Te Whatu Ora – Te Toka Tumai Auckland (TTTA), formerly Auckland District Health Board, has been found to have failed to investigate the cause of a six-year-old girl’s illness. The girl was later diagnosed with flu and atypical pneumonia and died weeks later.
Health and Disability Commissioner Morag McDowell said while she was unsure whether improved care would have saved the girl’s life, the girl was not investigated in time. timely and was prevented from receiving treatment earlier.
The girl first presented to the emergency department and was discharged with a diagnosis of pneumonia. She was admitted to hospital two days later and despite her condition deteriorating, she was transferred to another hospital, before returning to the first hospital for treatment when her right lung filled with excess. of liquid.
McDowell found that when the girl was admitted to hospital before her transfer, nurses failed to assess her properly and did not notice that her condition was deteriorating.
“It was a missed opportunity to reevaluate and possibly postpone the transfer decision given the change in the girl’s observations,” McDowell said.
The cause of the girl’s illness had still not been established when she was admitted to hospital for the third time, and despite her poor condition, testing for viral and atypical pneumonia and treatment with antibiotics were delayed .
“Further investigations should have taken place when it became clear that the girl was not responding to treatment and her pneumonia was becoming more severe,” McDowell said.
She recommended that TTTA apologize to the girl’s family for the poor care. Several other recommendations were also made, including possible systems improvements in its review processes prior to patient transfers, and reminding staff of the importance of accurately documenting clinical care.
Following this case, TTTA updated its clinical guidelines with more details on the management and treatment of pneumonia, and amended its early warning system chart.