A toddler went into multi-organ failure and died of sepsis despite being seen by multiple doctors and discharged from hospital.
The toddler, who was discharged with a viral illness, died shortly after his mother drove him back to Gisborne Hospital as his situation deteriorated.
The care provided to the 23-month-old boy has been criticised by the Health and Disability Commissioner (HDC) who found a locum GP and Health New Zealand Tairāwhiti breached of the patient’s rights.
In a report released on Monday, the HDC also made adverse comment against another GP and a primary health organisation (PHO) for the multiple failures and lack of awareness of the difficulties faced by families living in remote locations.
The child’s 2018 death from sepsis shock caused by bronchopneumonia – a bacterial infection in the lung – was referred to the HDC by a Coroner to determine whether the young boy was given an appropriate standard of care.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell said there were systemic and organisational issues that contributed to the failures.
The boy was first brought to a community health clinic a 20-minute drive from the whānau’s rural home, by his mother — identified as Ms A — on the afternoon of day one.
He had a temperature of 39.9C (37C is normal), and had been vomiting.
The clinic called 111 and requested an ambulance take the toddler to Gisborne Hospital emergency department (ED), a two-hour drive away.
In the ED, they waited 90 minutes before a paediatrician assessed the boy, admitting him to the children’s ward.
The whānau were critical that an unwell child was not given higher priority for timely medical attention and that no bloods or X-rays were taken and that he wasn’t administered antibiotics.
Health NZ Tairāwhiti said the boy presented with fever and was given a triage of 4, which meant he should be seen within one hour of arrival, but that he was cared for in the ED as the whānau waited for a doctor.
They believed the boy probably had a viral illness and a paediatrician, Dr F, assessed the patient in the morning as slightly improved and discharged him with no follow-up required.
The whānau later said the boy had vomited, had little water and his mum was worried about discharge given their remote location.
“Ms A stated that she felt powerless to challenge the doctor’s decision to discharge Master A, but she remained uneasy about it. She said that her fears were reinforced that evening when Master A’s condition deteriorated,” the report said.
But there was no record of her concerns and Health NZ said its paediatricians took a cautious approach to remote families and would keep children in if there was any concern or ask whānau to stay locally.
The next night, the boy’s grandmother went to a local ambulance station and asked to borrow a thermometer but instead a paramedic visited the home and checked the boy, and found a high fever but no signs of respiratory distress, advising the family to keep treating him with paracetamol and see a doctor if his condition worsened.
The ambulance service provider said it only became aware of the visit at the boy’s tangi and an internal incident review found no notes were recorded for the visit and the provider was not informed.
It told the HDC an informal visit to a family home was most unusual and not generating an ambulance incident via the communications centre showed very poor judgement by the paramedic.
The next night the boy’s temperature increased and whānau attempted to contact the ambulance and a rural nurse to no avail.
Ms A took her son to a local, rural hospital after calling ahead and talking to an on-call GP, Dr C, who told her the hospital had limited facilities to investigate a sick child and that she should probably go to Gisborne Hospital.
The boy’s grandmother, Mrs A, told the HDC they were reticent about attempting a two-hour drive in the night with an ailing toddler who appeared to have breathing difficulties.
Instead, they drove 20 minutes to consult a doctor in the hope he could call an emergency helicopter if appropriate.
“She stated that they knew that Master A’s symptoms had changed, they were frightened, and they needed a doctor to see him urgently to make that call.”
By now, the boy had a high fever of 40C, a cough and rapid breathing but he had no indication of meningitis and his chest and abdomen appeared normal.
Dr C rang Gisborne Hospital to check details of the earlier admission because the discharge notes had not been sent and spoke to Dr F, who advised the boy be brought into Gisborne Hospital.
The whānau told the HDC by then it was after midnight and that Dr C left it up to them to make the decision about whether to go to Gisborne or not, but they were tired and worried about driving on an isolated highway in the middle of the night with an ailing child.
“The whānau found themselves faced with trying to determine the urgency for medical care at a time when they themselves were tired, stressed, and vulnerable.”
They also felt Dr C was dismissive of the boy’s symptoms as simply a fever and viral illness, which the doctor denied, and were critical of him for showing a lack of leadership.
Ms A and her mother did not believe they were in the best position to make such a critical decision and wanted the boy to stay overnight at the rural hospital but Dr C declined the request.
Caldwell said the GP should have explained the PHO’s policy that the admission of children be cautioned against because of the hospital’s limited resources.
Dr C did not call a helicopter later saying they were reserved for the most urgent patients and in his experience they were often delayed.
Eventually the women took the boy home and returned to the community health centre at midday on the fifth day.
By then the toddler was extremely unwell, with a high fever, accelerated heart rate, low oxygen levels, difficulty breathing, and was pale and jaundiced.
A locum GP, who had only been with the PHO for three weeks, rang Gisborne Hospital ED saying she had a child who looked very sick and might have sepsis.
“She said that she wanted Master A in hospital as soon as possible, but she considered his condition was not immediately life-threatening.”
Dr B made detailed notes but they didn’t transfer to Gisborne because she didn’t know to save them first.
She told the HDC alternative transport was discussed with the family but weather would not permit an air ambulance to fly and that the whānau decided to go by car.
Dr B said she didn’t insert an IV line for fluid because the toddler was sipping water and it would have taken time, and that the ED consultant agreed with her plan that a more skilled team treat the child.
By the time Ms A and her father-in-law drove the boy to Gisborne Hospital, he was seriously unwell, with grunting breathing, severe jaundice and his body was shutting down.
Complicating matters was that the whānau took the boy straight to the children’s ward who were not expecting him because Dr B had sent the referral to the ED.
Cardwell was critical that urgent blood tests took 80 minutes to come back making it difficult for doctors’ to establish the cause of the infection.
An X-ray showed a collapsed left lung, the boy was anaemic and more tests showed kidney, liver and blood-clotting problems.
Doctors discussed transfer to a children’s hospital but the toddler stopped breathing.
He suffered respiratory arrest and was intubated but resuscitation failed and he died.
Caldwell found a the failures involved multiple staff members, and included a lack of Health NZ staff awareness in relation to the difficulties faced by patients from remote communities and the need for follow-up and support.
She said a lack of documentation and poor communication resulted in the full picture not being apparent when needed.
“In particular, the repeated presentations should have been a red flag.
“In addition, in my view there was an element of confirmation bias such that clinicians continued to believe that Master A had a viral illness even when he failed to improve after several days and developed a cough, a high temperature, and fast breathing.”
In recording an adverse comment against Dr C she said it was essential he provided sufficient information to enable Master A’s mother to make an informed decision about whether to go to Gisborne Hospital.
Caldwell said she could not determine if Dr C was dismissive but reminded him that whānau concerns should be taken seriously and they should be treated with respect.
In her breach opinion against Dr B, Caldwell agreed with a serious event review that an ambulance service should have been called that last day and it was not appropriate for Dr B to make the decision not to.
“There is no evidence that she discussed with Ms A the potential for a child to deteriorate suddenly, the symptoms to watch out for, or the risks to Master A of travelling that distance by car.”
“However, Dr B said that she advised Ms A that if Master A’s condition deteriorated on the way, she should stop at one of the clinics on the way to Gisborne. I find it concerning that Dr B thought that Ms A had sufficient clinical knowledge to assess Master A’s condition and know when help was needed.”
She said family transfer should only have been considered if all other options were not possible.
Caldwell also noted that Dr B did not call a paediatrician who may have been able to offer advice such as administering IV fluids, antibiotics, and oxygen before the toddler left.
“Overall, I am left with the impression that Dr B provided minimal support to Master A’s whānau, failed to think critically, and failed to seek advice from the paediatric service at Gisborne Hospital.
“I acknowledge that Dr B had been working as a locum at the PHO. However, she was an experienced doctor. In my view, she should have sought advice in light of her lack of experience in this remote area.”
She was critical of the PHO for its lack of follow-up care.
Caldwell recommended Health NZ Tairāwhiti, the PHO and Dr B each apologise to the boy’s whānau. Dr C already had.
Health NZ and the PHO said they had made a number of changes since the boy’s death including implementing all the recommendations made in a child health unit case review.
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