Asthma victim neglected by 'over confident doctor', DHB: Report

Tauranga Hospital. Photo / Alan Gibson

A junior doctor and a regional hospital have been criticised for providing inadequate asthma care to a young boy who later died of brain damage.

Health and Disability Commissioner Ron Paterson this afternoon released his report on the case involving Tauranga Hospital's treatment of Reef Steiner.

Reef, aged 2-1/2, was admitted to the hospital in 2007 suffering from an asthma attack which was considered moderately severe.

He was treated in the emergency department during the afternoon then transferred to a ward. Reef was treated with asthma medications, paracetamol, steroid and antibiotics. His condition fluctuated in the evening and overnight.

At around 4.30am, his heart and breathing stopped. He was resuscitated, but suffered three more heart and breathing arrests. He was flown to Starship Hospital in Auckland, where it was found he had suffered severe brain damage. Life support was withdrawn and he died the following day.

Mr Paterson's decision, which names the boy only as "Master A", indicates he could have survived.

He said the junior doctor who was in sole charge of the paediatric ward where Reef spent the night, Dr B, did not provide an appropriate standard of care and his employer, the Bay of Plenty District Health Board, was vicariously liable.

Mr Paterson said Dr B was, "in his own words, an inexperienced house officer with little paediatric experience on night duty".

"Because of his inexperience, he did not realise the gravity of Master A's condition.

"He was over-confident. "He was out of his depth but did not know it. Paediatrician support was available to him, but he did not seek it soon enough."

But there were mitigating factors. The extent of the hand-over of Reef's care from another doctor was doubtful, the wording of a Starship asthma guideline used at Tauranga was unclear, and the nurses could have questioned Dr B's decisions.

Trained in Britain, Dr B has returned there. Mr Paterson said Dr B had apologised in writing to Master A's family. He had acknowledged to the parents he did not recognise the severity of the boy's asthma and should have called for help sooner.

Mr Paterson said he had decided not to refer the case for consideration of disciplinary proceedings because the health board had placed Dr B out of his depth, he had striven to address his shortcomings and he was no longer in New Zealand.

The health board's chief operating officer, Graham Dyer, said it "deeply regrets the death of Reef Steiner and we offer our sincere condolences to Reef's family. It is always a tragedy to lose a child and our staff were genuinely distressed by Reef's death.

"The DHB and medical staff accept the report's clinical findings and changes in practice have been instituted as a result of this investigation."

The Resident Doctor's Association said the tragic case was a reminder to all DHBs to work harder to protect their patients and staff.

"Night shifts are the riskiest time of day, as our hospitals are run on minimum staff levels," said the union's general secretary, Deborah Powell. "While consultants may be called in, they are not on duty in the hospital, and house officers are being left on their own."

The union had confirmed with DHBs and the Medical Council that first year house officers were not to be asked to do night duties in their first six months as a doctor. But due to the shortage of house officers, some DHBs "are looking at revising this policy".