Multiple failures have been found in the care provided to a baby who died from meningococcal septicaemia.
The baby, 13 months old, had arrived at Oamaru Hospital with a fever and vomiting. He was assessed and left in the care of nurses, who re-examined him and found a rash and symptoms worse than previously thought.
However, the subsequent treatment of the baby was inadequate in multiple ways. His parents were left wondering if he would still be with them had there not been a "comedy of errors" in his care.
The doctor, immediately concerned that the baby had meningococcal disease, gave him fluids and antibiotics and, when confident his condition had stabilised, organised a transfer to a larger hospital nearby.
He was advised by other staff to transfer the baby by helicopter but decided to use an ambulance instead. Asked why he'd decided against transferring the baby by air he said "we don't need it" and was confident the baby's condition was stable.
This decision was found by Health and Disability Deputy Commissioner Dr Vanessa Caldwell to be inappropriate because, "while the transfer by air may not have been quicker, the baby would have received monitoring en route".
Further failures include a lack of appropriate equipment at Oamaru Hospital — including a lack of paediatric monitoring equipment — and poor or no documentation of the baby's condition at multiple stages.
Caldwell criticised the doctor's handling of the transfer to the secondary hospital, noting that the ambulance service was told the baby had meningitis, which is time sensitive but not as time critical as meningococcal septicaemia.
"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," Caldwell said.
The baby arrived at the larger hospital but was not expected at the ED due to a communication failure. By this point, the baby was lethargic and his lips were pale.
He was transferred to the ICU before being flown to a children's hospital where he remained in unstable condition for six days before his care was redirected to palliation.
The baby's parents stated that reading Caldwell's provisional opinion brought to light more mistakes than they were aware of.
They said it felt "that the odds were against [their baby] at every level of care". 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."
Standing by his decision to use the ambulance service, the doctor said he will factor case severity and the management capability of different transfer options into future decisions.
He provided his sincerest condolences and acknowledged a temporary improvement in the baby's condition after arrival meant he may have missed a trend of a slowly worsening picture.
The Waitaki District Health Service Limited said it had taken these oversights very seriously and worked hard to improve its care, including adopting the Paediatric Early Warning Score, which was lacking in the baby's initial assessment.
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