A District Health Board (DHB) has been criticised for failing to provide adequate care over the death of a toddler.
The 16-month-old boy had been to hospital four times, unable to bear weight on his left leg, and was eventually diagnosed with a fracture. But following discharge from hospital, the boy sustained further injuries and died.
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During the course of the hospital visits, it was noted that the cause of injury was unknown. Other injuries were also picked up, including bruising and a chipped tooth, but the possibility of non-accidental injury wasn't considered specifically.
A report released on Monday found the DHB failed to provide the toddler with adequate care.
Health and Disability Commissioner Anthony Hill said that the DHB's systems did not encompass an adequate safeguard for the boy, and that the evidence overwhelmingly demonstrated a systemic failing on the part of the DHB.
"In my view, the system that was meant to wrap around this boy had the information it needed to diagnose his fracture and non-accidental injuries earlier," he said.
"However, a series of failings in assessment, communication, documentation, and coordination of care, and a failure to adhere to policies and procedures prevented this from occurring."
Mr Hill requested that the DHB provide a letter of apology to the boy's family.
He also made a series of recommendations that would enable the DHB to provide better care for, and better identify injuries to children.