Nurses' care of toddler who died 'negligent'

Two ex-Auckland nurses have been found guilty of professional misconduct over the case of a severely-scalded toddler, who died after being given four times the prescribed dose of paracetamol on three occasions.

Two-year-old Heremoana Jonot was admitted to Auckland's Middlemore Hospital on March 17, 2002 with severe burns.

On March 23, his nurse, known only as Ms A, gave him three one-gram doses of paracetamol -- four times the prescribed dose of 250 milligrams -- and he died 10 days later.

Two experts found he died of liver and kidney failure caused by the paracetamol overdose, but the coroner ruled his death was caused by complications from his burns.

In finding the nurse guilty of professional misconduct, the Health Practitioners' Disciplinary Tribunal said the oversight raised serious questions about her competency.

However, the tribunal granted name suppression and did not impose a penalty, as Ms A had already suffered "severe depression" because of Heremoana's death.

She retained her practising certificate but was no longer working as a nurse.

The tribunal also noted that at the time, Middlemore Hospital "lacked safeguards to minimise the risks and consequences of human error".

The hospital carried out an internal review after Heremoana's death and made changes.

The tribunal ruled that Marjorie Cruzada, who took over Heremoana's care from Ms A, was the "more culpable" of the two because she had noticed the fatal medication error on the patient's file, but failed to act on it.

She told the Health and Disability Commissioner that she "intended to tell the doctors" "call the nurse [Ms A]", "put it in the patient's notes" but it "slipped her mind".

The tribunal found this was "a significant departure from the standards expected of a nurse in her circumstances".

Ms Cruzada has since left New Zealand but she was ordered to practise under supervision for six months if she planned to work here again.

- NZPA