Staff at Waikato Hospital's neonatal intensive care unit have been censured after failing to act fast enough to treat a newborn baby with a brain infection.
In 2017, the baby girl was born with a lack of blood and oxygen. Half an hour later, she was taken by ambulance to Waikato Hospital. When she was admitted to the neonatal ward, she was pale, floppy and required a ventilator.
Four days later, she developed an infection and the following day her condition deteriorated and she died.
The Health and Disability Commissioner's report noted that on the day she died, the baby was given oxygen, a chest x-ray, and placed on a ventilator, but staff were not aware the baby girl's condition had deteriorated overnight.
Anthony Hill found a shortage of overnight staff and a lack of critical thinking contributed to the newborn's death. No medical records were taken for a 24 hour period, during which the baby's condition deteriorated. He said the importance of keeping accurate clinical notes was something his office had continually raised.
"Consumer information must be accurately recorded, current, and accessible when required. In my view, the documentation in this case was seriously sub-optimal."
He says there were indications the infection was present in the early hours on the day the baby died, but the baby was not properly assessed and antibiotics were not given until almost four hours before the baby's death.
He also found overnight staffing on the neonatal ward was inadequate.
Hill recommended the Waikato DHB educate staff in the unit about the signs of infection as well as providing adequate handovers and documentation.
Waikato Hospital's clinical unit leader, Child Health, Dave Graham said it accepted the Commissioner's decision and their thoughts were with the baby's family.
"As noted in the HDC report this was a rare and challenging case and it is unclear whether earlier detection could have altered the outcome, however all patients should expect and receive care in line with best practice at all times," he said.
Dr Graham said that over the past three years, Waikato DHB had introduced new practices and additional resources including a weekly education session, a training package staff on infection and a more robust handover process between shifts.
It also added five new staff in the neonatal intensive care unit and staff are encouraged to seek help from the senior medical team.