The Ministry of Health failed to pass on American warnings about the dangers of powdered milk formula for premature babies two years before a Waikato baby died from an infection linked to infant formula.
An international review into the actions of the ministry and the New Zealand Food Safety Authority surrounding the death of Linnea Jones-Baillie last July said the ministry acted "reasonably" but could have passed on Food and Drug Administration recommendations in 2002 to hospitals with neo-natal intensive care units.
Linnea's family are angry and upset by the report, which they say gives them "no closure", and they want compensation.
Linnea died in Waikato Hospital's neo-natal intensive care unit from meningitis linked to bacteria found in powdered formula.
Her death was believed to be the first in New Zealand from the bacteria, called Enterobacter sakazakii.
Yesterday, the ministry's Director of Public Health, Dr Mark Jacobs, one of the authors of the report, said it would never be known if Linnea's death could have been avoided.
"Certainly there were things the ministry could have done overall to reduce the risk," he said.
But Dr Phil Weston, neo-natal specialist at Waikato Hospital, believed her death could have been avoided if the hospital had known the risks and had ceased using powdered infant formula.
"It was tragic and unnecessary. We all feel ghastly about it."
Powdered infant formulas are not sterilised because sterilisation removes key nutrients needed for a baby's development.
In 2002, the United States-based Centres of Disease Control and the Food and Drug Administration warned American health providers against using powdered infant formulas in neo-natal intensive care units unless there was no alternative available. The warning followed a fatal case of e.sakazakii.
The same year, a dietitian from National Women's Hospital contacted the ministry about the issue.
Dr Jacobs said the ministry did not pass on the American advice because there had been no reported cases here, the risk of infection was "very small" and the product implicated in the American death was not available in New Zealand.
Last year, the World Health Organisation highlighted the warnings and New Zealand began developing a "local response", but within months of that starting, Linnea died.
Jamie Baillie, Linnea's father, said the family were still angry and upset after meeting ministry officials yesterday. They had hoped for some form of compensation, possibly a headstone for Linnea's grave, but were told to contact ACC.
"We didn't get any closure at all ... They have taken a life away from us that by rights should still be here today. It's quite devastating, really."
Dr Jacobs said the ministry and Food Safety Authority had agreed on clearer roles in relation to food-borne illnesses. International alerts and recommendations would be more closely monitored and passed on to the appropriate clinicians.
The report also said the meningitis caused by e.sakazakii should be a notifiable disease.
Baby’s parents slam milk report
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