T 59: 23-16
6 Thid — Page 1, Para 7
" Tbid— Page 1, last para
8761: 21
Coroners Court (Amendment No, 1) Rules 201 | 5
Dr. Kefford says she went on to check Rhys’ throat, ears and ear drums all of which were fine. She also listened to his chest and checked his abdomen which was soft and exhibiting no tenderness.
Except for the reference to ‘no tenderness’, she recorded these results in her notes together with the fact that there was no diarrhoea. In addition to these factors, Dr. Kefford says Rhy’s movements did not suggest any major problems. His skin was clear of any rash and it was established that he had no allergies.’”
At the conclusion of her consultation with Rhys, Dr. Kefford passed on her diagnosis to Ms. Moulin that Rhys probably had gastroenteritis caused by a Rota virus. As a result, she directed that an injection of Maxolon be given and provided a script for follow up tablets on his return home. She advised Ms. Moulin to keep up his fluids.” Before leaving the Practice, Ms. Reaburn told Ms.
Moulin that if Rhys continued to vomit and could not keep fluids down by 11.00 p.m. she should bring her son back in the morning or take him to hospital.”!
Upon arriving home, Rhys went straight to bed continuing to complain of a headache. Ms. Moulin gave him three paracetamol and continued to care for him until she went to bed at about 1.00 a.m. in the morning of Wednesday 24 November 2010. Before leaving for work at about 5.00 a.m. that moring, Mr. Rodger looked in on Rhys. He didn’t try to wake him, not wanting to disturb him.
Some time later after taking Hayley to school Ms. Moulin checked on Rhys who appeared to be asleep. She checked on him two more times after that and when there had been no movement of Rhys by 1.10 p.m. she opened the curtains in his room. Upon closer inspection, it became clear to Ms, Moulin that Rhys was deceased. She immediately telephoned her husband and called for an ambulance that arrived shortly thereafter. Ambulance officers confirmed that Rhys had died prior to their arrival.
At 1.28 p.m. Leading Senior Constable Barr attended the Rodger family residence at 7 Bennett Close, Lancefield and commenced an investigation. This investigation included the taking of statements from both family members and personnel at the Lancefield Country Practice. Copy medical! records were also obtained from the Practice.
Submissions and Expert Reports
These include:-
® Statement by Dr. Kefford (supra) Page 2 para 1, T 61
~ Coroners Court (Amendment No. 1) Rules 2011 6
These include:-
1, areport by Dr. Dianne Chambers, General Practitioner and Clinical Lecturer in General Practice dated 20 August 2011 and;
2, areport by Infectious Disease Expert, Associate Professor Berard J. Hudson, dated 12 October 2011.
Keeping in mind that I do not feel it necessary to respond to every point raised in the submissions and reports, I do make the following comments:-
RE:- Submissions on behalf of Dr. Marina Kefford and Registered Nurse (Division 1) Ms.
Amy Reaburn
Part ‘B’ — Legislative Framework:-
I accept counsel’s submissions in part B, paragraphs 3-9 inclusive as a correct statement of the law regarding a Coroners powers and duties.
Part ‘C’ — Background
Para 10 — Ms. Moulin and Mr. Rodger confirmed that about a month before his death, Rhys had a fall off his bicycle and struck his head. He did not require medical treatment after this suffering only from some grazing and scratches.””
Dr. V. Murdolo, Director of Pathalogy established during autopsy, that there was “no evidence of internal musculo-skeletal injuries, In particular, there were no injuries to the scalp or skull”,
No weight is attached to the comment of Sarah Rodger that she “heard that Rhys had had a heavy fall while riding with Shannanon Bertoni and Chris Kimpton in the Black Forest on the Saturday before his death. Both Mr. Bertoni and Mr. Kimpton stated that they were both with Rhys the whole time and saw no such fall.”
Statement by Leading Senior Constable Barr dated 17 March 2011, Page 3 para 4 See autopsy report dated 1 December 2010 Page 3, para 5
Statement by Leading Senior Constable Barr (supra) Page 3 para 8
Coroners Court (Amendment No. 1) Rules 2011 7
Part ‘D’ — General
’
Para 12 — Rhys had an appointment at 4.20 p.m, His mother rang the Practice at 3.50 p.m. and asked that Rhys be seen by a Doctor in the event of a cancellation that day, There was a cancellation at 4.20 p.m. which was taken up by Rhys.
Para 13 — When making a statement to Detective Leading Senior Constable Grunden the day after Rhys’ death, Ms. Reaburn says Ms. Moulin told her that Rhys “.. had been vomiting at home and had a headache.””*
When giving evidence to this Court, Ms. Reaburn said “the mother stated to me that he had had a headache and had been vomiting since Sunday and that’s when I asked about does he have any past history of migraines or if because he has a headache is he sensitive to light...”
A few moments later in her evidence, Ms. Reaburn went on to say “the only thing we also discussed was because he had a headache, pain I asked if he had any pain relief, he said he had Panadol before he just come in.”
Rhys had first complained of a headache to his father on the Monday afternoon of 22 November
About thirty minutes before taking Rhys to the Practice on Tuesday 23 November 2011 Ms. Moulin says Rhys “looked like death... his head was killing him...”
After he retumed home from the Practice Rhys continued to complain about his head. His mother gave him three more paracetamol.
If it is being put by Counsel that Ms. Reaburns comment that Rhys “...had had a headache...” means that it was in the past tense and that he was not suffering a headache at the time he attended the Practice, I reject this proposition. The evidence overall atid the weight of such evidence enables this Court to find on balance in my opinion that Rhys was suffering (amongst other things) from a severe headache at the time he saw both Nurse Reaburn and Dr. Kefford.
Para 14 — as to the nature and extent of the symptoms that were communicated to Ms. Reaburn by Ms. Moulin are concerned, I accept that when Leading Senior Constable Snell asked the question at
_ the inquest “Do you recall any of that (ie dizziness, disorientation, sore neck) being passed onto yourself?” Ms. Reaburn said “No”.
® Statement by Reaburn (supra) Page 1 para 5
*” Statement by Ms, Moulin (supra) Page 2, para’s 3 & 4 °§ Thid Page 2, para 7
7 38: 22. At T $3: 27-28 Ms. Reaburn again said “No” when asked by Mr. Goetz of Counsel whether she was told by either Rhys or his mother that he had asore neck.
Coroners Court (Amendment No. 1) Rules 2011 8
Para 17 & 18 I accept Dr. Kefford’s evidence that she took Rhys’ temperature during her examination of him and found it to be 37 degree which she recorded in her progress notes, Further, that at the time of her examination Rhys did not exhibit any pain in his neck and was able to move his head without difficulty. Similar observations were made by Ms. Reaburn at the time she gave Rhys an intra-muscular injection of Maxolon.
Para 21 - l accept that Dr. Kefford is an experienced General Practitioner as evidenced by her curriculum vitae. I accept that Dr. Kefford has had some previous personal experience in dealing with patients, both children and adults’ who were being treated for meningitis, but it is not clear tom the evidence as to the extent of such experience.
Para 22 —J accept that there is a dispute between the interested partics as to what information was provided to Dr. Kefford, particularly by Ms. Moulin during Dr. Keffords consultation with her son.
That much is also conceded by the family’s lawyers.*!
Ms. Moulins’ evidence is that she told Dr. Kefford ‘everything’ (ie all the symptoms that he had).
Dr. Kefford disputes this and says at no stage was she given detailed information as asserted by Ms.
Moulin,?
Para 24 — It is submitted by Counsel for Dr. Kefford that “...it is simply inconceivable and highly improbable that given Dr. Kefford’s training, previous knowledge of and experience with meningitis, she would dismiss or ignore this vital information (ie all the symptoms as stated by Ms.
Moulin) and not act upon it.”
Whilst there may be some merit to this submission, it is equally inconceivable in my opinion that Ms. Moulin would not and did not raise the issue of headaches with Dr. Kefford given that this symptom was one of, if not the primary reason why she wanted her son to be examined as a matter of some urgency by a Doctor on Tuesday 23 November 2010.
Ms. Moulin gave evidence that she did tell Dr. Kefford about headaches that came on the Monday then got worse. Really bad headaches,** Hayley agrees that her mother told Nurse Reaburn about Rhys’ really bad headache then repeated this symptom (amongst others) to Dr. Kefford when the doctor asked what’s been happening.*
7 64: 25-31, T 65: 1-2 3 See legal submissions on behalf of the farnily dated 31 May 2012. Page 3, Part C, Para 1
» These symptoms are identified by Dr. Keffords lawyers at para 23.2 of their submissions and by the families lawyers at para 8 of their submissions. See also evidence of Ms. Moulin at T 11: 22-28
Coroners Court (Amendment No. 1) Rules 2011
Dr. Kefford was pressed on this point during cross examination by Mr. Reid, Mr. Reid put to her that when she made her statement to police two days after Rhys had died, Dr. Kefford had said
“I cannot recall any conversation about headaches, it may have been mentioned but it was very briefly.’*
Dr. Kefford was quite definite that she was not told about such things as a sore neck, disorientation or slurring of words,” but the same can’t be said in my view regarding the symptom of headache.
Upon assessment of the witnesses and all the evidence on this point, I am satisfied to the requisite standard of proof that Dr. Kefford was told that Rhys was suffering a headache.
When giving her evidence to the Court and in answer to questions put by Mr. Reid of Counsel. Dr.
Kefford acknowledged that there were a number of symptoms that can be indicators of meningitis.
These included a stiff neck, headache, fever, vomiting, light sensitivity, drowsiness or confusion, joint pain and fitting. Further, that these symptoms can occur in any order and may not occur at the same time.**®
As to the symptoms for gastroenteritis, Dr. Kefford said that they would include “fever, could be mild headaches, vomiting and later on they can have diarrhoea, not particularly, not always”, going on to say in relation to diarrhoea “most of the times, yes, but not always." Again on the question of diarrhoea, Mr. Reid put to Dr. Kefford, “do you agree that in relation to rotavirus gastroenteritis that first of all, it’s a condition that usually and generally presents with severe diarrhoea.”
Dr. Kefford replied “no not particularly. Sometimes presentation starts with vomiting and a couple of day’s later diarthoea.”*!
Had Dr, Kefford established as part of Rhy’s history that he had already been vomiting for a couple of days prior to her consultation with him and diarrhoea had not at that stage manifested itself, it would have been a matter that Dr. Kefford could have taken into account before making her actual diagnosis of gastroenteritis in my opinion.
On the evidence, common denominators between Meningitis and Gastroenteritis Rotavirus are headache, fever and vomiting, On this Courts finding of fact, the headache Rhys was suffering from when he attended the Practice was severe not mild.
5° Statement by Dr. Kefford (supra) Page 2 para 3
7 73: 14-18
Coroners Court (Amendment No. 1) Rules 2011 10
Whilst he had a temperature of 37 degree which Dr. Kefford described as borderline, there was a history of fever since Sunday. Further to this, Dr. Kefford did agree as a general proposition that paracetamol can reduce the level of a fever or a temperature in a person.” Much depends on the time the medication is taken according to Professor Rawlinson.*? Whilst Ms. Moulin is uncertain of the last dose Rhys had, in response to a question about pain relief from Ms. Reaburn, Rhys said he had panadol just before he came into the clinic.“
L accept the evidence of Ms. Moulin that Rhys had been vomiting since Sunday although this is not reflected in Dr. Keffords progress notes. Only that Rhys was vomiting on the day he attended the Practice,
The upshot of the presence of these symptoms in my view, is that as indicators, a diagnosis of bacterial meningitis could not be excluded.
Because there was a spate of gastro going around the district at the time, and given that a number of symptoms are peculiar to both Gastroenteritis and Meningitis the question arises as to whether Dr.
Keffords judgment was clouded in all the circumstances.
When it was put to Dr. Kefford by Mr. Reid, Counsel for the family that she came to the conclusion that “This is most likely gastroenteritis because there’s been a lot of it going around at the moment” Dr. Kefford replied “pretty much, yep.
Part ‘EK’ — Medical Care
Para 33 —L accept that the Court should assess Dr. Keffords performance as a General Medical Practitioner and not that of a specialist in infections diseases,
Para 34 — | accept that not all of the detailed symptoms Rhys suffered from including sore neck, slurring of words, dizziness and disorientation were given to Dr. Kefford.
Part ‘F’ — Procedures and Practice
Para 38 — l acknowledge that after Rhy’s death, the Practice acted without delay in dispensing with the whitcboard triage system of recording observations. That it has now introduced a system of recording observations on a sheet which is then handed to the medical practitioner,*®
°T 71: 7-9 Professor Rawlinsons supplementary report dated 9 October 2011 Page 2, dot point 4
"077: 11-13 *° See Exhibit ‘E’
Coroners Court (Amendment No. 1) Rules 2011 in| | | | i
|
Part ‘G’ — Medical Reports
Thave taken into account the content of all medical reports previously mentioned and tendered to the Court for its assistance.
Part ‘Kk? — Conclusions
Ihave attempted to address all relevant issues in my assessment of the evidence.
lLacknowledge the challenges faced by clinicians in attempting to diagnose meningitis as highlighted by Drs Kefford and Stanton, Professor Rawlinson and Associate/Professor Hudson.
As to the cause of death as previously mentioned, I accept the opinion of Pathologist, Dr. V.
Murdolo as adopted by Associate Professor Hudson, that on the balance of probabilities, Rhys died from Bacterial Meningitis.
From the perspective of the family and their lawyers written submissions, I am attracted with certain qualifications, to Part C of these submissions headed “Alternative submission on findings based on the evidence”.” This is on the basis that I am not satisfied as already mentioned that Ms.
Moulin gave the level of detail regarding Rhys symptoms to Dr. Kefford as she says she did.
Having said that, and keeping in mind the Courts finding as to the disclosure of headache by Ms.
Moulin to Dr. Kefford in consultation, I accept:-
2, That the symptoms disclosed to Dr. Kefford were suggestive of a diagnosis of bacterial meningitis such that bacterial meningitis could not be ruled out;
3, That there was a failure by Dr. Kefford to communicate with Ms. Reaburn and to ascertain the symptoms reported to her;
That as a first time patient the history obtaincd and clinical enquiries made by Dr. Kefford were deficient in that they were lacking in scope and detail;
That there was a failure of the systems in place at the Practice attended by Rhys in that any information obtained by the Practice Nurse other than through a full assessment (Triage) would not be noted on the white board for the benefit and knowledge of the treating General Practitioner.
To answer all the conclusions and findings sought by the Lawyers for the interested parties in this inquest would be to exceed the powers of a Coroner in my view. The Court reminds itself that a Coroner is required pursuant to S. 67 of the Coroners Act 2008 to find, if possible a) the identity of
*” . Legal submissions on behalf of the family dated 31 May 2012
Coroners Court (Amendment No. 1) Rules 2011 12
the deceased, b) the cause of death and c) the circumstances in which death occurred. A Coroner may of course, make comments and recommendations.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:
[specify comments]
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:
1, That the Department of Health conduct a public awareness campaign to all arcas of the community as to the signs and indicia of bacterial meningitis (particularly when affecting children) emphasizing the need to seek urgent medical advice if the presence of those symptoms are noticed or reasonably suspected.
[specify any finding, comment or recommendation that is not to be published|
U4 *W.P. Gibb Date: /.7 / 7, 14
*Delete if inapplicable
Coroners Court (Amendment No. 1) Rules 2011 13
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