By Jeremy Wilkinson of
The 13-month-old baby was taken to Oamaru Hospital in 2019. Photo: Google
The parents of a baby who died of meningococcal disease say the care their child received felt like "swiss cheese" where "there were so many holes that we fell through every single one.
"Our lives have been completely shattered with the loss of our son and we will forever live with the pain of knowing that he suffered a tremendous amount more than what he needed to," the child's parents said.
"We will also always wonder if he would still be here if it was not for the comedy of errors the team at Oamaru Hospital made that night - that is not something that is easy to live with I can assure you."
Those comments were made to Deputy Health and Disability Commissioner Dr Vanessa Caldwell who today released her finding that a lack of equipment at the hospital and failings by its staff to notice the child's deteriorating condition contributed to his death.
The parents went on to say that the thought of taking their other two children to Oamaru Hospital filled them with "complete panic" and they would rather drive more than an hour to the next-closest hospital instead.
The 13-month-old baby boy was taken to the hospital by his mother just after 2am with a fever and vomiting and allocated a triage score of three - meaning he was to be seen within 30 minutes.
A nurse found a rash on the back of the baby's neck and recommended he needed to be seen straight away, but did not document her recommendations to upgrade the triage score.
The baby had a fever, a pulse rate significantly above normal and was breathing much faster than he should have been.
However, the baby's Paediatric Early Warning System (PEWS) score was not calculated. This scoring system is used to calculate a patient's risk of deteriorating further based on the number of abnormal vital signs they exhibit. The more abnormal signs the higher the score and the greater the patient is at risk.
The on-shift doctor attended and was immediately concerned that the baby had meningococcal or meningitis and needed to be transferred to another hospital.
In the meantime he and other staff at the hospital managed to stabilise the baby and bring his temperature and his pulse down. However, 30 minutes later the baby's temperature was still higher than it should have been and his pulse began climbing again.
The baby was taken to a second hospital by ambulance - which was not named in the decision - as the doctor at Oamaru Hospital calculated that it would be quicker than scheduling a helicopter and his assessment was that the baby's condition had stabilised.
However, the clinical director at the second hospital said the baby would have received monitoring en-route if he had been taken by helicopter and would have been admitted directly to the intensive care unit.
A nurse at Oamaru Hospital did not specify the baby was suspected of having meningococcal. Instead, she wrote on the form that it was suspected meningitis which is not as severe.
When they got in the ambulance the portable oxygen monitor available would only work intermittently and only when it was kept very still. They couldn't find a replacement.
The nurse who accompanied the baby during the trip tried to check his oxygen levels during a brief stop but couldn't get the machine to work. Instead, she calculated the baby's breathing and temperature manually.
When the baby arrived at the second hospital he was floppy and lethargic with pale lips and a rash, however, ambulance staff had not radioed ahead to notify the hospital the baby's condition had deteriorated.
The second hospital immediately categorised the baby as being triage one - the highest-risk category.
The baby was taken to the intensive care unit where blood tests showed severe septic shock and multiple organ failure of which meningococcal sepsis was the likely cause.
The baby was flown to a children's hospital where he died six days later.
Medical staff's failures outlined
Dr Caldwell said in her findings that the hospital staff failed to use a PEWS chart, communication between them was inadequate and the hospital did not at the time stock the appropriate paediatric fluids.
She said the doctor's decision to send the baby by ambulance rather than helicopter was inappropriate, he didn't document sufficient information and he failed to reassess the baby's condition.
The deputy commissioner made a number of recommendations to the hospital and its staff including training on which ambulance service to use, an audit of the paediatric monitoring equipment at the hospital and an amendment to the PEWS chart to include a space for a signature to show it had been assessed.
Overall Dr Caldwell found that the hospital, the doctor and two nurses had breached the code in their care of the baby.
"[The baby] was unfortunate enough to have a rapidly progressive and unforgiving disease that has a high level of mortality even with the highest level of care," she said.
"It is therefore unknown whether further intervention and/or a different course of action would have prevented the sad outcome…"
Changes made in response to tragic outcome
Waitaki District Health Service Limited told HDC it has taken the oversights in care provided to the baby very seriously and had worked hard to improve its systems and processes, including adopting the Paediatric Early Warning Score, delivering training to staff members using observation equipment during transfer, and devised an ambulance transfer flowchart.
Dr Caldwell acknowledged the changes made and noted the health service has taken seriously the responsibility it has to provide all staff with the necessary equipment and robust guidance to assist their decision-making.
Chief executive of the Waitaki District Health Service Limited Keith Marshall said the hospital accepted the commissioner's findings.
"Our hearts go out to the family and whānau of the patient for the distress caused; this is a truly awful situation for which we offer our sincere condolences again," he said.
"For our part, the commissioner's recommendations relating to our practices have already been implemented. Indeed, we were also heartened by the commissioner's recommendation to Te Whatu Ora to investigate the establishment of a National Transfer Desk; this would make a big difference for patient care in rural hospitals, and elsewhere, and would have had an impact in this tragic situation also."
This story was first published by the New Zealand Herald.
