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.

© Scoop Media