A three-year-old girl died after "multiple errors" at a rural New Zealand medical centre in 2019.
A report released today by Health and Disability Commissioner Morag McDowell outlined the tragic details leading up to the girl's death.
"The girl developed a worsening cough and wheezing that was not responding to medication," the report reads.
"Her mother took her to the rural medical centre, where a doctor gave her medication to open up the airways via a nebuliser. Her coughing settled and she was given an inhaler and spacer to take home."
However, the next day her condition worsened again and the family rushed her back to the clinic.
"She was struggling to breathe and had low oxygen saturation levels. While she was immediately given medication via a nebuliser, she was not given oxygen as required. When she failed to respond the on-call doctor gave her adrenalin. The girl became increasingly agitated, collapsed and stopped breathing."
The report then details "multiple errors" that were made in the girl's care.
"An emergency button in the room was pressed and the doctor began resuscitation immediately.
"During the next one and a half hours and the concerted efforts of clinical staff to resuscitate her, multiple errors were made in the girl’s care, including two staff members trying to use the wall oxygen, forgetting that it had been turned off due to a leak; the doctor directing incorrect resuscitation procedures for a child; technical issues when staff tried to make a video call to the ICU of the public hospital; and the girl being given an overdose of adrenalin."
Specialist paramedics who arrived by helicopter were unable to revive the girl and she died.
Due to the fact the medical centre provided "an integrated health service with the public hospital", McDowell stated the two health providers were responsible for the errors.
"I acknowledge the level of stress under which clinicians were operating at the time of the girl’s collapse, and their earnest, best efforts to resuscitate her.
"Nonetheless, I consider that such a facility should have appropriate processes and supports in place to assist staff to manage emergency situations, particularly when the facility deals with after-hours, acute emergency situations.
"The report highlights the importance of ensuring that facilities are fit for purpose, and that staff are trained and supported to provide appropriate care in stressful emergency situations such as this."
McDowell made a number of recommendations for Te Whatu Ora and the medical centre to avoid a repeat of the incident.
Among them was a recommendation for those involved to provide a written apology to the family who suffered the loss.
SHARE ME