Te Whatu Ora - Te Toka Tumai Auckland (TTTA), formerly Auckland District Health Board, has been found to have failed to investigate the cause of a six-year-old girl's illness. The girl was later diagnosed with the flu and atypical pneumonia and died weeks later.
Health and Disability Commissioner Morag McDowell said that while she was unsure if improved care would have saved the girl's life, the girl did not receive timely investigations and was prevented from earlier treatment.
The girl first presented to the emergency department and was discharged with a diagnosis of pneumonia. She was admitted to hospital two days later and despite her condition deteriorating, was transferred to another hospital, before returning to the first hospital for treatment when her right lung filled with excess fluid.
McDowell found that upon the girl's admission to hospital before her transfer, nurses failed to assess her correctly and did not notice her condition deteriorating.
"This was a missed opportunity to re-evaluate and possibly defer the decision to transfer given the change in the girl’s observations," McDowell said.
The cause of the girl's illness had still not been established by her third admission to the hospital, and despite her poor condition, testing for viral and atypical pneumonia and treatment with antibiotics were delayed.
"Further investigations should have occurred when it became clear that the girl was not responding to treatment and her pneumonia was becoming more severe," McDowell said.
She recommended TTTA apologise to the girl's family for the poor care. Several other recommendations were also made, including a possible improvement to systems in its review processes prior to patient transfers, and to remind staff of the importance of accurately documenting clinical care.
Following this case, TTTA updated their clinical guidelines with more detail on the management and treatment of pneumonia, and amended their Early Warning System chart.
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