15 Jul 2019

Baby repeat hospital admissions 'red flag' - health and disability commissioner

2:23 pm on 15 July 2019

A six-month-old baby with a superbug was seen at a hospital emergency department four times before being referred to a specialist, in what has been ruled a breach of patient rights.

Silhouette of a doctor walking in a hurry in the hospital corridor.

Photo: 123RF

Waikato District Health Board and an unnamed emergency department doctor breached patient rights, Health and Disability Commissioner Anthony Hill has found in a report released today.

The baby boy was taken into the ED in a rural hospital with flu-like symptoms in late November 2015. He was diagnosed with a viral illness and discharged.

His mother then brought him back three more times over six days, however, returning the first time on 1 December with a temperature, a bleeding nose and a rash.

Some of his vital signs were recorded but a full set of observations was not undertaken and no observations were repeated. The doctor diagnosed a rash.

Three days later the baby and mother were back - he had ongoing fever and new symptoms including a swollen face and inflamed throat. The baby was also only taking small amounts of food, was not sleeping and was crying all night.

A nurse reported her concerns to an emergency department doctor during this visit but he did not feel - in the context of the child's clinical picture as a whole - that the changes were strong enough to refute his view there was a viral illness.

According to Mr Hill's report, that doctor - "Doctor B" - did not believe the baby needed to be referred to the paediatric service.

"Dr B stated that nothing in Baby A's presentation was out of the ordinary for a viral infection..."

The next day, the baby's mother brought him back to the hospital ED at 2am.

"Baby A was crying inconsolably and refusing food," Mr Hill wrote. "[His mother] reported that the swelling of his lip had worsened throughout the day."

It was agreed that the baby needed to be seen by the paediatric service - a 100km drive at 3am which was left to the mother because an ambulance was not available. ED staff did not ask the mother if she was up to it or would prefer an overnight hospital stay and ambulance transfer next day.

At the second hospital the baby was intubated, because of a compromised airway, and transferred to the intensive care unit.

The superbug MRSA [methicillin-resistant Staphylococcus aureus] was diagnosed and the boy was started on stronger antibiotics. He was transferred next day to another hospital.

He was also diagnosed with severe sepsis with associated Ludwig's angina and needed the alternative antibiotic for a month.

The baby was discharged from the third hospital on 5 January 2016 with ongoing issues including partial paralysis or weakness of a facial nerve and an exposed area of bone in his mouth.

Mr Hill's report said the mother had said "the effect is that although Baby A is a good-looking boy, he looks crooked when he cries or smiles, and nothing can be done to remedy the condition until he is about 10 years old."

Repeat presentations of a baby to a hospital ED are a "red flag", the report noted, and despite the baby having been presented on four occasions a full set of observations was not done at one of the presentations, and repeat observations not done at two of them.

A Child Emergency Assessment Chart was also not used by staff appropriately.

These failures meant the DHB breached patient rights for failing to provide services with reasonable care and skill.

Mr Hill said the baby was significantly unwell when he arrived at the hospital ED on 4 December and Dr B did not refer him for specialist paediatric assessment, thereby also breaching the code.

Mr Hill said Dr B had relinquished his practising certificate, and should he return to practice his competence should be reviewed by the Medical Council.

Waikato DHB has updated its Child Emergency Assessment Chart since these events to include a section on "red flags". The DHB has also implemented a policy to ensure that at a second ED visit, children are discussed with the other hospital's paediatric service.