The death of a baby from severe dehydration came after "service failings" at Hutt Valley District Health Board, which has unreservedly apologised for its mistakes.
The Health and Disability Commissioner said there had been "service failing" in Hutt Valley DHB's care of the 11-month-old girl in the leadup to her death in Hutt Hospital in 2010.
In a decision issued yesterday, the commissioner said staff had not shared critical information about her with one another, and missed multiple opportunities to change her treatment and feeding as her health worsened
The baby, who was not identified, was admitted to Hutt Hospital with vomiting and poor weight gain. She was later found to have rotavirus, and continued to lose weight, to vomit and to develop diarrhoea in hospital.
On her 13th day in hospital, the baby was found unresponsive, having suffered severe renal failure and dehydration, and later died.
Despite her loss of fluids, the degree of dehydration was not properly monitored and many of the people involved in her care were not informed she had rotavirus. Some of the notes by medical staff were inconsistent.
Commissioner Anthony Hill said a lack of communication between the team caring for the girl meant several opportunities to improve her feeding regime were missed. However, the DHB was ultimately at fault for a failure in the overall service provided to her.
He recommended improvement in communication between medical staff, including better oversight of junior staff and auditing of handover notes.
DHB chief medical officer Iwona Stolarek said the DHB had apologised to the baby's family and acknowledged the care provided was "sub-optimal", with delays and missed opportunities worsening the illness.
"Any incident which involves a patient suffering harm or death while in our care is one event too many," she said.
Since the death, the DHB had improved its monitoring of child patients and reviewed staffing levels to ensure senior doctors and nurses were available every day. It had also upgraded the children's ward to decrease the risk of infection.
Plunket clinical advisory manager Karen Magrath said dehydration was a real danger in babies with stomach illnesses such as rotavirus.
"Children get dehydrated very quickly. They need to be watched very carefully," she said.
Parents should continue to give fluids even if the children vomited or had diarrhoea, and should seek the help of a doctor or nurse if they developed dry eyes or mouths, had decreased urine output or were lethargic.
Ensuring that children were immunised against rotavirus, starting from their sixth week, was also crucial, Magrath said.
Even with free vaccination, 1500 Kiwi children under 5 are admitted to hospital with rotavirus each year, although deaths were extremely rare, according to Immunisation Advisory Centre figures.
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