Hutt Valley DHB failed in its care of a teenage girl with a debilitating infection, the Health and Disability Commissioner (HDC) has found, after she was rushed to the emergency department four times before it was correctly diagnosed.
It comes as the HDC released a report on Monday finding the DHB in breach of the Code of Health and Disability Services Consumers' Rights (the Code).
The report says the girl went to the emergency department with increasing knee pain on multiple occasions.
"After participating in physical training several days earlier, she visited ED twice on the same day with pain in her right knee. She was diagnosed with a knee injury and given morphine on her second visit," the HDC says.
"The girl returned to ED three days later, at which stage the pain had spread to her left knee. An X-ray was performed and she was diagnosed with Osgood-Schlatter disease, an overuse injury that often occurs in growing adolescents.
"But a few days later she returned to ED significantly unwell and was finally diagnosed with a bacterial joint infection, known as septic arthritis, in both knees."
While the HDC acknowledged the condition the girl had developed was rare and that symptoms may have been subtle, they found "a number of shortcomings" in the care she received at ED.
HDC Morag McDowell said key symptoms were not documented when the girl was triaged on her first visit to ED and that on the second visit, the possibility of a more serious pathology was not recognised. On the third visit, "more critical thinking was needed".
McDowell says staff needed to "think critically, having regard for the wider clinical picture, and to consider alternative explanations when someone presents to ED multiple times with increasing pain".
She recommended Hutt Valley DHB train clinical staff on the importance of routinely checking vital signs on ED presentations and the importance of considering possible serious pathologies.
McDowell also recommended the DHB perform a random audit of 30 ED presentations, consider whether a review of its ED staffing levels is warranted, and provide a written apology to the girl and her family.
