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Emergency Department Fails In Its Care Of A Girl Who Developed Septic Arthritis

Health and Disability Commissioner Morag McDowell today released a report finding Hutt Valley District Health Board (HVDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a teenage girl suffering from a rare infection.

The girl went to an Emergency Department (ED) with increasing knee pain on multiple occasions. After participating in physical training several days earlier, she visited ED twice on the same day with pain in her right knee. She was diagnosed with a knee injury and given morphine on her second visit.

The girl returned to ED three days later, at which stage the pain had spread to her left knee. An X-ray was performed and she was diagnosed with Osgood-Schlatter disease, an overuse injury that often occurs in growing adolescents. But a few days later she returned to ED significantly unwell and was finally diagnosed with a bacterial joint infection, known as septic arthritis, in both knees.

The Commissioner acknowledged that the illness the girl had developed was rare, and accepted that the signs and symptoms of the diagnosis may have been subtle. However, she considered that there were a number of shortcomings in the care the girl received at ED and that ultimately HVDHB was responsible for the inadequacies in the services provided.

Ms McDowell said key symptoms were not documented when the girl was triaged on her first visit to ED. At the second visit, the possibility of a more serious pathology was not recognised, and at the third visit more critical thinking was needed.

In the report, Ms McDowell commented on "the need for Emergency Department staff to think critically, having regard for the wider clinical picture, and to consider alternative explanations when someone presents to ED multiple times with increasing pain."

The Commissioner recommended that HVDHB train clinical staff on the importance of routinely checking vital signs on ED presentations, unless it is clearly not clinically indicated, and the importance of considering possible serious pathologies. She recommended using the anonymised report as a case study.

She also recommended HVDHB perform a random audit of 30 ED presentations to assess the recording of vital signs, discharge instructions given, and whether Senior Medical Officer reviews were completed as appropriate; consider whether a review of its ED staffing levels is warranted; and provide a written apology to the girl and her family.

The full report on case 19HDC02034 is available on the HDC website.

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