On Saturday, July 9, 2022, when she was just 2, the girl developed a fever and was taken to her local medical centre, where her parents were told she had a viral infection, most likely influenza.
A GP conducted a physical examination, which did not show clear signs to suggest a cause other than flu-like illness, which was prevalent at the time.
The GP told the Health and Disability Commissioner (HDC) that appendicitis was difficult to diagnose in the early stages and rare at such a young age.
The GP did not order a blood test because it was not considered useful or appropriate, and no laboratory services were available at the medical centre at a weekend, so the family would have had to transfer to Wellington Hospital.
According to the HDC finding, the girl improved significantly after being given ibuprofen for fever and pain, and was sent home.
The next day, after her parents contacted Healthline for advice, the toddler was admitted to a paediatric ward at Wellington Hospital.
A nasogastric tube was inserted to facilitate fluid intake.
Her symptoms, as noted in the emergency department (ED) clinical record, included a four-day history of cough, inflammation of nasal mucous membranes, fevers, and a two-day history of reduced oral intake, episodes of loose bowel motions, and abdominal discomfort.
She was diagnosed with a viral illness and dehydration.
A paediatric consultant reviewed the girl on the morning of July 11, 2022. Her abdomen was soft, and she was noted to be crying during the abdominal examination.
That evening, a paediatric registrar tried to examine her, but she was reluctant to be touched because of her abdominal pain.
The registrar documented a clinical impression of possible gastroenteritis. The nursing documentation notes she was “miserable”, requiring regular pain relief and unable to lie flat.
At 4am on July 12, the toddler woke with a high temperature of 38.1C.
The paediatric registrar reviewed her at 11am and noted that she was miserable, lethargic and dehydrated. A plan was made to increase nasogastric fluids.
In an internal review after the events, Health NZ acknowledged that, at this point, the child’s clinical path began to diverge from the typical gastroenteritis picture as she had not improved after 48 hours, had a high heart rate, and had fevers again.
That evening, she was noted to have a tight, distended abdomen, something that was discussed with the paediatric registrar.
The nurse caring for the child on the afternoon shift told the girl’s parents that the doctor was coming to see them.
The doctor did not arrive that evening; after further inquiries, her parents were told that she would be reviewed in the morning.
Discharged despite high fever
In a handover the following day, it was noted the child had been diagnosed with gastrointestinal illness, and a doctor was asked to determine whether she was well enough to be discharged.
A faecal test result was reported as negative for all illnesses, but she was not discharged because she was not eating or drinking.
Health NZ stated that, by July 13, it was clear that her clinical path had diverged from what would be expected of viral gastroenteritis and that a full blood count and CRP test should have been done. (A CRP test measures the level of C-reactive protein in blood to check for inflammation.) Results from these tests would probably have shown that her white cell count and CRP were elevated, prompting further investigation.
The parents told the HDC that the doctor entered the room and said, “Right, let’s get her home. Everything we are doing, you can do at home. If you have any problems, don’t come back to ED, see your GP,” despite her not being medically reviewed.
The doctor explained that the child could be discharged because she no longer required the nasogastric tube and the hospital was not offering anything that could not be done at home.
On July 18, the child’s GP re-referred her to hospital. She had not improved and was complaining of a sore abdomen.
She was diagnosed with a ruptured appendix and required surgery to remove part of her bowel.
What was meant to be a keyhole surgery turned into open surgery.
She remained in hospital until August 1, 2022, but was readmitted a few days after discharge because of a complication from the first surgery.
She required further surgery to form an ileostomy stoma and was eventually discharged on August 18.
Her parents told the HDC their daughter has experienced ongoing stomach issues since these events, the most recent on April 19 this year when she was admitted to Wellington Children’s Hospital for small bowel obstruction.
She is on a two-year recall as she is likely to require further surgery on the scar as her stomach grows.
Last month, she started EMDR trauma therapy as a result of what happened in 2022, and her parents have both sought therapy to manage their own trauma.
They said they were unable to take her into a healthcare setting without her having a panic attack.
She needed to be sedated for medical interventions, such as inserting an intravenous line, during her recent admissions.
Caldwell found Health NZ did not provide services with reasonable care and skill. The child was discharged without a proper medical review, and a blood test was not done to rule out infections.
“During her stay, the child was seen by a different doctor each day, which did not allow any one registrar to have a full picture of the child’s progression.”
Sarah Fenwick, group director of operations at Capital, Coast & Hutt Valley, said Health NZ accepted the HDC’s finding that aspects of the child’s care “fell below the standard of healthcare New Zealanders should expect”.
“We remain committed to learning from these events, and continuing to improve the safety and quality of care we provide to children and their whānau.”
Caldwell made several recommendations to Health NZ:
Provide a formal, written apology to the parents.Provide training to junior doctors on the assessment and escalation of red flag symptoms, including persistent fever and tachycardia (rapid heart rate), in children. Undertake an audit of 20 paediatric discharge summaries, covering the most recent 12-month period, for compliance with the provision of appropriate safety netting advice.Provide HDC with a copy of evidence of completed recommendations from the systems analysis review dated June 12, 2024, including the guideline developed for children with persistent gastrointestinal symptoms. Audit a sample of 15 paediatric charts for the frequency of Paediatric Early Warning Score (PEWS) observations against accepted local guidelines. Consider reviewing the admission process to encourage early engagement with play specialists to reduce interventional distress, enable examinations, and enhance the ability to observe developmental behaviours in response to illness.
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.
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