Child dies after hospital error
A child died at Palmerston North Hospital after a feeding tube became dislodged so food and fluids went directly into the abdomen causing massive poisoning.
The tragedy was one of three potentially avoidable deaths reported in MidCentral District Health Board's summary of 15 serious and sentinel events in the year to the end of June.
In the case of the poisoned child, it was determined that insufficient knowledge and inadequate guidelines for the acute management (less than 6-8 weeks) of a dislodged feeding tube lead to the death.
There was also a failure to recognise a potentially serious diagnosis or condition.
Another patient died three days after a fall that caused a brain bleed.
The third death happened at home and was discovered when a nurse came to change the dressing on a surgical wound where an abscess had been treated.
Falls were the most common incident, accounting for nine of the 15 events, most often when patients got out of bed to go to the toilet.
Five incidents involved clinical mismanagement, such as a swab left inside a patient during surgery.
There were no mistakes with medications.
MidCentral reported 22 events last year, and 18 the year before.