The Whanganui DHB has apologised after failing in its duty of care of a severely premature newborn. Photo / Bevan Conley
The Whanganui DHB has apologised after failing in its duty of care of a severely premature newborn. Photo / Bevan Conley
The Whanganui District Health Board has been reprimanded by the Health and Disability Commissioner for failing to take appropriate care of a premature newborn in 2018, resulting in the child being left permanently blind.
In a decision published late last month, commissioner Morag McDowell blasted both Waikato and Whanganui DHBs for the joint care of the newborn, who developed a serious eye condition not picked up on by either DHB.
According to the published decision, the baby boy was born three months prematurely at Whanganui Hospital alongside a twin sibling.
A day later, both babies were transferred to Waikato Hospital for further care, owing to their extreme prematurity.
While the twin died shortly after the transfer, the newborn at the centre of the complaint, referred to as Baby A, developed a number of serious conditions, including chronic lung disease, high blood glucose concentrations and anaemia requiring blood transfusions.
The commissioner said during this period Waikato DHB should have been aware of an increased risk of retinopathy of prematurity (ROP), an abnormality in the growth of blood vessels in the eye.
According to the published decision, 61 per cent of babies born at less than 28 weeks of gestational age, or less than 1000 grams, develop some degree of ROP.
Four weeks into the baby's care at Waikato Hospital, a doctor recorded a note on the baby's file, noting there were no abnormalities in the blood vessels of the eye.
Thirteen days later, a further note confirmed an eye check was completed, but the result of the assessment wasn't documented in the child's clinical notes.
The doctor who undertook that assessment later confirmed to the commissioner that the baby was showing early signs of ROP, diagnosed at that point as "mild". The doctor advocated for fortnightly checks on the child's eyes.
The child was transferred back to Whanganui Hospital due to a variety of factors, including being deemed well enough for care back in Whanganui, as well as Waikato DHB being over-capacity at the time.
An over-the-phone handover was conducted between a doctor in Waikato and a doctor in Whanganui, but there was no discussion around ROP.
A written discharge letter listing 10 neonatal problems was provided to Whanganui DHB by Waikato DHB, but there was no mention of ROP.
The DHB was found to be in breach of code 4.1 of the Health and Disability Services Consumers' Rights. Photo / NZME
Once transferred to Whanganui Hospital, a doctor put in place a care management plan for the newborn, but did not arrange an ROP assessment.
The child's father told the commissioner that a nurse at Waikato DHB who managed the transfer to Whanganui DHB told him to "make sure they test his eyes". The father said he mentioned it numerous times to doctors and nurses at Whanganui DHB.
While in the care of Whanganui DHB, no ROP assessment was undertaken.
Just over a month after being transferred to Whanganui, the baby was discharged from hospital, but the doctor in charge of the discharge noticed an ROP assessment wasn't completed, and filled out a referral for an assessment to be undertaken at a later date.
That referral was received by the outpatient doctor a week later, but that doctor returned the referral saying it had insufficient information.
That referral then got lost in a chain of communication for a month as it was transferred back and forth between different departments.
A new referral was completed and an ROP assessment was finally undertaken, where it was discovered the newborn had total retinal detachment in the right eye with a complete loss of vision, and partial loss of vision in the left eye.
The baby was transferred to hospital via air ambulance, but the right eye was found to be inoperable, while emergency surgery was undertaken on the other.
The parents of the child subsequently confirmed to the Chronicle that the child was left permanently blind.
Baby 'fell through the cracks' - commissioner
McDowell said the incident was an example of Whanganui DHB offering care well below an acceptable standard.
"Whanganui DHB recognised the need for ROP screening at admission, and documented the family's query about the need for eye tests for Baby A. However, through a series of medical and administrative errors by multiple staff, Whanganui DHB failed to screen Baby A for ROP at the critical 34-week PMA mark.
"In my view, this outcome could have been prevented if adequate mechanisms had been in place for ROP screening at Whanganui DHB. The series of errors indicate a system that lacked adequate safety-netting or clear protocols to ensure that babies like Baby A did not fall through the cracks.
"I regard these errors as a serious departure from the expected standard of care."
In a statement to the Chronicle, a Whanganui DHB spokesman said the DHB acknowledged the decision, and accepted that an appropriate level of care was not provided.
"The DHB accepts the findings of the commissioner that it is in breach of the Code of Health and Disability Services Consumers' Rights, and that the care given to the baby boy fell below an acceptable level.
"The DHB has provided a formal, written apology for Baby A's family, acknowledging its failings and the outcome."
The DHB said it had conducted a series of audits as recommended by the Health and Disability Commissioner and had put in place systems to ensure such an incident did not happen again.
