An accidental mix-up almost cost a young Auckland boy with cerebral palsy his life after he was given 10 times the normal dose of his prescribed medicine at Starship Hospital.
Auckland mother Andrea told Newshub her four-year-old son Ryan* was admitted to hospital for a routine surgery to cut some of his muscles in the groin to stop his legs from crossing - a symptom of his condition.
"I kept saying 'this is not normal, there's something wrong'. It took three-and-a-half hours for them to agree that there was something really wrong - and that's when he coded," she told Newshub.
Andrea says her gut instincts were screaming that something was wrong when Ryan's mood suddenly changed as he recovered from his scheduled operation.
She says it took a lot of persistence to raise alarm bells with his doctors before they fully grasped Ryan had been given a near-fatal amount of a muscle relaxant, Baclofen, due to the strength of doses varying between the hospital pharmacist and a community pharmacist.
Newshub contacted Starship Hospital to verify the circumstances surrounding how the error was able to occur, but a spokesperson said they were unable to comment due to privacy reasons.
However, in Ryan's discharge notes, which Andrea supplied to Newshub, a breakdown of the medical event matches sequencing as she remembers and includes clarification.
"Overdose secondary to administration error due to disparity between formulation of patient's personal supply of Baclofen (1mg/ml) and the hospital pharmacy supply (10mg/ml)," it states.
"Nursing staff were not aware of the difference between these concentrations and therefore gave the same amount in mls as would receive in the community."
'That's not normal'
Andrea says Ryan's behaviour initially started to cause her serious concern while having his dressing changed back at his ward following a successful surgery, when out of nowhere, her boy began to appear disorientated and very angry.
She says staff decided to give her son morphine because they thought the reaction was from the pain.
Ryan's eyes rolled into the back of his head before he hit the pillow and the four-year-old slumped into what appeared to be an unconscious state.
She says staff thought Ryan's declining condition could have been caused by the morphine, but Andrea was adamant the painkiller had been given after he crashed.
"I kept saying 'the morphine was administered after he lost it, it wasn't the morphine'," she says.
"'I actually take photos of him every couple of hours, I said 'this is what he looked like a couple of hours ago, the kid you're looking at now, that's not normal - look'."
With Ryan snoring and his tongue hanging out of his mouth, she quickly became convinced the situation was out of the ordinary. Worried, she tried desperately to get Ryan's attention but he wouldn't stir.
"I wasn't getting any real responses," Andrea told Newshub.
As the room filled up with more and more Starship staff, Andrea says she burst into tears.
"His surgeon just grabbed hold of my hand, and stood there and held my hand."
Each moment was full of emotion, as time slowed and Andrea's son slipped what looked like a semi-coma.
"I opened his eyes so the doctor could have a look and his pupils didn't change," Andrea says. "My phone call to my mum was that his pupils didn't change and she hung up and was there within 15 minutes."
Andrea says Starship staff moved to lay out all of the medicines Ryan had been given on the bed.
Eventually, it became clear that the Baclofen the family give to Ryan at home and Starship's version of the same drug had been mixed up.
The strength of the hospital's version is 10 times that of the community pharmacists.
When Andrea had arrived at Starship, hospital policy required her to hand over any of the medicines she gives her son while he is at home and the staff used Baclofen from that.
At some point, they got the pharmacist in the hospital to make up Ryan's medicine and switched, but failed to switch dosages.
"As they were figuring it out, they had my bottle and their bottle next to each other. Up until then they'd been giving 7ml out of my bottle and it was supposed to swap to 0.7ml out of their bottle," she explains.
"The poor nurse had gone away and checked, and he was told that 7ml was right, came back and gave it.
"I was hearing the conversation on the other side of the room between a lot of nurses in different colours. You know it's bad when you've got nurses wearing different-coloured shirts, and there were a couple of very high-up doctors. Standing in a room of medical professionals and you look around and over half of them look absolutely petrified - it's actually really scary, you realise your fear is fully justified."
The realisation didn't come a moment too soon, as teams rushed into the room as he "coded".
"They almost killed him, he was very close, he was very close to having to be intubated."
Ryan spent a night in the Pediatric Intensive Care Unit (PICU) before returning four nights back at his ward.
When Newshub spoke to Andrea the day Ryan returned home, she said she was still processing everything.
"I haven't got my head around it yet. We still don't know the full extent of if, or whether or not any damage has been done."
The mum-of-three is going to make a complaint through the Health and Disability Commissioner and believes an internal complaint process within Starship Hospital is already underway.
Ryan's discharge notes say the incident was "reported to MedSafe" and the hospital's adverse events team, and is being reviewed.
Newshub approached MedSafe however a media representative said they were unable to comment.
'They are exhausted'
Andrea says the orthopedics ward where her son was admitted is "normally patch and dispatch", not normally having to deal with investigating an adverse reaction to a drug.
"They are looking at bones and making sure wounds are okay, and not something like that, and the poor nurse who did it cried when he apologised to me, and cried when he saw us the next day. Clearly he didn't do it on purpose."
She says while the mix-up was a genuine error, Andrea says it is clear the hospital is struggling.
"They are under so much pressure and so overloaded and you can see it all over their faces, they are exhausted. Even walking past the nurses' station, you hear them, they are all juggling staff around just trying to cover shifts and consistently you hear them say things like 'we've got four for this shift', where clearly they should have more.
"They're just slammed; there's not enough people, there's not enough staff, the equipment is not always working."
Despite the incident, Andrea says all the nurses are amazing but hopes processes can be reviewed so this doesn't happen again.
"I believe the nurses are the bosses in the hospital, realistically, the nurses do all the hard work, they're just so slammed, and the Government needs to do something."
In a statement to Newshub, Starship said it was unable to comment on details of individual patient care for ethical and privacy reasons.
"We promote a culture of patient safety by creating an environment where patients, staff and whānau can speak up and report any concerns.
"We have well established processes and systems to capture, investigate, and enhance clinical safety. We encourage impacted patients and their whānau to discuss concerns with us and if they wish make a formal complaint directly to us or through the Health and Disability Commissioner."
A spokesperson said when incidents occur, hospital staff work closely and openly with whānau to provide reassurance and explain review processes.
"It’s hard for everyone involved when incidents occur that potentially expose patients to additional risk, and the best possible outcome is that we listen, acknowledge the error and learn from it.
"Our doctors and nurses across all our hospitals continue to provide quality care for our tamariki and whānau."
*Names have been changed to protect the identity of the child