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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a three-year-old boy with pneumonia.
The boy became unwell and was seen twice at a medical centre. On the second presentation, the GP kept the boy for observation until the clinic closed, and then transferred him to an urgent care clinic. The urgent care clinic then referred him to the public hospital.
The boy was transferred to the children’s ward when he arrived at hospital. Records of his vital signs were entered into an observation chart on nine occasions. However, some of his vital signs were not observed regularly or entered into the chart accurately and, as a result, the corresponding Paediatric Early Warning Scores (PEWS – a clinical tool used to help identify patients at risk of deterioration, and to ensure care is escalated and the appropriate interventions are made) were inaccurate. Overnight the boy’s vital signs remained fairly stable, but in the morning his condition deteriorated rapidly. Tragically, he passed away. The cause of his death was identified as bilateral pneumococcal pneumonia, and tests completed following his death indicated he had developed sepsis (a life-threatening whole-of-body response to infection).
Deputy Commissioner Rose Wall considered that there were multiple failures in the care provided to the boy. Specifically, staff made assumptions, including that the boy’s illness was pneumonia without sepsis, that because his PEWS (calculated incorrectly) were relatively stable overnight he was not deteriorating, and, when his observations did indicate deterioration, that he would be reviewed promptly during the morning ward round. She also found that nursing staff failed to think critically about the boy’s overall clinical picture and, as a result, failed to escalate his care appropriately; medical staff failed to consider the overall clinical situation and to explore the possibility of sepsis more thoroughly; and there was a culture of non-compliance with the PEWS management plan by nursing and medical staff.
“It is impossible to know whether the outcome would have been different if these errors had not occurred,” said Ms Wall. “However, I consider that the above failures resulted in a lack of recognition and response to [the boy’s] serious illness and the emerging signs of his deterioration.”
Ms Wall was also critical that when the boy presented to the medical centre the second time, pneumonia was not included in the differential diagnosis, and other than the triage nurse’s observations, no further observations were recorded in the clinical notes.
Ms Wall recommended that the DHB provide evidence that all the recommendations from its Serious Event Review have been implemented and their impact evaluated. She also recommended that the DHB provide training to paediatric nursing and medical staff on the recognition of a deteriorating child based on the clinical picture and on critical thinking and challenging assumptions; consider whether a review of its health pathway for administering oxygen therapy is warranted; and provide a written apology to the boy’s parents.
Ms Wall recommended that the medical centre provide training to clinical staff on the recognition and treatment of sepsis in children, and a written apology to the boy’s parents.
The full report for case 18HDC02160 is available on the HDC website.