A toddler who died from a bacterial infection and pneumonia in Dunedin Hospital did not get the care she needed, the public health watchdog says.
In a report today, Health and Disability Commissioner Anthony Hill faulted the Southern District Health Board, an unnamed supervising consultant doctor in the hospital's emergency department, and an unnamed registered nurse at a telehealth service over the two-year-old girl's death in 2013.
A second doctor also received adverse comment but was not found to have breached patient rights.
The child had had a runny nose, cough and temperature, which worsened over several days. On the fifth day, a Friday, her mother took her to the emergency department (ED).
She was seen by two doctors, cooled down and sent home, with advice to her mother to return if there were any concerns.
She deteriorated and both parents took her back at 9.14pm on Saturday with a temperature of 37.3°C, a heart rate of 170-175 beats per minute and a breathing rate of 44 breaths a minute. A nurse recorded the child was "irritable, lethargy, cough, grunting, not eating and diarrhoea X 2".
Mr Hill said the child was given an urgency, or triage, level of two (the highest being one), but despite this there was no evidence a paediatric doctor was notified.
Instead, she was assessed by an inexperienced house officer, a Dr C, who diagnosed viral illness. Mr Hill said in his report that when the child's father asked the doctor why his daughter was making "that noise" with her breathing, "Dr C looked confused and said, 'It's like when you have something stuck in your throat , she's just trying to clear that'".
This doctor consulted the more senior consultant, Dr B, who, without assessing the child himself, said she could be discharged. This happened at 10.07pm.
Mr Hill said this discharge from the ED less than an hour after she was brought in amounted to a "woefully short" time for observation of her needs.
He said Dr C said later the child's heart and respiratory rates worried him but that was not reflected in his clinical notes. Dr C thought further investigations were needed for the toddler, "but he did not challenge Dr B's decision as it was not then his practice to challenge a consultant".
For his part, Dr B said it was not correct to say there were "red flags" presented to him, and from where he stood in the ED, the child did not appear unwell and the parents appeared supportive of the discharge plan.
The child's father, however, told Mr Hill he was not happy about being told to take his daughter home, as he felt she should stay overnight in the hospital to be monitored.
Next day the toddler deteriorated, with a temperature of just over 40°C, and her mother phoned the ED about 7am, only to have the call transferred, under hospital policy, to a telehealth service.
The telehealth service nurse, referred to as RN D, spoke to the child's mother for about three minutes, before the mother said she would have to go as the child was crying. She said she was "going to go", meaning get off the phone, but RN D said later he took that to mean (without checking) that she was going to go to the ED.
The toddler stopped breathing at 1pm that day and died at the ED at 2.50pm. An autopsy found pressure on her brain as a result of a bacterial infection and pneumonia.
Underlying acute myeloid leukaemia was also diagnosed, but Mr Hill said that had no bearing on his assessment of the quality of the care provided to her.
Order for review of unplanned re-presentations
Mr Hill said in his report that there were service failures that were directly attributable to the DHB. The first ED presentation was handled correctly but the child should not have been discharged the second time, and there was no written record of a discharge plan, he said.
"Given that Miss A was being discharged home for the second time in 48 hours, in my view it was also important that Miss A's parents were provided clear and specific discharge instructions (verbal and written) identifying specific symptoms to look for and recommending time-specific review."
The doctors involved had the information they needed to provide good care, he told RNZ.
"The system had enough information to know that it could have treated this patient appropriately; it should have [treated her appropriately]. Sadly, by virtue of some communication failures and some errors of judgment, that did not occur and this little girl was discharged when she should have been helped longer in the hospital and further inquiry undertaken."
The commissioner has told those involved to apologise.
He has also told the DHB to conduct an audit, concerning all patients under five, of all unplanned presentations to the ED within 48 hours of discharge. It is to be done in the next six months and to cover a minimum period of three months.
Dr B is overseas, RN D is not working as a nurse now and Dr C has been told to do more training in effective communication and paediatric care.
Southern DHB responds
In a statement, Southern DHB medical director of patient services Richard Bunton said the child's death was a tragedy.
"This was a very sad event. We extend our sincere condolences to the family, and have formally apologised to them for our failure to deliver the care they were entitled to," he said.
"Such events are, fortunately, rare, and weigh heavily upon all involved. Any learnings that can be taken from this situation are welcome, and an opportunity for us to continue to improve our processes to take the greatest possible care to our patients.
"Southern DHB accepts the commissioner's recommendations and is taking steps to implement them."