Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for the care provided to a new born baby in its neonatal intensive care unit (NICU).
The baby was born with perinatal hypoxic-ischaemic encephalopathy (HIE) and was admitted to NICU at Waikato DHB. Treatment for HIE was commenced, but on day four the baby developed neonatal sepsis. Her condition deteriorated rapidly and she subsequently died from an overwhelming infection.
Mr Hill was critical of staffing levels overnight in the NICU, and considered that the DHB staff involved showed a lack of critical thinking. Mr Hill found that staff delayed commencing aEEG monitoring, failed to undertake an adequate assessment of the baby as she began to deteriorate which delayed antibiotic treatment, and did not document adequate medical records. As a consequence, treatment for both of the baby’s conditions was delayed.
The Commissioner recommended that the DHB introduce an education programme for all NICU staff about the signs of possible infection, and about handover and documentation, and that they provide a formal apology to the whānau of the baby. He also recommended that the DHB analyse the number of cot-side EEG monitoring units required; review the staffing levels in the NICU; and review its procedures for “Early Onset Neonatal Infection Prevention”.
The full report for case 17HDC02291 is available on the HDC website.