The health board which was too slow to report that a toddler's injuries were non-accidental has described it as a tragic situation. Photo / 123RF
The health board which was too slow to report that a toddler's injuries were non-accidental has described it as a tragic situation. Photo / 123RF
A district health board reprimanded after doctors failed to report suspected abuse of a toddler who later died has apologised to the child's family and says the tragedy has deeply affected staff.
Though the child had a fractured leg which doctors suspected may have been non-accidental, they failed to alert authorities.
A student nurse noticed bruising, blackened fingernails and missing teeth at a later hospital visit but authorities were not alerted until he was sent to a different hospital for further testing five days later. He died of other injuries soon after.
The Herald is unable to identify the DHB for legal reasons.
In a statement provided to the Herald tonight, the DHB acknowledged its failings.
"This was a tragic situation, and our sincere sympathies remain with the family and all others affected by the loss of this young child," the DHB's chief executive said.
"Such tragedies impact us deeply, including our staff who work hard to provide the right care to those who need it."
The chief executive said the organisation had co-operated with all investigations and would continue to do so.
"We accept the recommendations in the Health and Disability Commissioner's report and continue to be committed to making improvements in the hope we are able to prevent such a situation ever happening again."
Hill's report found the DHB failed to provide adequate care for the boy and recommended the organisation provide the family with a letter of apology.
Anthony Hill, Health and Disability Commissioner. Photo / Supplied
When the 16-month-old began to avoid using his left leg, his mother took him to hospital for treatment.
Despite at least three doctors admitting they considered it was possible that the tibia fracture was non-accidental, it was not until the boy's fourth visit and transfer to another hospital that those concerns were noted and the appropriate agencies informed.
The second hospital recorded two black fingernails, two damaged fingernails, a missing left bottom incisor, bruises around the hips and chest, and a light pink discolouration over the right lower quadrant of the abdomen and alerted authorities.
Because of the number of unexplained injuries, the boy was referred to Oranga Tamariki and the police child protection team.
Oranga Tamariki staff were asked to prepare a safety plan before the boy could be discharged but he went home after police arrived and spoke to his mother.
Following the release of the report, Children's Commissioner Andrew Becroft told the Herald it was a "profoundly concerning incident that experts in our office call dreadful and appalling".
Children's Commissioner Andrew Becroft said the situation was profoundly concerning. Photo / File
"This is as bad a systems failures could possibly be imagined," he said.
He told Radio New Zealand he believed the health board involved should be identified although it would have to wait until any further action had been resolved.
Health Minister David Clark said he expected the DHB to review its policies. Photo / File
"Clearly in this case mistakes were made, with tragic results," he said.
"Domestic violence is sadly all too common in New Zealand and it's important our health professionals look out for signs of abuse, and respond appropriately. I'm sure they work hard to do just that," he said.
Clark said one of the strengths of the health system was the willingness and commitment of those involved to learn lessons when something went wrong.
"I expect the DHB will reflect on whether their policies and practice are up to date in light of this case."
Ministry of Health deputy director-general of population health and prevention Deborah Woodley and chief adviser of child and youth health Pat Tuohy said the case would be discussed at the next inter-agency meeting with police, health boards, the Paediatric Society and Oranga Tamariki.
"This sad case demonstrates that there is room for improvement and provides learnings for us all," they said in a statement.
