A young girl who was later diagnosed with a rare brain tumour after her parents took her to hospital four times was failed by the Counties Manukau District Health Board.
This was the conclusion of the Health and Disability Commissioner in a decision released today.
The "poor care" given to the girl, who was five to six at the time, began when her GP referred her to outpatient care at the end of 2016 due to persistent abdominal pain.
It was in this outpatient clinic in February 2017 her parents said she had had symptoms since she was about three months old.
The doctor trialled Omeprazole, a medication used to treat gastroesophageal reflux disease, and noted they would "see how this goes".
In a follow-up appointment two months later, the doctor referred the girl to the gastroenterology department and ordered an ultrasound.
She was set for another follow-up in two to four months' time.
About three days later, the girl was taken to the emergency department (ED) by her parents, in what would be their first of four presentations. She weighed 23 kilograms.
Just over a week later, the girl was back in ED, weighing 22.9kgs. It was here her parents mentioned she had recently experienced slurred speech amid her pain and vomiting episodes.
It was recommended to her GP her Omeprazole be reduced and that she receive an EEG, which was scheduled for September.
But in July, the girl returned to ED, weighing 22.4kgs.
It was noted she had presented to ED due to concerns about vomiting, disorientation and an impaired ability to speak or vocalise.
However, a CT scan was not ordered until her fourth presentation at ED in August 2017, where she weighed 22kgs.
An emergency medicine registrar on this visit had noted episodes of disorientation, headache, shivering, confused and slurred speech followed by vomit.
They thought this could be symptoms of atypical seizures or a neurological disorder.
The CT scan found significant bleeding on the right side of the girl's brain and there was evidence of brain movement and other damage from old bleeding.
Left-side lesions were also identified.
She was later diagnosed with a very rare aplastic brain tumour.
"I don’t want any other child to go through what our daughter had been through ... If a patient keeps on coming back to you, it means something is wrong, perform all the required tests, and think out of the box," the girl's mother told the HDC.
"The distress caused by CMDHB to our entire family, especially my daughter, we are still struggling to recover from it. We have been emotionally and mentally destroyed."
Commissioner Morag McDowell said a different approach to the girl's diagnosis and management should have been considered when she presented with "new and concerning symptoms" on May 5 and July 10, 2017.
"This is not a case of clinicians failing to diagnose a rare brain tumour, but rather, is focussed on the failure to think more critically and respond with greater urgency to those emerging and concerning symptoms," McDowell said.
"As identified, it is my view that on 5 May it would have been prudent for a senior medical officer to have reviewed Miss A in person.
"The above failures involved numerous individuals across multiple presentations, and, in my view, indicate a pattern of poor care across Miss A’s patient journey," she said.
"I consider this to be a service delivery failure for which, ultimately, CMDHB is responsible."
McDowell recommended CMDHB use this investigation as an anonymous case study for emergency medicine and paediatric teams, and review resident medical officer to senior medical officer escalation practices in the Paediatric Department.
She also asked the DHB provide a written letter of apology to the child and her parents.
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