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Assessment and treatment of young child with fever and respiratory symptoms (14HDC01187)
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(14HDC01187, 30 June
Public hospital ~ District health board ~ Emergency
department ~ Consultant ~ House officer ~ Telehealth service ~
Registered nurse ~ Assessment ~ Supervision ~ Coordination ~
Communication ~ Documentation ~ Right 4(1)
A girl, nearly three years old, had a cough and a runny nose
which worsened over several days. She awoke with a fever shortly
after midnight, and her mother took her to a public hospital's
emergency department (ED).
On arrival, the girl had a cough, a temperature of 38.5°C (which
soon increased to 39.3°C), and an increased heart rate. She was
assessed by two doctors. Following cooling techniques and the
administration of paracetamol and ibuprofen, the girl's temperature
reduced to 37.4°C and her heart rate also reduced. She was
discharged home at 3.35am with the instruction that they should
return if there were any concerns. The discharging doctor requested
that the Paediatric Department call the family to follow up, but
this did not occur.
The girl's condition worsened over the next two days. On the
second day, the girl began to make a wheezing noise when exhaling,
and her parents took her back to ED.
On arrival, the girl's temperature was 37.3°C, her heart rate
was between 170 and 175 beats per minute, and her respiratory rate
was 44 breaths per minute. A house officer assessed the girl and
discussed her presentation with his supervising consultant. The
consultant did not assess the girl personally. The house officer
recorded an impression of a viral illness, and the girl was
discharged home less than one hour after presentation. The house
officer did not document any discharge information provided to the
girl's parents, and he did not request a follow-up telephone call
from the Paediatric Department.
At 7am the following day, the girl's temperature had increased
to 40.2°C and her mother called the ED for advice. She was
transferred to a triaging telehealth service, where she spoke with
a nurse. The girl's mother told the telehealth nurse her daughter's
temperature, and that they had been to ED twice in two days. The
girl's breathing is audible throughout the call. The girl's mother
ended the call after 3 minutes and 12 seconds, telling the
telehealth nurse that she was "going to go". The telehealth nurse
did not call back the girl's mother or contact the service's
resource nurse for advice.
At approximately 1pm that day, the girl stopped breathing. Her
mother called an ambulance and the girl was taken to ED. Attempts
to resuscitate her were unsuccessful.
It was held that by approving the girl's discharge home on her
second visit to ED without first taking sufficient steps to
investigate the cause of her presenting symptoms, the consultant
breached Right 4(1).
Adverse comment was made about the house officer for discharging
the girl home without further investigation, and for the quality of
It was also held that DHB staff inappropriately discharged the
girl home on her second visit to ED without first taking sufficient
steps to consider her history and investigate the cause of her
presenting symptoms; staff failed on two occasions to provide
adequate discharge information to the girl's family; the DHB's
system for paediatric follow-up was not sufficiently robust to
ensure that follow-up would occur when requested; the DHB failed to
encourage a culture where staff felt comfortable questioning or
challenging decisions; and it lacked a multidisciplinary approach
to the girl's care. The DHB team had sufficient information to
provide the girl with appropriate care. However, a series of
judgement and communication failures meant that it did not do so.
Accordingly, the DHB failed to provide services to the girl with
reasonable care and skill, and breached Right 4(1).
The telehealth nurse did not rule out all of the girl's relevant
emergent symptoms, nor did he triage her clinical presentation
within an acceptable timeframe, and therefore did not provide
appropriate advice to her mother. Furthermore, he did not advise
the girl's mother to take the girl back to ED or verify that she
intended to do so, and he failed to take appropriate steps when the
girl's mother ended the call. For these reasons, the telehealth
nurse breached Right 4(1).
The Commissioner's recommendations included that the DHB:
a) In relation to patients under 5
years, conduct an audit of all unplanned re-presentations to the ED
within 48 hours of discharge, to measure compliance with:
- the requirement for assessment by a
consultant or senior registrar prior to discharge;
- the requirement for nursing/medical
consultation prior to discharge; and
- the requirement for a follow-up telephone
call from paediatric staff to families following referral
(following both the first and second discharge).
b) Commission an independent
review of senior/junior staff rostering to establish whether
sufficient levels of supervision are available for junior staff
working in ED.
c) Include in its training and
induction for all staff, information that the practice in the DHB
is that the asking of questions and reporting of concerns is
expected and accepted from all members of the multidisciplinary
d) Update HDC on the completion of
outstanding recommendations from its Serious Adverse Event review,
and monitoring of ongoing changes made.
e) Review its Memorandum of
Understanding between the Emergency Department and Paediatric
Department and its policy for transfer to the national telephone
The Commissioner recommended that the house officer undergo
training on effective communication, paediatric care, and
The DHB, the consultant, the house officer and the telehealth
nurse were asked to apologise to the girl's parents.