A coroner heard that the ‘extremely rare’ death of a father from rabies happened after he had been told by medics the cat bite to his finger was not a problem and he should buy some ‘anti-itch’ cream.
The 58-year-old contracted the fatal disease while on holiday in Morocco when he was one of several people bitten by a rabid cat in the street.
Full-time carer Omar Zouhri died in hospital in Oxford within days of doctors realising he had ‘furious rabies’ – a disease which has been eradicated in the UK since 1902.
Oxfordshire Coroner Darren Salter said: ‘This is a very sad case, of course, but it is also an extremely rare case here in the UK.’
He had earlier been told of the ‘anti-itch cream’ bungle at the walk-in clinic Mr Zouhri visited and of a second blunder in which a doctor claimed rabies came from dogs rather than cats.
Omar Zouhri, 58, of Aylesbury, was bitten by the rabid animal while he was on holiday with his family on August 31 last year. This is the last photo of him in hospital shortly before he died
An inquest in Oxford heard that Mr Zouhri had contracted rabies on August 31 last year when he had been with his 12-year-old son outside a family home in the northern city of Meknes, in Morocco, and a rabid cat leapt at him and sank its teeth into his right ring finger.
The 58-year-old carried the rabies from then on, the inquest heard, but it was not until as late as October 28 that ‘the die was cast’ when he started to report symptoms of ‘furious rabies’ – itching, pain and muscle twitches – which showed the virus had already entered his central nervous system, rendering any treatment ineffective and sealing his fate.
Mr Zouhri had been flagged up as a high-risk case by Public Health England and given the only known treatment for rabies from October 12.
However Mr Salter highlighted a failure at the Stoke Mandeville Hospital in Buckinghamshire which meant Mr Zouhri was diagnosed as being rabid five days later than he should have been.
August 31, 2018: Omar Zouhri is bitten by a rabid cat in Meknes, Morocco, one of seven people attacked.
‘Immediately afterwards’: He went with a boy who was also bitten to a local hospital in Morocco and was given a tetanus jab.
Shortly after that he went to a Moroccon police station to complain about the hospital doctors’ unhelpfulness. He said they had not administered anti-rabies medication.
September 1: He buys antibiotics over the counter at a pharmacy in Morocco
September 5: Mr Zouhri returns home to Aylesbury, Bucks
‘Early October’: Mr Zouhri receives word from Morocco that the young boy has died.
October 6: Mr Zouhri attends Stoke Mandeville A&E and is seen by nurse Menchie Mallari. She asked a plastic surgeon about the bite, who advised: ‘Rabies can acquire most from dog, not cat’.
October 12: He begins to receive rabies vaccination. The treatment is only effective if four doses of the immunoglobulin are administered over a 21-day period.
October 27: Mr Zouhri was still ‘fit and well’, according to his widow.
October 28: Mr Zouhri attends an out-of-hours GP clinic to complain of pain and itching, but was told he did not have rabies and was instructed to try anti-itching cream.
October 29: He attends his GP surgery and tells Dr Rachel Moghal the pain is ‘radiating’ up his arm.
October 31: Mr Zouhri goes back to Stoke Mandeville Hospital where he is seen by GP Sheila Paul, who said he was confused and unable to answer questions clearly.
November 1: Mr Zouhri is rushed to the John Radcliffe Hospital in Oxford in an ambulance. the disease having reached his central nervous system he is diagnosed with ‘furious’ clinical rabies, which is inevitably fatal.
November 4, 2018: Omar Zouhri dies, in the same Oxford hospital where he lost his eldest child to leukemia several years before.
The inquest heard that, immediately after the bite, the victim had taken himself and a boy, who had also been bitten, to hospital in Morocco, where he was given a tetanus injection and paid for the boy to have one too.
Mr Zouhri later went to a local police station to complain about how unhelpful the medics had been and that they had not given him the proper treatment for rabies, which is most effective when given within 24 hours of exposure to rabies, the inquest heard.
The same cat had also bitten six other people within half an hour of biting Mr Zouhri, including a young boy who later died, Mr Salter was told.
Mr Zouhri, who was born in Morocco and had been visiting family, returned to his home on Prebendal Avenue, Aylesbury, Bucks, on September 5, the ordeal seemingly behind him but after a period of normality his health was called into question when he and his family were informed about the boy’s death by a Moroccan doctor in early October
Concerned that he too might be infected, Mr Zouhri rushed to A&E at the Stoke Mandeville Hospital a day or so later, after his wife had put in worried calls to the South Central Ambulance Service 111 number, in the early afternoon on October 6, where he was seen by a nurse, Menchie Mallari.
Nurse Mallari, under cross-examination, admitted she did not know at the time when Mr Zouhri arrived at hospital and told her he had been bitten by a cat, about the Buckingham Healthcare NHS Trust’s policy that a person who had been bitten by a suspected rabid animal should be reported and managed urgently, a risk assessment should be carried out and a microbiologist should be contacted.
Instead, Nurse Mallari had sought the advice of a registrar in plastic surgery, Dr Marie Song, explaining to the coroner: ‘Plastics deal with animal bites.’
According to Nurse Mallari’s note from a telephone call with Dr Song, the registrar had told her: ‘Rabies can acquire most from dog, not cat.’
Dr Song, giving evidence at the inquest, said: ‘I do not recall that. I would not normally bring up rabies in a conversation about animal bites.’
However, Dr Song had made no note of the advice she gave ad-hoc while working the first day of her 48-hour shift on the busy ward, the inquest heard, and she was not even able to say for certain whether she had spoken to Nurse Mallari over the phone or in person.
Mr Zouhri was discharged from A&E shortly afterwards and a note was sent to his GP on the same day reporting his attendance.
Coroner Mr Salter told the inquest in his closing remarks: ‘It does seem that the onset of symptoms of clinical rabies was from October 28.
We have heard reference to the phrase, ‘the die was cast’, but it is also important to understand, the likelihood is it must follow that the virus had already travelled from the site of the bite to Mr Zouhri’s central nervous system prior to October 28.
‘We have evidence there was a difference in recollection of events, what has been described as a miscommunication. It seems to me that Nurse Mallari has a better recall of events.
Omar Zouhri, 58 (pictured) of Aylesbury, was bitten by the rabid animal while he was on holiday with his family on August 31 last year. He died on November 4
‘There was a failure to carry out a risk assessment which, if it had been carried out, almost certainly would have resulted in Mr Zouhri being recognised as a high risk case who required the rabies vaccine. The Bucks Healthcare Trust carried out their own investigation and that failure has been accepted.
‘A related issue is: what about delay with administering the rabies vaccine and the issue of causation – a period of about five days if you take into account time required to request and obtain the vaccine from Public Health England.
Rabies: Death from a scratch
Rabies is a viral infection which targets the nervous system and the brain.
It is deadly in 100 percent of cases left untreated – and has an incubation period of 20 to 60 days.
It is only spread by infected animals to humans, most often through the animal biting or scratching the person.
It can also be spread by an animal’s saliva being in contact with a graze or cut on a human’s skin. The majority of rabies cases result from being bitten by an infected dog.
The symptoms of the illness include high temperatures, numbness at the area where the bite occurred and hallucinations. Some victims also have hydrophobia, which is a fear of water.
There are about 55,000 cases of rabies worldwide each year with most cases occurring in Africa and Asia.
Half of all rabies cases occur in India.
‘It is very, very difficult for anyone to say at what stage the virus reached Mr Zouhri’s central nervous system.
‘It seems unlikely that a five-day delay is causative but all I can say is that it seems unlikely but it remains a possibility that if the vaccine had been given five days earlier and that if the virus had not spread to the central nervous system by that time, then there may have been a different outcome.’
The coroner added that the real tragedy was Mr Zouhri, who was born in Morocco, was not able to access the proper treatment while he was in Morocco, despite his best efforts.
Dr Stephen Gardner, Chairman of the Division of Medicine, said a Serious Incident Investigation carried out by the Bucks Health NHS Trust had concluded there had been a failing and both Dr Song and Nurse Mallari had undertaken personal reflection and learning.
In addition, Dr Gardner explained, the rabies vaccine had since become routinely stocked at the Stoke Mandeville Hospital, which had not been the case at the time Mr Zouhri was being treated.
Dr Gardner said: ‘We see one or two patients a year who have had an animal bite from abroad. We have had an episode since November of last year and we have the vaccine stocked, so I know the process works.’
Chadia Zouhri, a housewife and Mr Zouhri’s widow, told the inquest in a statement that as late as October 27, her husband was ‘fit and well,’ but said by October 30 he was in extreme pain.
The full-time carer went to two hospitals in Morocco (capital Marrakech pictured) but was not provided with the anti-rabies vaccine
Mr Zouhri had attended an out-of-hours GP service on October 28, where he complained of pain and itching in his finger but the inquest heard he was reassured his symptoms were not due to rabies and was advised to try anti-itch cream.
On October 29 he contacted his GP Dr Rachel Moghal and said pain was ‘radiating’ up his arm from the bite on his finger, which had fully healed and two days later he was calling the GP again to tell them about muscle twitching randomly.
With his son, Mr Zouhri attended Stoke Mandeville Hospital again on October 31, where he was seen by a GP Sheila Paul, who said: ‘He seemed confused and unable to answer my questions clearly.
‘I asked his son if he was here to translate but he told me his father spoke excellent English when he was well – this was unusual.’
Mr Zouhri had been rushed to the John Radcliffe Hospital in Oxford in an ambulance on November 1, with a South Central Ambulance Service paramedic riding in the back of the vehicle with him while wearing full protective equipment, the inquest heard.
Dr Andrew Brent, the clinical lead for infectious diseases at the John Radcliffe Hospital, who was part of the team to treat Mr Zouhri, said the father had been speaking on arrival at the JR, reminiscing about previous visits to the hospital when his eldest child had sadly died from leukemia.
Mr Zouhri had developed ‘furious rabies,’ Dr Brent explained to the inquest, so by the time the patient arrived at the hospital the only realistic option was palliative care.
Dr Brent said: ‘Clinical rabies is almost unique as an infectious disease as having, essentially, a 100 per cent mortality. There are a very small number of cases where patients have survived.
‘There is no treatment with a good evidence base which would prevent death in this situation.’
However, it is possible, Dr Brent explained, to save a patient who has contracted rabies if they can begin treatment before the virus enters their immune system.
The course of treatment for rabies, the inquest was told, is four doses of the vaccination for rabies and human rabies immunoglobulin (antibodies) applied over a 21-day period.
Mr Zouhri had been started on this course of treatment and received his first dose on October 12, Dr Mughal told the inquest.
He had been classed as a ‘high risk – red category’ case by Public Health England, which had been informed by doctors at his local surgery in Aylesbury that he had been bitten by a cat in Morocco, where rabies is endemic.
He did not receive his fourth and final dose, the inquest heard, because his rabies had already developed into fatal, clinical rabies.
It was not until November 4 when Mr Zouhri died in the John Radcliffe Hospital and a pathologist, Professor Ian Roberts told the coroner the cause of death was ‘rabies following a cat bite in Morocco.’
Mr Roberts added that symptoms from rabies only appeared after one to three months following the bite, although it can take years, but death occurs within 10 days on sight of the symptoms.
The inquest was told that 99 per cent of human rabies is caused by a deep bite from an infected dog and the last recorded case of rabies originating in the UK was 1902.
Since 1946, there have been 25 cases of rabies reported in the UK, all imported from abroad and in one case in 2002 a licensed bat handler, David McRae contracted a special form of rabies found in several Northern European countries from a bat in Scotland.
In a narrative conclusion, Mr Salter said: ‘Mr Zouhri was on holiday visiting family in Morocco on August 31 2018 when he was bitten on the finger by a rabid cat.
‘He initially sought treatment in the UK on October 5 and was seen on October 6 at Stoke Mandeville Hospital and commenced the rabies vaccine by his GP on October 12.
‘He began to experience symptoms on October 28 and subsequently deteriorated and died on November 4 at the John Radcliffe Hospital from rabies following a cat bite.’