KEY POINTS:
Auckland City Hospital failed to clearly inform Middlemore Hospital that a transferred patient might have been exposed to the deadly Creutzfeld-Jakob disease.
The mistake - which created the risk of spreading the fatal brain condition - happened because the young girl's condition was not properly flagged on the computerised note sent by Auckland City Hospital.
The girl was one of 43 adults and children who might have been exposed to CJD at Auckland in March.
All had brain, head or neck operations involving surgical instruments which were used weeks before in brain surgery on a woman who later died from CJD.
The girl was transferred to Middlemore last month for plastic surgery - but Auckland City Hospital did not tell Middlemore clearly that she might have been exposed to the disease.
The case has exposed an apparent flaw in the computer system that highlights important referral notes.
The hospitals yesterday said there was little or no risk from the "breakdown in communication".
But a senior source familiar with the case told the Weekend Herald: "It's part of the problem throughout the country. The district health boards can't communicate with each other because they have been allowed to develop their own systems."
The three Auckland health boards - Auckland, Counties Manukau and Waitakere - share intranet computer systems that enable them to post referral notes when patients move between hospitals.
Some doctors can also see full patient records held by any of the three boards, but levels of access vary.
Ron Dunham, chief operating officer of the Counties Manukau board, which runs Middlemore, said the neurosurgery flag on the girl's electronic referral note for elective plastic surgery was visible only if staff "drilled down into" the note, and it did not refer to her possible exposure to CJD.
Computer systems were being modified so the neurosurgery flag would become more obvious and would note affected patients' possible exposure to CJD.
The Auckland District Health Board's chief medical officer, Dr David Sage, conceded that the neurosurgery flag sent when the girl went to Middlemore had been insufficient to highlight her possible exposure to CJD.
"There was a flag which was looked up, but there was an assumption made about the flag that it referred to something else, not the CJD instrument exposure at Auckland Hospital."
He said the 43 patients or their parents had been asked to tell dentists of the patients' possible exposure and, if they were having root-canal treatment, to advise the dentist to contact the hospital for information on how to deal with the instruments used in the procedure.
Although the risk of any of the 43 developing CJD is considered extremely small, it is a health worry the patients will carry for the rest of their lives, as the symptoms can take decades to develop after infection.
The disease, caused by an abnormal brain protein called a prion, can be spread on surgical instruments, although only eight cases of this have been reported worldwide, and the last instance was in the 1970s.
The patients might have been exposed to the disease because, although instruments used on them were sterilised, the prions are hard to kill.
Auckland City Hospital says they can be destroyed by washing with a specialised enzyme and high-temperature sterilisation.
Middlemore says the risk of spreading the disease from the girl's surgery was eliminated by quarantining any non-disposable instruments used.
They were washed and sterilised separately from other instruments, and will now be used only on that patient.
Auckland Hospital says the risk of transmission by instruments arises only in neurosurgery and theoretically in some ear-nose-and-throat surgery and root-canal dentistry.
WHAT IS CJD?
* Creutzfeld-Jakob disease destroys not only the brain, but also muscle control and movement.
* It leaves patients with severe dementia, unable to walk properly or care for themselves.
* Death usually occurs within a year of symptoms appearing.
