Missed opportunities to manage a girl’s care appropriately and in a timely manner

Health and Disability Commissioner Morag McDowell declared Te Whatu Ora – Te Toka Tumai Auckland (TTTA), formerly Auckland District Health Board, in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failing to adequately investigate the cause of a six-year-old girl’s illness. The girl was later diagnosed with flu and atypical pneumonia and tragically died a few weeks later.

The girl presented to the emergency department (ED) and was discharged with a probable diagnosis of pneumonia. Two days after her discharge, the girl was admitted to hospital with persistent symptoms. Despite continued deterioration in her condition, she was briefly transferred to another hospital, but was readmitted to the first hospital for treatment of excessive fluid buildup in her right lung. The girl was largely cared for in the pediatric intensive care unit, with input from other departments until her tragic death.

Ms McDowell noted that in this deeply saddening case, it is clear that “the girl’s presentation to the hospital was complex and atypical. I offer my sincere condolences to the family for the loss of their loved one in such circumstances. so tragic and unexpected”.

In her decision, Ms McDowell concluded that TTTA’s failures were not isolated incidents and that the relevant departments had missed numerous opportunities to investigate more intensively and more quickly.

Ms McDowell found that on the girl’s second admission and prior to her transfer to another hospital, the nursing staff had failed to properly assess the girl and therefore failed to recognize her deterioration and referred her to medical personnel for further examination.

“It was a missed opportunity to reassess and possibly postpone the transfer decision given the change in the girl’s observations,” Ms McDowell said.

At the third admission, it was clearly necessary to establish the cause of the girl’s illness. However, further testing and investigations for viral and atypical pneumonia, and appropriate treatment with empirical antibiotics, have been delayed.

“Further investigations should have taken place when it became clear that the girl was not responding to treatment and her pneumonia was becoming more severe.

“While I am unable to determine whether previous diagnosis and treatment would have altered the course of the girl’s condition, I am critical that she was not investigated in time. timely and that she was not able to get proper treatment sooner,” Ms McDowell said.

Ms McDowell recommended that TTTA provide a written letter of apology to the family for the aspects of care identified as deficient. She also made several recommendations to TTTA, including communicating changes to her guidelines to other districts, providing an update on changes to pneumonia management and audit compliance, considering improvements to systems in its review processes prior to transferring patients, and to remind staff of the importance of complete and accurate documentation of clinical care.

Following the events of this case, TTTA advised that a review of the treatment provided to the girl resulted in updated clinical guidelines in 2018, including indications for severe pneumonia, and further details on Investigations to consider and undertake for the management and treatment of pneumonia. TTTA further reported that in August 2018, the Clinical Governance Committee on Patient Deterioration approved changes to the “recommended actions” in the Patient Early Warning System table.

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