A six-month-old baby with a life-threatening infection was repeatedly sent home from a Waikato District Health Board (DHB) hospital before he was referred to a specialist.
The baby's mother took him to the emergency department (ED) four times over six days before he was diagnosed with the superbug MRSA and had to be placed in intensive care.
A report released on Monday by Health and Disability Commissioner Anthony Hill has found the DHB and an emergency department doctor breached patient rights by failing to provide healthcare with "reasonable care and skill."
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Hill says these repeat visits were a "red flag."
The unnamed baby was taken to ED by his mother in late November 2015. He had flu-like symptoms and was diagnosed with a viral illness and sent home.
Two days later, on December 1, he was back in hospital. This time, he had a temperature, a rash and a bleeding nose. Some of his vitals were checked, but his breathing was not.
None of the observations were repeated, which is considered to be poor practice.
Typically observations would be repeated every hour while a child remains in ED. If there was concern the patient would worsen, the frequency of these observations would be increased, said rural health expert Dr Scott Wilson.
On three of the baby's visits to ED, only one set of observations were taken and of those three, one was incomplete.
On December 4, the baby was brought back into ED.
This time he had a swollen face as well as his other symptoms. He was diagnosed with a viral infection, and his mother was given ibuprofen and amoxicillin to treat him. Again he was discharged.
When his face was swollen, the doctor who saw him should have seen he was significantly unwell and referred him to a specialist.
Hill's report notes that failure to ensure the child was seen by a specialist at this point is a breach of patient rights.
When his mother went to administer the medicine, in the early hours of December 5 she noticed his face was even more swollen.
She took him back to hospital again, and was told she needed to drive him to another hospital as no ambulances were available.
At 3am, his mother was forced to drive him to a separate hospital despite telling the doctor on duty she was uncomfortable driving an unfamiliar road so late.
At the second hospital, the infant was intubated due to a compromised airway and transferred into intensive care.
He was diagnosed with MRSA - a superbug which can be fatal. He was also severely septic and associated Ludwig's angina. Ludwig's is a rare skin infection which occurs on the floor of the mouth.
The child was discharged home on December 15. He has ongoing issues such as partial facial paralysis and an area of exposed bone inside his mouth.
The report notes Waikato DHB breached patient rights for failing to provide healthcare with reasonable care and skill.
Waikato DHB should have ensured its staff was using the Child Emergency Assessment Chart appropriately.
It has since updated this chart to include a section on "red flags".
Waikato DHB has also introduced a policy which ensures that on a child's second visit to ED they are discussed with the hospital's pediatric service.
The ED doctor who failed to refer the baby to a specialist has stopped practicing but Hill recommends if he ever returned to practice, his competency should be reviewed by the medical council.
He also recommended the doctor write a letter of apology to the baby's family.
Newshub.
