Waikato DHB told to apologise to family of infant who died after substandard care

The Health and Disability Commissioner has found the Waikato District Health Board to have breached the Code of Health and Disability Services Consumers' Rights following its failure to care for a three-month-old baby who died from respiratory difficulties.


The baby was admitted to a public hospital following a referral by his GP, who had made an informal diagnosis of laryngomalacia, a congenital softening of the tissues of the larynx above the vocal cords, Health and Disability Commissioner Anthony Hill said in a statement.

The baby was admitted to the paediatric ward, where a consultant requested a review by the ear, nose and throat (ENT) service.

Waikato DHB policies require that reviews requested by senior medical officers should be carried out by another senior medical officer. Although the clinical notes recorded that an ENT specialist was to be consulted, the consultation did not occur. Instead, an ENT registrar, or trainee specialist, reviewed the baby and documented that he was to have a scope - involving a fiber-optic camera on a flexible tube - for an awake flexible fibreoptic nasendoscopy and laryngoscopy.

The scope was later cancelled and the DHB was unable to tell the Health and Disability Commissioner who made this decision and why. However, it considered that the baby appeared to be improving. The baby was then discharged back to his GP without a formal diagnosis or follow-up care planned with paediatrics or an ENT. Other important information was also not documented during this time.

Following his discharge from the hospital, the baby received some care from two medical practices, but later died from respiratory failure.

Mr Hill was critical that a scope did not occur in the hospital or shortly after being discharged at an outpatient clinic.

He added that the baby did not receive a consultant-level ENT review, despite being requested by the paediatrics team. He was also critical of the poor documentation around key decision-making points and that the baby was discharged without a formal diagnosis or a plan for specialist follow-up care.

The Waikato DHB was found to have breached the Code of Health and Disability Services Consumers' Rights following the incident.

Mr Hill recommended that the DHB apologise to the baby's family, and that it carry out an audit of 50 child presentations to the hospital, where care is shared between paediatrics and ENT, to ensure that there has been appropriate communication between consultants and adequate documentation.

He also recommended that the DHB report back on its consideration of the use of a Paediatrics/ENT shared care form, use of growth charts, testing of oxygen levels in the blood using an oximeter tool, and progress on implementing actions to reduce the risk of similar events as advised to Accident Compensation Corporation.