Coordination of care for toddler with suspected non-accidental injury
Source: Health and Disability Commissioner
EMBARGOED UNTIL 2:00pm, Monday 6 May 2019
--
Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board (DHB) in breach
of the Code of Health and Disability Services Consumers’ Rights. The DHB failed to provide a 16-month-old boy with
adequate care, and failed to ensure there was cooperation amongst providers to ensure quality and continuity of
services.
The report considered the care provided to the boy across four presentations to hospital, each relating to him not
weight-bearing on his left leg. Eventually, he was diagnosed with a fracture. During the course of these presentations,
the possibility of non-accidental injury also became a key diagnosis. Following discharge from hospital, the boy
sustained further injuries and died.
Health and Disability Commissioner Anthony Hill said the boy’s care demonstrated the challenges clinicians face when
diagnosing non-accidental injuries.
He found that the DHB’s systems did not encompass an adequate safeguard for the boy, and that the evidence
overwhelmingly demonstrated a systemic failing on the part of the DHB.
"In my view, the system that was meant to wrap around this boy had the information it needed to diagnose his fracture
and non-accidental injuries earlier. However, a series of failings in assessment, communication, documentation, and
coordination of care, and a failure to adhere to policies and procedures prevented this from occurring," Mr Hill said.
Mr Hill recommended that the DHB provide a letter of apology to the boy’s family. He also made recommendations that
would enable the DHB to provide better care for, and better identify injuries to children. He also recommended that the
DHB follow up with Oranga Tamariki and the New Zealand Police regarding a multi-agency meeting to discuss the findings
from the DHB’s serious adverse event report and the Commissioner’s report.
The report for case 16HDC00134 is available on the HDC website.
ENDS