saw a young baby with a high fever and diarrhoea in surgery one afternoon. full h/o and o/e, including full set vital signs, and cns+skin examination, fortunately all properly documented. mother concerned but ok. arranged to see baby next am if still feverish and 'safetynetted'- again all documented. next morning, some 20 hours later, one of my good partners saw baby as he was going the branch surgery clinic, baby was now feverish+irritable but nil found otherwise so he admitted baby. between seeing baby and arriving on ward, baby developed x3 tiny non-blanching spots and so was treated for meningococcal meningitis subsequently confirmed. baby was surprisingly well thruout and has made a quick and full recovery. 
when this happens, one always thinks "did i miss it?". in this case i cannot believe that the baby had a clinically diagnosable meningococcal illness when i saw her nor if i had admitted the child-and there seemed no clinical reason to do so-do i really believe that the paeds would have found one at that moment either, but knowing it and believing it is different. mother is ok about it, but if she wasnt, no amount of hard-nosed clinical explanation is going to persuade her or her lawyers otherwise that a potentially fatal illness had been missed, the emotional impact is simply too great.
should this be notified as a significant event? and did you know that 1-in-3 cases of meningitis results in a formal complaint?

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