Health and Disability Commissioner Anthony Hill today released a report finding Waikato District Health Board (DHB) in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a
The baby was admitted to a public hospital following a referral by his general practitioner (GP). The GP had made an
informal diagnosis of laryngomalacia (a congenital softening of the tissues of the largnx above the vocal cords).
The baby was admitted to the Paediatric ward and a consultant requested a review by the Ear Nose and Throat (ENT)
service. Waikato DHB policies require that when a senior medical officer (SMO) requests a review it should be carried
out by another SMO. Although the clinical notes recorded that an ENT specialist was to be consulted, this did not
happen. Instead, an ENT registrar reviewed the baby and documented that he was to have a "scope" (an awake flexible
fibreoptic nasendoscopy and laryngoscopy).The scope was later cancelled and the DHB was unable to tell HDC who made this
decision and why, however it considered that the baby appeared to be improving. The baby was then discharged back to his
GP without a formal diagnosis nor with follow-up care planned with Paediatrics or ENT. Other important information was
also not documented.
Following his discharge from hospital, the baby received some care from two medical practices. Sadly, the baby died. The
cause of death was found to be respiratory failure.
Mr Hill was critical that a scope did not occur in hospital or shortly after discharge at an outpatient clinic, and that
the baby did not receive consultant-level ENT review, even though this was requested by the Paediatrics team. He was
also critical of the poor documentation around key decision-making points and that the baby was discharged without a
formal diagnosis or a plan for specialist follow-up care. Accordingly, the DHB failed to provide services to the baby
with reasonable care and skill and was found to be in breach of the Code.
Mr Hill recommended that the DHB apologise to the baby’s family, and that it carry out an audit of 50 child
presentations to the hospital, where care is shared between Paediatrics and ENT, to ensure that there has been
appropriate consultant-to-consultant communication and adequate documentation. He also recommended that the DHB report
back on its consideration of the use of a Paediatrics/ENT shared care form, use of growth charts, testing of oxygen
levels in the blood using an oximeter, and progress on implementing actions to reduce the risk of similar events as
advised to ACC.
The full report for case 16HDC01663 is available on the HDC website