A family spent five days trying to get adequate treatment for their sick 23-month-old boy before he died in Gisborne Hospital.

The whānau sought help from a community health centre, the ambulance service, a rural health nurse, a rural hospital and Gisborne Hospital in the days before he died.

The boy died from sepsis and multi-organ failure brought on by bronchopneumonia – an infection of his lower left lung caused by bacteria.

An experienced doctor who saw the boy on the day he died failed to realise how sick he was, according to a report by the Health and Disability Commissioner (HDC).

That doctor, identified only as Dr B, and Health NZ Tairāwhiti, which runs hospitals and health services in Gisborne and surrounding districts, have been found to have breached patient rights in their treatment of the boy.

Sections of the report which relate to Dr B, a locum at the time, have also been sent to the Medical Council of New Zealand, the professional body which registers doctors and monitors their performance.

The HDC has also recorded adverse comments against another clinician, Dr C, and a community health centre.

The boy died in 2018 and the HDC report has redacted the names of all the parties involved apart from Gisborne Hospital.

The boy, called Master A, lived in a rural area, about 30 minutes’ drive from a community health centre, which was in turn 30 minutes from a rural hospital.

Gisborne Hospital was a further 90 minutes to two hours away from the rural hospital.

Master A was seen at the community health centre on Day 1 of his illness with fever and vomiting before being taken from there to Gisborne Hospital by ambulance.

He was discharged and taken home on Day 2, but was visited by ambulance officers that night after his grandmother visited their station asking to borrow a thermometer.

On Day 3, the family tried to contact the ambulance service again but they were on a call-out. Relatives unsuccessfully tried to contact a rural nurse, then took Master A to see Dr C at the rural hospital.

It was late at night, the boy had a fever and rapid heart rate, and Dr C diagnosed a viral illness. The discharge notes from Gisborne Hospital had not been sent through.

Dr C consulted a paediatrician at Gisborne Hospital, who advised he should be taken back there.

Overnight stay request refused

Master A’s whānau said they pleaded to be allowed to stay at the rural hospital overnight as it was after midnight and they were exhausted.

Dr C refused and instead gave them the option to drive to Gisborne, which they declined because they did not want to make the 90-minute journey while fatigued and without medical assistance along the way.

Dr C also declined a helicopter transfer.

The family returned home but went to the community health centre the following day.

Master A still had a temperature of 38.9C and Dr B advised the family to take him to Gisborne Hospital.

By the time he arrived, he had developed jaundice and was “yellow and grunting”. A chest X-ray showed his lung had collapsed.

After further tests, multi-organ failure was diagnosed.

Master A stopped breathing before he could be transferred to a children’s hospital. He could not be revived.

An investigation later found that the initial diagnosis of a viral infection “set the scene” for subsequent interactions.

Master A was not referred for follow-up care when he was discharged from Gisborne Hospital on Day 2 or after presentation at the rural hospital on Day 3.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell released the report on the 23-month-old boy who died. Photo / James Gilberd Photography Ltd

The investigation found that on the night of Day 3, Dr C did not advise the family strongly enough to take Master A to Gisborne hospital from the rural hospital.

On Day 5, Dr B did not call an ambulance or a helicopter to take Master A to Gisborne Hospital, nor did she call a paediatrician in Gisborne, phoning ED instead.

Master A’s whānau said that they sought leadership, professional support and expertise from doctors and trained medical personnel who they believed would make the best medical judgments.

They believed that over the course of five days they did everything in their power to access and acquire the best possible medical care and advice that was available to Master A.

Deputy Health and Disability Commissioner Vanessa Caldwell said it was clear that Master A’s family had made “every attempt” to get him the care he needed.

“However, a lack of documentation and poor communication resulted in the full picture not being apparent when needed,” Caldwell said.

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“In addition, in my view, there was an element of confirmation bias such that clinicians continued to believe that Master A had a viral illness even when he failed to improve after several days and developed a cough, a high temperature and fast breathing.”

Caldwell said that, overall, she was left with the impression that Dr B provided “minimal support to Master A’s whānau, failed to think critically, and failed to seek advice from the paediatric service at Gisborne Hospital”.

She said an independent reviewer had found that Dr B failed to understand how sick the boy was, failed to consult appropriately with specialists and did not consider transport options.

She found that Dr B failed to provide Master A with reasonable care and skill, in breach of the Code of Health and Disability Services Consumers’ Rights.

She said that Health NZ Tairāwhiti breached the code through failures by multiple staff members, and a lack of awareness in relation to the difficulties faced by patients from remote areas.

“This is reflective of systemic and organisational issues at Health NZ,” she said.

Caldwell recommended that Health NZ Tairāwhiti, the primary health care provider and Dr B each separately apologise to the family.

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.