A Dunedin toddler who died after being sent home from hospital could have survived if she'd been examined by a senior staff member, an expert paediatrician says.
Two-year old Hineihana Sosefina Mausii died of a brain herniation, sepsis and advanced leukaemia in 2013.
A coronial inquest into her death was held in the Dunedin District Court on Wednesday.
University of Auckland specialist paediatrician Prof Stuart Dalziel said there was a "major failure" in Mausii's care, the Otago Daily Times reports. The opinion of a junior doctor was not reviewed by his superior. Instead, the senior consultant viewed Mausii from across the ward and discharged her.
"It is a tragedy she died and that could have potentially been avoided," Dalziel told coroner Brigitte Windley.
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In 2015 the Health and Disability Commissioner launched an inquiry into the circumstances which contributed to her death.
Mausii died on September 29, 2013 after being discharged from Dunedin Hospital's emergency department (ED).
On September 26 the two-year-old was feeling unwell with what appeared to be a cold, the report reads. The next night she woke up screaming in pain.
Her parents took her to ED and she was discharged at 3:35am the following day. The doctor who discharged her requested the paediatric department follow up with her family, but this never happened.
Back at home, the toddler grew lethargic and refused food. She was feverish, had diarrhea and was wheezing.
Her mother returned to ED on the September 28, where Mausii was diagnosed with a viral illness. The doctor discussed her condition with a supervising consultant, but this consultant did not assess the toddler personally. The consultant told the Health and Disability Commissioner they could see the girl across the ward, and she seemed fine.
She was discharged at 10pm. Her family was not given any discharge information, nor was she given a follow-up call from paediatrics.
Mausii went into cardiac arrest the following day at 1pm. She was taken to Dunedin Hospital and declared dead at 2:50pm.
An autopsy revealed Mausii died from cerebellar herniation caused by a severe bacterial infection which left her septic. She also had pneumonia and underlying acute myeloid leukemia.
Dalziel told the court the toddler's leukemia was advanced. It was present in her lungs, bone marrow and abdomen, reports Otago Daily Times.
Dalziel said she should not have been discharged from ED the night before her death, and senior staff should have reviewed her case.
"The mistake was to let her go."
Tapping her chest could have indicated abnormalities in her lungs, and if the sepsis had been detected she could have been put in intensive care to support her breathing. A simple blood test could have diagnosed her leukemia.
Dalziel says she may still have died, but it was "certainly possible" she would have survived if she had been diagnosed earlier.
The inquest will continue on Thursday.
Newshub.
