A 2-year-old girl who died in Dunedin Hospital's emergency department was let down by a ''series of judgement and communication failures'', the Health and Disability Commissioner has found.
The department had previously discharged her twice without following correct procedure.
In a statement yesterday, patient services medical director Richard Bunton offered his ''sincere condolences'' to the family. The board had apologised for its failure to deliver appropriate care.
''Such events are, fortunately, rare and weigh heavily upon all involved. Any learnings that can be taken from this situation are welcome, and an opportunity for us to continue to improve our processes to take the greatest possible care to our patients,'' Mr Bunton said.
In a written decision released yesterday, the commissioner found against the health board, a supervising consultant, and a registered nurse at Telehealth. They breached the patient rights code by failing to provide services with reasonable care and skill.
A junior doctor who discharged the girl had told the commissioner he felt unable to challenge the view of the supervising consultant.
The commissioner criticised the junior doctor over the standard of his documentation, and for failing to advocate for his patient, but stopped short of finding him in breach of the code.
Identified as Miss A in the report, the girl was aged 2 years and 10 months when she died in 2013 due to cerebellar herniation as a result of group A streptococcal sepsis, including pneumonia.
At that time she had no known medical problems, but an autopsy discovered the presence of acute myeloid leukaemia.
The emergency department is identified in the report as being in a Southern District Health Board public hospital, but it is understood to be Dunedin Hospital.
The girl was taken to the ED with a cough, runny nose and fever, shortly after midnight on a Friday.
She was given paracetamol and ibuprofen, and discharged at 3.35am with a reduced temperature and lower heart rate. The doctor asked the paediatric department to call the family to follow up, but this did not occur.
The next day the girl had diarrhoea and refused food but continued to drink water. Her mother took her back to the ED. She was triaged to be seen within 10 minutes. The paediatric registrar was not notified, despite this being required.
The girl's temperature was 37.3degC, her heart rate was between 170 and 175 beats per minute, and her respiratory rate was 44 breaths per minute.
A junior house officer, identified as Dr C in the report, assessed the girl and discussed her symptoms with the supervising consultant.
Dr C did not document the discharge information provided to the girl's parents, and did not request a follow-up phone call from the paediatric department.
The accounts of the junior doctor and consultant about what was discussed differed, the commissioner noted.
''Dr C told HDC that Miss A's heart rate and respiratory rate concerned him. However, I note that this concern is not reflected in his documentation. Dr C said that he thought further investigations ... were warranted but he did not challenge Dr B's decision, as it was not then his practice to challenge a consultant, and it is not easy for a junior doctor to challenge a senior doctor.
''Irrespective of any difficulty, part of the privilege of registration as a doctor is accepting responsibility for the care of patients.''
A nurse in the department reported being surprised the girl was discharged, and wanted to speak to the doctors, but was unable to find them.
The next day Miss A's temperature had increased. Her mother called the ED for advice and was transferred to the Telehealth national service.
She spoke to a registered nurse at Telehealth. Her daughter's breathing could be heard throughout the call. The girl's mother ended the call after three minutes and 12 seconds.
About 1pm the same day, Miss A stopped breathing and was taken back to the ED, where attempts to resuscitate her were unsuccessful.
Southern District Health Board staff had ''inappropriately'' discharged Miss A on the second visit without taking sufficient steps to consider her history and investigate the cause of her illness.
Staff failed to provide adequate discharge information to the child's family, and the SDHB's system for paediatric follow-up was not sufficient to ensure follow-up would occur as requested.
The board failed to encourage a culture where staff felt comfortable questioning or challenging decisions, and lacked a multidisciplinary approach to Miss A's care, the commissioner found. The hospital had sufficient information to provide the child with appropriate care, but a ''series of judgement and communication failures'' meant it did not do so.
Of the Telehealth nurse, the commissioner found he did not provide adequate advice and failed to take appropriate steps when the mother ended the call.
The consultant ought to have taken account of the junior doctor's inexperience, and ought to have ordered further investigation of the girl's symptoms before approving her discharge.
The commissioner's recommendations to the DHB included conducting an audit to ensure discharge procedures for young children were followed.
The commissioner recommended an independent review of staff rosters to ensure junior staff received appropriate supervision.
Two emergency department doctors - the house officer and the consultant - as well as the health board, and the Telehealth nurse were ordered to provide a written apology to the girl's parents.
