Report finds 'multiple failures' in hospital care of three-year-old boy who died with pneumonia

A report from the Health and Disability Commissioner found there was "multiple failures" in the hospital care of a three-year-old boy who died with pneumonia in Canterbury.


Deputy Health and Disability Commissioner Rose Wall's report finds the Canterbury District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights.

After becoming unwell, the boy was sent to hospital on the recommendation of an urgent care clinic.

"The boy was transferred to the children’s ward when he arrived at hospital. Records of his vital signs were entered into an observation chart on nine occasions," the report states.

"However, some of his vital signs were not observed regularly or entered into the chart accurately and, as a result, the corresponding Paediatric Early Warning Scores (PEWS - a clinical tool used to help identify patients at risk of deterioration, and to ensure care is escalated and the appropriate interventions are made) were inaccurate.

"Overnight the boy’s vital signs remained fairly stable, but in the morning his condition deteriorated rapidly. Tragically, he passed away. The cause of his death was identified as bilateral pneumococcal pneumonia, and tests completed following his death indicated he had developed sepsis (a life-threatening whole-of-body response to infection)."

According to Wall, there were "multiple failures" in the care provided to the three-year-old boy.

"Specifically, staff made assumptions, including that the boy’s illness was pneumonia without sepsis, that because his PEWS (calculated incorrectly) were relatively stable overnight he was not deteriorating, and, when his observations did indicate deterioration, that he would be reviewed promptly during the morning ward round.

"She also found that nursing staff failed to think critically about the boy’s overall clinical picture and, as a result, failed to escalate his care appropriately."

Wall gave an overall assessment of the incident in the report.

"It is impossible to know whether the outcome would have been different if these errors had not occurred," said Wall.

"However, I consider that the above failures resulted in a lack of recognition and response to [the boy’s] serious illness and the emerging signs of his deterioration."

Wall made a number of treatment protocol recommendations to the DHB in her report, also urging it to provide a written apology to the boy’s parents.

The full report for case is available on the HDC website.