A three-year-old girl with severe asthma died after nurses failed to give her oxygen and a doctor administered six times the required dose of adrenaline.
The Health and Disability (HDC) Commissioner Morag McDowell found a doctor, a rural medical centre and the DHB (now Te Whau Ora) in breach of the Code of Health and Disability Services Consumers' Rights.
In 2019, the girl was taken to the medical centre by her mother after the toddler developed a worsening cough and wheezing. The doctor gave her medication via a nebuliser which resulted in the cough settling.
But the following day the mother returned to the medical centre with her daughter who had worsening symptoms.
"She was struggling to breathe and had low oxygen saturation levels."
The girl was given medication via a nebuliser immediately, but not given oxygen "as required".
But the girl failed to respond to the medication, so the on-call doctor gave the girl six times the required dose of adrenalin which resulted in her becoming "increasingly agitated". The girl collapsed and stopped breathing.
The HDC said an emergency button was pushed 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."
Two staff members trying to use the wall oxygen failed to remember it had been turned off due to a leak.
The HDC said the doctor used incorrect resuscitation procedures for a child and there were technical issues when staff tried to make a video call to the ICU of the public hospital.
Intensive care paramedics arrived by helicopter and helped with resuscitation but the girl tragically died.
McDowell found the medical centre and the public hospital responsible for the failures as they provide an integrated health service.
"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."
McDowell said the centre 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 commissioner found the on-call doctor's decisions breached the code.
"I consider that by failing to arrange for the girl to be given oxygen prior to her collapse, giving her an overdose of adrenaline that amounted to almost six times the dose she should have received, and by coordinating the CPR effort with multiple inaccuracies, the GP failed to provide services with reasonable care and skill."
McDowell said the doctor has reflected on the case and committed to learning from the event and is "doing everything he can to avoid such an outcome in the future".
She added the DHB initiated a serious event review, which came after the need to identify systemic errors and areas for improvement.
"I strongly encourage both entities to take on board the recommendations and feedback from this review, at a systems level, to ensure future improvement in the joint service they provide."
Some of McDowell's recommendations for Te Whatu Ora and the medical centre:
- Provide HDC with an update on progress made with changes outlined in the serious event review, and continuous updates on the effectiveness of these changes every three months.
- Consider having a supply of printed resources (such as asthma management plans) available.
- Provide evidence of a co-designed governance structure with clear roles and responsibilities agreed upon.
- Develop a training plan for each clinical staff member that is to be reviewed and amended each year to identify and fix gaps in staff training and knowledge.
- Develop a clear communication pathway on processes for staff to contact external support in emergencies (such as the public hospital, Starship Hospital or the ambulance service).
- Undertake a review of the emergency information and equipment currently at the medical centre to ensure there is appropriate signage and reference charts available in emergency situations; and ensure all staff are familiar with the equipment, able to find it quickly and know how to use it.
- Consider sharing specific information about staff skill sets on daily staff rosters to ensure staff are familiar with each other's abilities and skills in the event of an emergency.
- Provide the family with a written apology.
McDowell added the GP has attended a course on advanced paediatric life support and urged him to report back to the HDC on further training he has taken up.
