Health and Disability Commissioner: Baby with meningococcal septicaemia died after doctor's, nurses' series of failures

Health and Disability Commissioner: Baby with meningococcal septicaemia died after doctor's, nurses' series of failures
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A health service, a doctor, and two nurses have been found in breach of the Health and Disability Services Consumer’s Rights code after a baby with meningococcal septicaemia died.

The 13-month-old arrived at Oamaru Hospital, which is operated by Waitaki District Health Service Limited (WDHSL), in 2019 with vomiting and fever. A report from the Health and Disability Commissioner said he was triaged by two registered nurses who gave him a triage score of three.

After he was examined, one of the nurses found a rash and dots on his neck and the other nurse believed the baby's triage score was higher than three and needed to be seen by the doctor immediately. She called for the doctor to attend but didn't document the change in triage code.

The baby's Paediatric Early Warning System (PEWS) score was not calculated. The PEWS is calculated from objective vital sign measures such as oxygen requirements, heart rate, and blood pressure. The more abnormal the vital signs, the higher the score.

The doctor arrived within a minute and was immediately concerned the baby had meningococcal disease or meningitis and that he was dehydrated and experiencing septic shock. The doctor ordered a test and the baby was given fluids and antibiotics. 

Once the doctor was comfortable the baby's situation had stabilised, he organised a handover to a larger hospital and an ambulance was ordered to transfer him.

But the doctor made the decision to use an ambulance to transfer the baby, as opposed to a helicopter, which the report said was "against the advice of other staff present". The request for an ambulance by one of the nurses was noted as an "ASAP inter-hospital transfer" not an "emergency transfer", which resulted in a delay of 40 minutes.

A nurse was tasked with caring for the baby during transit to the larger hospital in the ambulance, but the report said she was given inappropriate equipment to monitor the baby’s vital signs and so was unable to do so adequately during the transfer.

While a paediatric doctor at the larger hospital had verbally accepted the baby’s transfer, the emergency department (ED) wasn't notified and wasn't expecting the baby’s arrival. ED staff also didn't expect the baby to be so unwell on presentation, or that he would deteriorate significantly during his transfer. 

The baby deteriorated further at the larger hospital and died six days later.

Deputy Commissioner Dr Vanessa Caldwell found WDHSL breached Right 4(1) of the Code for failing to provide services with reasonable care and skill. She found that a PEWS chart was not used to document vital signs appropriately, there was no guidance in place for adequate objective observations or criteria to support decision-making on the mode of transfer, and staff communication was inadequate. She also criticised the lack of appropriate equipment at the hospital.

Dr Caldwell also found the doctor in breach of Right 4(1) because he failed to reassess the baby’s response to treatment and provide further treatment, his decision on the mode of transfer between hospitals was inappropriate. While the transfer by air may not have been quicker, she said the baby would have received monitoring en route. Dr Caldwell also criticised the doctor’s handover discussion with the receiving hospital and inadequate documentation.

The first nurse was also found in breach of Right 4(1) of the Code for failing to calculate a PEWS score and for not providing adequate documentation, including adequate information on the ambulance request form.

Dr Caldwell found the second nurse in breach of Right 4(1) for failing to monitor and document the baby’s vital signs during transfer, for failing to recognise the baby’s worsening condition and seek support, and for inadequate documentation.

The parents of the baby boy, identified only as Mr and Mrs A, said reading the Health and Disability Commissioner's report brought to light more mistakes than they had been initially aware of. They said it felt "that the odds were against [our son] at every level of care" and it reminded them "of Swiss cheese - there were so many holes and 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," they 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."

WDHSL gave its "deep sympathies" to the family. They've taken the matters raised "very seriously" and are committed to continuing improving the health services they provide. Its improvements include adopting the Paediatric Early Warning Score, delivering training to staff members using observation equipment during transfer, and devising an ambulance transfer flowchart.

Dr Caldwell acknowledged the changes made by WDHSL and noted that it has taken seriously the responsibility it has to provide all staff the necessary equipment and robust guidance to assist their decision-making. She made a number of recommendations, including that WDHSL undertake an audit of paediatric monitoring equipment available for all potential patient transfers and an educational comment on improving the quality of communication by the paediatric doctor at the larger hospital.