Report finds Auckland DHB in breach of code in relation to six-year-old girls death

The former Auckland District Health Board has been found in breach of the health and disability code in relation to the death of a six-year-old girl.

The Health and Disability Commission has released its report finding the DHB failed to adequately investigate the cause of the girl’s illness in 2017.

Commissioner Morag McDowell said the girl’s death from influenza and pneumonia was tragic and a “deeply saddening case”.

The report states the girl was admitted to hospital three times, and briefly transferred to another hospital, but testing for viral and atypical pneumonia and the appropriate treatment were delayed.

“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,” McDowell said.

In her decision, McDowell found the failures by the former DHB, now Te Whatu Ora – Te Toka Tumai Auckland were not isolated incidents, and there were numerous missed opportunities by the services involved to investigate more intensively and in a more timely way.

The girl went to the emergency department (ED) with a cough and fever and was discharged with a likely diagnosis of a lung infection, pneumonia.

Two days later, she was admitted to hospital with ongoing symptoms.

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

Despite a continuing deterioration in her condition, she was briefly transferred to another hospital closer to her home before being readmitted to the first hospital.

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

Back at the first hospital, the girl received treatment for the excess fluid build-up in her right lung.

She was largely cared for in the Paediatric Intensive Care Unit, with input from other services.

In her decision, McDowell said that by the third hospital 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,” she said.

“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.”

At the time of her death she was suffering from a strain of the flu and atypical pneumonia, which caused respiratory failure that needed life support, ultimately resulting in swelling and bleeding in her brain.

McDowell has made multiple recommendations to Te Whatu Ora – Te Toka Tumai Auckland, relating to its management of pneumonia and transferring patients.

She also recommended they provide a written letter of apology to the family for the aspects of care identified as deficient.

Te Toka Tumai Auckland reviewed the treatment provided, resulting in updates to its clinical guidelines in 2018.