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Infant with Rhesus disease develops fatal haemolytic anaemia after discharge from hospital (07HDC10316)

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(07HDC10316, 1 December 2008)

Paediatrician ~ District health board ~ Instructions on discharge ~ Post-discharge paediatric care ~ Haemolytic anaemia ~ Rights 4(1), 4(5), 6(1)

Parents complained about the care provided to their baby daughter, who was born with a rare condition, rhesus iso-immunisation, which had been diagnosed during pregnancy. This condition requires close monitoring in the postnatal stage to ensure that a baby does not become anaemic. However, in this baby's case, monitoring did not occur after she was discharged from hospital. Although she had one blood test taken two days after her discharge, the results of the test were not acted upon and no further blood test was performed.

The baby's condition suddenly deteriorated, and she died that day despite attempts to resuscitate her. It was found that she had become severely anaemic.

It was held that, although the paediatrician's subsequent actions were laudable (to review and alter his practice, communicate openly with the parents, and apologise for his lapses), the care he provided fell some way short of the standard expected of a paediatrician. By failing to ensure that the instructions for the baby's care after her discharge were communicated and carried out, and to refer her to the neonatal homecare team, he breached Right 4(5). In addition, by failing to inform the parents of the requirement for further blood tests, and the rationale for that testing, he breached Right 6(1).

In failing to have an effective system in place to ensure that a copy of the discharge summary was provided to the parents, and important blood tests reviewed by the responsible clinician, the DHB breached Right 4(1).