When he developed a rash in the early hours of the morning, a doctor sought lab testing, suspecting he might be “developing sepsis”.

But instead of starting IV antibiotics straight away, he decided to wait for test results.

By 5am, the boy was unresponsive, and his heart stopped. A defibrillator was used at 5.12am, but he remained unresponsive and was pronounced dead.

The day before, he’d “attended a soccer practice with no difficulty”, but had been experiencing “upper respiratory tract symptoms consistent with a common cold”.

Now, Health NZ has been found to have been in breach of the Code of Health and Disability Services Consumers’ Rights, as it failed in ensuring it had “adequate systems and processes in place”, and “failed to ensure it had staff with sufficient paediatric experience”.

This meant Health NZ had failed to provide the 3-year-oldwith “reasonable care” when he was admitted in 2020.

However, Deputy Health and Disability Commissioner Rose Wall said she acknowledged “the resource constraints experienced by rural centres such as Health NZ”.

One of Wall’s key findings was the inadequate combination of staff on the night the boy arrived.

The “staff lacked sufficient paediatric training and/or dedicated paediatric experience to provide the expected standard of care for a rural paediatric inpatient service”.

In particular, a nurse rostered as the sole charge nurse of the children’s ward was “new to Health NZ, new to paediatrics, and new to nursing in the New Zealand context”.

This rostering decision was a “moderate departure” from the accepted standard of care.

There was also an adverse comment made about the training Health NZ had provided in the area of CPR, which meant incorrect concentration and volume of adrenaline was given when the boy became unresponsive.

“It is evident that staff did not have adequate CPR and paediatric-specific emergency training. I consider this to be a system failure by Health NZ,” Wall said.

A nurse’s lack of critical thinking

Wall’s main concern was with the shortcomings of Health NZ and the resourcing of the hospital, but there were also specific criticisms of the medical staff’s conduct that night.

The nurse referred to as “RN A” had the most contact with the boy.

“…she was principally responsible for the hands-on nursing care he received, and for monitoring his deteriorating health and reporting it to more senior colleagues,” Wall said.

She hadn’t adequately monitored his fluid intake – failing to keep track of how little fluid he was taking in, and how much he was losing through vomiting, fever and sweating.

The boy’s mother had become increasingly concerned as her son continued to vomit “stringy mucus” in the children’s ward, especially given he’d been vomiting before arriving at hospital, and hadn’t been drinking.

“[The mother] stated that she alerted RN A numerous times, but RN A was ‘not concerned at all’.”

Her “lack of critical thinking about fluid intake and output in the context of a young child who was vomiting frequently with a high fever” represented a moderate departure from the accepted standard of care.

She had also taken incomplete observations, including failing to take blood pressure, and failing to record the parents’ concerns.

At 4.30am, there was a missed opportunity where the nurse failed to use the “Pediatric Early Warning Score” tool to calculate how he was tracking – a number that would have signalled that escalation and an urgent review was needed.

The nurse wasn’t alone in her failing to use the PEWS tool properly though, which led Wall to conclude it was a systemic failing by Health NZ.

Despite eight assessments by three different staff members, no complete PEWS was calculated for the boy while he was in hospital, a failure considered a “serious departure from a fundamental nursing task”.

She’d also failed to make a “777 call” when the boy became unresponsive, paging another nurse and doctor instead, delaying an emergency response.

“Although I cannot make a finding on whether a different course of action would have changed the outcome for (the boy), I remain critical of the care RN A provided to (him).”

Delayed start to IV antibiotics

Wall was also critical of “Dr B”, while acknowledging that, like RN A, the junior doctor had insufficient training, experience, and orientation to the hospital.

The doctor failed to start IV antibiotics when he should have, choosing instead to wait until he had lab results to confirm sepsis.

However, the boy was showing symptoms, including a rash, that under Starship’s guidelines, should have prompted antibiotics before results came through.

Wall saaid “it cannot be known whether earlier administration of antibiotics would have changed (the boy’s) devastating outcome”.

The doctor also failed to give the correct amount of IV fluids when the boy’s condition became worse.

There was also an “educational comment” made about senior doctor “Dr C” who assessed the boy when he arrived, and was only brought back in when called to “urgently assist” in the child’s resuscitation.

While he’d assessed the boy’s fluid status thoroughly, there was a lack of “formal documentation”. The doctor accepted this and has said he will endeavour to do better.

Changes since events

Health NZ has revised its staffing in acute zone and paediatrics, and no longer rosters sole registered nurses to work night duties.

It has implemented a new model of senior medical staffing, where there is a combined medical handover attended by medical, rural hospital medical doctors, and/or ED senior medical staff each morning, along with all oncoming junior medical officers.

There’s also increased access to the “Health Pathways” guidelines. The Paediatric Sepsis Screening and Action Tool is accessible from all local hospital logins and it has increased its training and recruitment to focus on paediatric experience.

In an apology letter to the boy’s family, Dr B accepted the severity of the situation should have led to the “immediate involvement of senior medical staff”.

Dr B stated that his lack of any Advanced Paediatric Life Support training at the time may also have lessened his degree of urgency during the response.

RN A accepted the proposed criticisms around the care provided and the recommendations proposed.

However, she disputed the proposed breach finding, stating given the serious systems failings, the proposed breach finding as it related to her should be reduced to an “adverse comment”.

The boy’s parents said they have had to relive the trauma, from which they will never recover, and that “no words can mend the deep wounds they carry”.

They remain concerned about RN A’s continued practice, and her apparent lack of reflective practice and ability to take responsibility for her actions.

While they find it encouraging that Health NZ has taken steps to improve care, they remain concerned about how these actions will be monitored to ensure that they are sustained.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.