Missed Opportunities To Manage Care Of Girl Adequately And In A Timely Manner

Health and Disability Commissioner Morag McDowell has found 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 influenza and atypical pneumonia and, tragically, died some weeks later.

The girl presented to the Emergency Department (ED) and was discharged with a likely diagnosis of pneumonia. Two days following her discharge, the girl was admitted to hospital with ongoing symptoms. Despite a continuing deterioration in her condition, she was transferred to another hospital briefly, but was readmitted to the first hospital for treatment of excess fluid build-up in her right lung. The girl was largely cared for in the Paediatric Intensive Care Unit, with input from other services until her tragic death.

Ms McDowell noted that in this deeply saddening case, it is clear "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 tragic, unexpected circumstances".

In her decision, Ms McDowell found the failures by TTTA were not isolated incidents, and there were numerous missed opportunities by the services involved to investigate more intensively and in a more timely way.

Ms McDowell found that during the girl’s second admission, and prior to her transfer to another hospital, nursing staff failed to adequately assess the girl and consequently did not recognise her deterioration and escalate it to medical staff for further review.

"This was a missed opportunity to re-evaluate and possibly defer the decision to transfer given the change in the girl’s observations," says Ms McDowell.

By the third admission, there was a clear need to establish the cause of the girl’s illness. However further testing and investigations for viral and atypical pneumonia, and appropriate treatment with empiric antibiotics, were delayed.

"Further investigations should have occurred 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 an earlier diagnosis and treatment would have altered the course of the girl’s condition, I am critical she did not receive timely investigations, and was prevented from being afforded appropriate treatment earlier," says Ms McDowell.

Ms McDowell recommended TTTA provide a written letter of apology to the family for the aspects of care identified as deficient. She also made multiple recommendations to TTTA, including, to communicate changes to its guidelines to other districts, provide an update on changes made relevant to management of pneumonia and audit compliance, consider systems improvements in its review processes prior to transfer of patients, and to remind staff of the importance of full and accurate documentation of clinical care.

Following events of this case, TTTA advised a review of the treatment provided to the girl resulted in the update of Clinical Guidelines in 2018, including the indications of severe pneumonia, and further detail on investigations to consider and undertake for management and treatment of pneumonia. TTTA further advised that in August 2018, the Patient Deterioration Clinical Governance Committee approved amendments to the "Recommended Actions" on the Patient Early Warning System chart.

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