Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
- In accordance with the National Immunisation Schedule, children aged 9 to 14 years need two doses of the HPV (human papillomavirus) vaccine. The second dose is given at least 6 months after the first dose.
- HDC received a complaint from the mother of Miss A (aged 12 years) that Miss A was given a third dose of the HPV vaccine at school, despite Miss A telling the vaccination nurses that she had already received the second dose at her local GP clinic.
- Miss A received her first dose of the HPV vaccination on 30 March 2023 at school. She had her second dose of her HPV vaccination on 19 October 2023 at her GP clinic during the school holidays, after her mother received a text message from the clinic advising her that it was due.
- The National Immunisation Register (NIR) was replaced by the Aotearoa Immunisation Register (AIR) on 2 December 2023. On 27 November 2023 the NIR had been checked by the community nurses ahead of the school vaccinations and, at that time, it did not show that Miss A had received her second HPV dose.
- On 6 December 2023 Miss A was at school when her name was called on the list to receive the second HPV vaccination. HDC interviewed Miss A, who said that she told her teacher she did not have to get the vaccination because she got her second dose at the doctors. Miss A said her teacher told her to go along, but to tell the nurses she had already received the vaccine. Miss A said she let the woman with the clipboard and the woman at the front of the queue know that she had already had the vaccine, and both told her: ‘No, that was the Covid one.’
- Miss A said that when she got to the vaccinating nurse, she told her, ‘I am pretty sure I have had the vaccine before at the doctors, but I had the first one at school,’ but the nurse again told her that it was the Covid vaccine she had had at the doctors. Miss A was given the HPV vaccination that day.
- Miss A recalls being convinced that the vaccination she had had at her GP clinic must have been for Covid. She also recalls asking for her mother to be contacted, but this was declined because they did not have enough time as there were a lot of students to get through.
- When Miss A went home, she was upset about having received an extra vaccination. Her mother contacted the school and spoke to a community nurse, who checked the AIR that day and noted that a second HPV dose had been given. The nurse apologised that this had happened.
- HDC spoke with Miss A’s teacher. While she could not recall the conversation with Miss A, she said that if Miss A remembered having had a conversation with her about already having been given the second HPV vaccination, she would have done so, because Miss A is a very reliable and trustworthy student.
- The staff involved were offered a chance to speak to HDC, but they declined. The community nurses involved were interviewed on 19 or 20 December 2023 as part of an internal investigation. All answered that they could not recall any student having told them that they had already had the second dose of the HPV vaccination. The nurse who administered the vaccine confirmed that all students were asked pre-screening questions, which include checking previous immunisations and confirmation of consent. Health New Zealand|Te Whatu Ora (Health NZ) told HDC: ‘No child advised the nurse administering the vaccine that she had already had the vaccine.’
- Health NZ’s policy if a child is unsure whether they have been vaccinated is that the NIR/AIR would be checked immediately and the parent contacted. If the NIR/AIR did not show a record of the previous vaccination, the GP would be contacted, and the vaccine would not be administered.
- There are different accounts of the events on 6 December 2023. Miss A’s account is convincing, and she spoke about it clearly during her interview with HDC. Her teacher described her as reliable, and I consider that a student who received a vaccination they did not require would recall their interactions around the vaccination much more clearly than a nurse who is administering vaccinations to multiple students in one day. I am therefore inclined to accept Miss A’s version of events. I find that it is more likely than not that she raised concern with at least one person from Community Nursing about having already had the second HPV vaccination.
- Health NZ’s policy is to check the NIR/AIR if a student raises concerns about having had the vaccination previously. This did not occur in Miss A’s case.
- I appreciate that the NIR was checked the week prior to the school vaccinations and that at that time it did not show that Miss A had received a second dose. The system was changing over to the AIR in the interim, and it should have been checked that day considering Miss A’s concern.
- Health NZ had a responsibility to provide Miss A services with reasonable care and skill. I find that by allowing Miss A to receive an additional dose of the HPV vaccine, despite Miss A voicing her concern that she had already received it, Health NZ breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights.
- Community Nursing has reiterated to all staff that if any concerns are raised by a child at school regarding having received a vaccination or being asked to call a parent, staff must follow protocol and not vaccinate the child. A stamp has been developed with questions for the pre-vaccination form, which must be checked off in front of the child.
- I recommend that Health NZ provide a written apology to Miss A for having administered her with an additional dose of the HPV vaccination, despite her having voiced her concern that she had received it previously. The apology is to be sent to HDC within three weeks of the date of this decision, for forwarding to Miss A.
- I recommend that the Community Nursing team use this decision for educational purposes, with a focus on ensuring that its staff listen to concerns raised by children and act according to its policies.
- Health NZ has confirmed that it agrees with my recommendations.
- An anonymised copy of this decision (naming only Health NZ) will be placed on the HDC website (www.hdc.org.nz) for educational purposes.
Dr Vanessa Caldwell
Deputy Health and Disability Commissioner