Three-year-old dies of sepsis after several mistakes at hospital

A three-year-boy died of septic shock in a rural hospital after critical opportunities to save his life were missed by an on-call doctor and a nurse who shouldn't have been in sole charge of the children's ward that night.

It has prompted the Health and Disability Commissioner (HDC) to write to Health NZ to ensure sole-charge clinical staff are suitable at rural hospitals, where resourcing is a problem.

An investigation into Alexzander Sutherland-Hunt's death by the HDC, released on Monday, found systemic failings in the care provided to the little boy when he was taken to then Grey Base Hospital in Greymouth by his parents Matt Hunt and Sapphire Sutherland-Hunt with a fever and vomiting in July 2020.

Deputy Commissioner Rose Wall found the on-call junior locum doctor suspected sepsis but did not administer a broad-spectrum intravenous antibiotic, contrary to the Starship fever guideline which he reviewed when assessing the boy.

But it wasn't the first mistake that night.

According to the report, the boy's parents took him to the emergency department at 9.41pm where he was admitted by a senior doctor for observation for suspected early appendicitis.

A registered nurse, identified only as RN A, was in sole charge of the children's ward overnight despite not being up-to-date with paediatric-specific emergency training, and not having worked as a nurse in New Zealand for very long having trained overseas.

Sutherland-Hunt told the HDC by the time her son was assessed in the ED he wasn't drinking fluids and after he was admitted to the ward about 11.30pm she alerted RN A to the fact he continued to vomit stringy mucus, but the nurse was "not concerned at all".

"It was not overly concerning that he had vomited because medical staff were aware of his previous vomiting and so it was not a new symptom that required further escalation," the nurse told a Serious Event Review undertaken by the hospital after the death.

She gave Zandy – as his parents called him – an ice block but he vomited that up soon after and later when his mother said he was "hot and clammy", RN A gave the boy paracetamol which he also vomited up.

Wall criticised the nurse's fluid balance monitoring saying she "lacked critical thinking" and failed to recognise the need to escalate Zandy's care to senior staff after multiple episodes of vomiting with a fever and minimal rehydration.

Despite Zandy being scored a two in the Paediatric Early Warning System [PEWS] in the ED, the nurse consecutively scored him zero over several hours, with no score at 2.30am.

PEWS is a protocol used by healthcare professionals to identify hospitalised children at risk of deteriorating, with zero the lowest concern.

Her hourly observations were also incomplete but at 4.30am Zandy's accelerated heart rate was noted among other deteriorating vital signs.

Wall said even without calculating the PEWS score the observations should have prompted the nurse to escalate Zandy's care.

The nurse told the HDC she responded to the parents' growing concern appropriately but the Serious Event Review found RN A should have responded with more urgency and taken more action to identify the cause of Zandy's deterioration.

She was also criticised for failing to use the 777 emergency call system, which she'd never used before.

It was only when another nurse turned on the lights and noticed a rash on Zandy's face and trunk that she called for the locum junior doctor at 3.30am.

But despite the rash and considering the possibility of early sepsis, the doctor opted to wait for a "gram stain", a test for bacteria, before administering IV antibiotics.

This was against guidelines he reviewed at the time and the standard care in the management of sepsis.

Wall found it couldn't be known whether earlier administration of antibiotics would have changed the devastating outcome.

Dr B, as he was identified, charted IV fluids but by the time he was called back an hour later when Zandy became unresponsive, none of the fluids had been given by RN A.

Wall said the doctor should have immediately directed the fluids be given in a bolus, a concentrate form that would act faster.

Her expert, urgent care and rural hospital medicine specialist Dr Sarah Clarke, said, "failing to give a bolus of IV fluid to a child in septic shock resulting in cardiac arrest would be considered a severe departure from the accepted standard of care".

Shortly after Zandy crashed in his mother's arms a marathon resuscitation began, during which and it was noted RN A repeatedly drew up the wrong amount of adrenaline.

Wall said other staff present didn't intervene and that "it is evident that staff did not have adequate CPR and paediatric-specific emergency training".

"I consider this to be a system failure by Health NZ."

Wall was also critical of Health NZ for "allowing this situation to manifest" by failing to ensure it had adequate systems and processes, including sufficient rostering and support, correct and current paediatric-specific and CPR training, thorough inductions and orientation, and that staff had poor systemic understanding of the PEWS policy.

She found it, Dr B and RN A all breached the Code of Health and Disability Services Consumers' Rights.

Health NZ had implemented a raft of changes since Zandy's death including no longer rostering sole nurses to work nights, shifting to a rural generalist model of nursing so that nurses rotate between specialities and receive extra training and support, implementing an escalation of care pathway for families and a new model of senior medical staffing, increasing the frequency of advanced cardiac care training, and making sure junior doctors maintain current CPR training.

Zandy's parents told RNZ they were disappointed with the outcome and called the breaches found a "slap on the hand".

They said they weren't confident the changes made since Zandy's death would be monitored or prevent the death of another child.

The couple said losing their eldest – and at the time only – child in such a traumatic and avoidable way left then in a dark place for a long time.

Sutherland-Hunt, 31, said she tried hard to advocate for her son on the night and she and Hunt, 34, didn't want hospital hierarchy to stand in the way of medical staff from escalating concerns.

She described the horrific moment their "gentle, cheeky, outrageous" boy – who was a month shy of turning four – had a seizure and cardiac arrest, moments after he'd been talking.

"He just went floppy in my arms and his eyes went back and he stopped breathing."

They said Dr B arrived and began giving oxygen to their son and telling them there was nothing to worry about.

"'Everything's fine, things are just progressing a little bit faster than what we'd expected' – those words haunt you to this day."

The couple said there was mention of sepsis.

They had to watch for 90 minutes as medical staff worked on Zandy, before he was pronounced dead after 5.25am.

She said if Zandy had received the correct care and still died, it would have been easier to accept.

"The lack of care that he got right down to when he passed away. He was left with all these cords and everything attached to him.

"He was left in really bad condition... soiled, he was all wet. He still had his tubing. We were just left. Nobody came to the room, not one person... nobody said sorry.

"Everybody walked out of the room. We were left for hours and hours. We ended up finally being able to leave the hospital with him and taking him to the funeral home. We took him in our own vehicle."

Sutherland-Hunt was critical the hospital couldn't "even get the aftercare right" for families, yet staff were debriefed and well supported.

The parents each took a month off work without pay to try to cope with their grief and said they felt lost in the aftermath.

They said there was no support and no-one to guide them through the overwhelming processes of an internal review, an external review, the HDC complaint process and a coroner's inquest – which they said wouldn't happen after the coroner decided not to open an inquiry.

The couple, who'd gone on to foster children, lose a baby in pregnancy, and have two more boys of their own – who both have Alexzander as a middle name – wanted other parents to feel empowered to advocate for their children in hospital.

"The biggest message we want to get out there is, even though they're trained medical staff, if in doubt, question them, ask for a second opinion," Hunt said.

Both parents told the HDC they'd had to relive the trauma, from which they would never recover, and that "no words can mend the deep wounds" they carry.

They remained concerned at RN A's continued practice, although she no longer works in sole charge, and her apparent lack of ability to take responsibility for her actions.

The couple also found it concerning the decision had similarities to a previous HDC investigation regarding care provided by Health NZ.

"It just breaks your heart, really, because you know exactly how that parent is feeling."

They said Zandy was deeply loved in Greymouth and missed by many people and though they'd had more children, the pain of losing him never went away.

"There's birthdays and Christmases and all the family functions and there's always somebody missing."

Health NZ has been approached for comment.

rnz.co.nz