Pattern Of Poor Care Of Child With Worsening Symptoms

Health and Disability Commissioner Morag McDowell today released a report finding Counties Manukau District Health Board (CMDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a child later diagnosed with a rare brain tumour.

The child, aged 5-6 years at the time of these events, was under the care of CMDHB’s paediatric service. Her family took her to the public hospital on multiple occasions with symptoms of persistent abdominal pain, vomiting and headache. Later, she developed neurological symptoms including slurred speech.

The fourth time she went to hospital a CT scan was carried out, leading to a diagnosis of a rare brain tumour.

The Commissioner found that there were missed opportunities for CMDHB staff to think critically about the child’s care, and to carry out further investigations into her symptoms with greater urgency.

Ms McDowell also commented that she is mindful of hindsight bias, and that she had carefully considered the symptoms that the child presented with at the time of each of her assessments, and the expert advice regarding these symptoms.

"This is not a case of clinicians failing to diagnose a rare brain tumour, but rather, is focussed on the failure to think critically and respond with greater urgency to the child’s emerging and concerning symptoms," said Ms McDowell.

"The failures in care involved numerous individuals across multiple visits, and indicate a pattern of poor care for the patient for which CMDHB is ultimately responsible."

The Commissioner made a number of recommendations including that CMDHB use this investigation as an anonymous case study for emergency medicine and paediatric teams; review resident medical officer to senior medical officer escalation practices in the Paediatric Department; and provide a written letter of apology to the child and her parents.

She also recommended that CMDHB consider the Health Quality and Safety Commissions’ resource on Patient, family and whānau escalation: Kōrero mai projects - what we know so far and advise whether any continuous improvement projects could flow from what has been learnt in this investigation.

The full report on case 18HDC01075 is available on the HDC website.

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