About 10 minutes later, he regained consciousness but could not talk, walk, sit, or stand.<\/p>\n
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.<\/p>\n
At ED, the boy was unable to stand to measure his height and had to be weighed while seated. <\/p>\n
A nurse conducted observations, including blood pressure, heart rate, and oxygen saturation, and noted that his blood pressure was unusually high, but didn\u2019t inform the paediatric registrar. <\/p>\n
The report stated that when the mother tried to talk to the registrar, he told her he knew what had happened because she\u2019d spoken to the boy\u2019s GP. <\/p>\n
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. <\/p>\n
The registrar discussed the case with the on-call paediatrician, but while the decision notes further observations were recorded, these didn\u2019t include blood pressure readings or neurological examinations. <\/p>\n
By mid-afternoon, the boy seemed to be recovering, eating and drinking small amounts and could walk when supported. <\/p>\n
At a shift handover that afternoon, the nurse was informed that the boy had high blood pressure and further measurements were needed. <\/p>\n
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. <\/p>\n
In contrast, his mother said that he was unable to walk and stand independently, and she used a wheelchair to get him home. <\/p>\n
The boy was discharged from hospital with information about seizures, despite his mother raising concerns about the decision. <\/p>\n
She was told not to worry and that many patients take time to recover after seizures. <\/p>\n
The registrar told the HDC she did not go through the discharge information herself, having delegated that task to a nurse.<\/p>\n
The boy\u2019s blood pressure wasn\u2019t rechecked before he was discharged, because he was asleep and the nurse didn\u2019t want to disturb him. <\/p>\n
The mother reported that once home, he retched all evening, walked abnormally, and had only eaten a small amount of dinner. <\/p>\n
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. <\/p>\n
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. <\/p>\n
Clinical advice provided to the commission by paediatrician Dr Heidi Baker was critical of the failure to recheck the boy\u2019s blood pressure before he was discharged.<\/p>\n
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. <\/p>\n
Dr Vanessa Caldwell, deputy health and disability commissioner, found that Health NZ had failed to provide services with reasonable care and skill.<\/p>\n
She said in her report that the boy\u2019s 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.<\/p>\n
\u201cI 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,\u201d Caldwell wrote. <\/p>\n
\u201cThe rationale given for not rechecking [the boy\u2019s blood pressure] was to avoid waking him. <\/p>\n
\u201cTaking observations is a key safety measure and as such, eclipses the patient\u2019s comfort in allowing them to sleep.\u201d<\/p>\n
Changes made<\/p>\n
As a result of the report, Health NZ says it\u2019s made several changes to extensive education for paediatric medical and nursing teams about communication and escalation of abnormal observation findings. <\/p>\n
The nursing electronic template has been updated to include a prompt to check if observations have been completed within the hour before discharge. <\/p>\n
An assessment of a person\u2019s language to determine if an interpreter is needed has been added to assessment templates used by both medical and nursing staff. <\/p>\n
Finally, nursing staff and their managers were required to complete the online communication package called K\u014drero Mai. <\/p>\n
The HDC ordered that Health NZ provide a formal apology to the family and updates on how it has adopted the commission\u2019s recommendations. <\/p>\n
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. <\/p>\n","protected":false},"excerpt":{"rendered":"About 10 minutes later, he regained consciousness but could not talk, walk, sit, or stand. The GP suspected…\n","protected":false},"author":2,"featured_media":501241,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[74,536,2511,7126,43945,11424,71,11423,42,2241,43,4371,40,38,41,39],"class_list":["post-501240","post","type-post","status-publish","format-standard","has-post-thumbnail","category-headlines","tag-after","tag-care","tag-child","tag-dies","tag-failures","tag-finds","tag-from","tag-hdc","tag-headlines","tag-hospital","tag-news","tag-stroke","tag-top-news","tag-top-stories","tag-topnews","tag-topstories"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/501240","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=501240"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/501240\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/501241"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=501240"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=501240"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=501240"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}