About 10 minutes later, he regained consciousness but could not talk, walk, sit, or stand.
The GP suspected the boy had suffered a seizure and referred him to an emergency department (ED) at a hospital not named in the report, where he was taken for further assessment before midday.
At ED, the boy was unable to stand to measure his height and had to be weighed while seated.
A nurse conducted observations, including blood pressure, heart rate, and oxygen saturation, and noted that his blood pressure was unusually high, but didn’t inform the paediatric registrar.
The report stated that when the mother tried to talk to the registrar, he told her he knew what had happened because she’d spoken to the boy’s GP.
When the mother explained that her son could not stand, the registrar told her that many patients who had experienced a seizure took a long time to recover and that she should not worry.
The registrar discussed the case with the on-call paediatrician, but while the decision notes further observations were recorded, these didn’t include blood pressure readings or neurological examinations.
By mid-afternoon, the boy seemed to be recovering, eating and drinking small amounts and could walk when supported.
At a shift handover that afternoon, the nurse was informed that the boy had high blood pressure and further measurements were needed.
Shortly after, the boy was encouraged to go to the playroom, where the registrar and nurse observed that he was walking unaided without any weakness in his leg or gait.
In contrast, his mother said that he was unable to walk and stand independently, and she used a wheelchair to get him home.
The boy was discharged from hospital with information about seizures, despite his mother raising concerns about the decision.
She was told not to worry and that many patients take time to recover after seizures.
The registrar told the HDC she did not go through the discharge information herself, having delegated that task to a nurse.
The boy’s blood pressure wasn’t rechecked before he was discharged, because he was asleep and the nurse didn’t want to disturb him.
The mother reported that once home, he retched all evening, walked abnormally, and had only eaten a small amount of dinner.
His mother checked on him several times throughout the night, but early the following morning, she found him unresponsive. She called emergency services, who took him to the hospital.
A subsequent CT scan in the ICU found the boy had suffered a posterior cerebral circulation stroke and had unsurviveable brain swelling. He died surrounded by his family.
Clinical advice provided to the commission by paediatrician Dr Heidi Baker was critical of the failure to recheck the boy’s blood pressure before he was discharged.
In addition, the abnormal blood pressure reading was not communicated to the paediatric registrar, so it could be considered when forming a differential diagnosis and treatment plan.
Dr Vanessa Caldwell, deputy health and disability commissioner, found that Health NZ had failed to provide services with reasonable care and skill.
She said in her report that the boy’s blood pressure should have been brought to the attention of medical staff and repeated, as hypertension would normally warrant further assessment or observation until it returned to normal.
“I am highly critical of the failure to notify medical staff of an abnormal blood pressure reading and that observation was not carried out as outlined in the policy,” Caldwell wrote.
“The rationale given for not rechecking [the boy’s blood pressure] was to avoid waking him.
“Taking observations is a key safety measure and as such, eclipses the patient’s comfort in allowing them to sleep.”
Changes made
As a result of the report, Health NZ says it’s made several changes to extensive education for paediatric medical and nursing teams about communication and escalation of abnormal observation findings.
The nursing electronic template has been updated to include a prompt to check if observations have been completed within the hour before discharge.
An assessment of a person’s language to determine if an interpreter is needed has been added to assessment templates used by both medical and nursing staff.
Finally, nursing staff and their managers were required to complete the online communication package called Kōrero Mai.
The HDC ordered that Health NZ provide a formal apology to the family and updates on how it has adopted the commission’s recommendations.
Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.