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Coordination of care for toddler at fault

Coordination of care for toddler with suspected non-accidental injury

Source: Health and Disability Commissioner

EMBARGOED UNTIL 2:00pm, Monday 6 May 2019


Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights. The DHB failed to provide a 16-month-old boy with adequate care, and failed to ensure there was cooperation amongst providers to ensure quality and continuity of services.

The report considered the care provided to the boy across four presentations to hospital, each relating to him not weight-bearing on his left leg. Eventually, he was diagnosed with a fracture. During the course of these presentations, the possibility of non-accidental injury also became a key diagnosis. Following discharge from hospital, the boy sustained further injuries and died.

Health and Disability Commissioner Anthony Hill said the boy’s care demonstrated the challenges clinicians face when diagnosing non-accidental injuries.

He found that the DHB’s systems did not encompass an adequate safeguard for the boy, and that the evidence overwhelmingly demonstrated a systemic failing on the part of the DHB.

"In my view, the system that was meant to wrap around this boy had the information it needed to diagnose his fracture and non-accidental injuries earlier. However, a series of failings in assessment, communication, documentation, and coordination of care, and a failure to adhere to policies and procedures prevented this from occurring," Mr Hill said.

Mr Hill recommended that the DHB provide a letter of apology to the boy’s family. He also made recommendations that would enable the DHB to provide better care for, and better identify injuries to children. He also recommended that the DHB follow up with Oranga Tamariki and the New Zealand Police regarding a multi-agency meeting to discuss the findings from the DHB’s serious adverse event report and the Commissioner’s report.

The report for case 16HDC00134 is available on the HDC website.


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