{"id":357694,"date":"2025-08-19T21:01:32","date_gmt":"2025-08-19T21:01:32","guid":{"rendered":"https:\/\/www.europesays.com\/uk\/357694\/"},"modified":"2025-08-19T21:01:32","modified_gmt":"2025-08-19T21:01:32","slug":"hdc-censure-for-doctor-gisborne-hospital-after-toddler-dies","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/uk\/357694\/","title":{"rendered":"HDC: Censure for doctor, Gisborne Hospital after toddler dies"},"content":{"rendered":"

That doctor, identified only as Dr B, and Health NZ Tair\u0101whiti,<\/a> which runs hospitals and health services in Gisborne<\/a> and surrounding districts, have been found to have breached patient rights in their treatment of the boy.<\/p>\n

Sections of the report which relate to Dr B, a locum at the time, have also been sent to the Medical Council of New Zealand,<\/a> the professional body that registers doctors and monitors their performance. <\/p>\n

The HDC has also recorded adverse comments against another clinician, Dr C, and a community health centre.<\/p>\n

The boy died in 2018 and the HDC report has redacted the names of all the parties involved apart from Gisborne Hospital.<\/p>\n

The boy, called Master A, lived in a rural area, about 30 minutes\u2019 drive from a community health centre, which was in turn 30 minutes from a rural hospital.<\/p>\n

Gisborne Hospital was a further 90 minutes to two hours away from the rural hospital.<\/p>\n

Master A was seen at the community health centre on day one of his illness with fever and vomiting before being taken from there to Gisborne Hospital by ambulance. <\/p>\n

He was discharged and taken home on day two, but was visited by ambulance officers that night after his grandmother visited their station asking to borrow a thermometer.<\/p>\n

On day three, the family tried to contact the ambulance service again but they were on a call-out. Relatives unsuccessfully tried to contact a rural nurse, then took Master A to see Dr C at the rural hospital. <\/p>\n

It was late at night, the boy had a fever and rapid heart rate, and Dr C diagnosed a viral illness. The discharge notes from Gisborne Hospital had not been sent through. <\/p>\n

Dr C consulted a paediatrician at Gisborne Hospital, who advised he should be taken back there. <\/p>\n

Overnight stay request refused<\/p>\n

Master A\u2019s wh\u0101nau said they pleaded to be allowed to stay at the rural hospital overnight as it was after midnight and they were exhausted. <\/p>\n

Dr C refused and instead gave them the option to drive to Gisborne, which they declined because they did not want to make the 90-minute journey while fatigued and without medical assistance along the way. <\/p>\n

Dr C also declined a helicopter transfer. <\/p>\n

The family returned home but went to the community health centre the following day. <\/p>\n

Master A still had a temperature of 38.9C and Dr B advised the family to take him to Gisborne Hospital.<\/p>\n

By the time he arrived, he had developed jaundice and was \u201cyellow and grunting\u201d. A chest X-ray showed his lung had collapsed. <\/p>\n

After further tests, multi-organ failure was diagnosed.<\/p>\n

Master A stopped breathing before he could be transferred to a children\u2019s hospital. He could not be revived.<\/p>\n

An investigation later found the initial diagnosis of a viral infection \u201cset the scene\u201d for subsequent interactions.<\/p>\n

Master A was not referred for follow-up care when he was discharged from Gisborne Hospital on day two or after presentation at the rural hospital on day three.<\/p>\n

\"DeputyDeputy Health and Disability Commissioner Dr Vanessa Caldwell released the report on the 23-month-old boy who died. Photo \/ James Gilberd Photography Ltd<\/p>\n

The investigation found that on the night of day three, Dr C did not advise the family strongly enough to take Master A to Gisborne Hospital from the rural hospital.<\/p>\n

On day five, Dr B did not call an ambulance or a helicopter to take Master A to Gisborne Hospital, nor did they call a paediatrician in Gisborne, phoning ED instead. <\/p>\n

Master A\u2019s wh\u0101nau said that they sought leadership, professional support and expertise from doctors and trained medical personnel who they believed would make the best medical judgments.<\/p>\n

They believed that over the five days they did everything in their power to access and acquire the best possible medical care and advice that was available to Master A.<\/p>\n

Deputy Health and Disability Commissioner Vanessa Caldwell said it was clear Master A\u2019s family had made \u201cevery attempt\u201d to get him the care he needed. <\/p>\n

\u201cHowever, a lack of documentation and poor communication resulted in the full picture not being apparent when needed,\u201d Caldwell said.<\/p>\n

\u201cIn addition, in my view, there was an element of confirmation bias such that clinicians continued to believe that Master A had a viral illness even when he failed to improve after several days and developed a cough, a high temperature and fast breathing.\u201d<\/p>\n

Caldwell said that, overall, she was left with the impression that Dr B provided \u201cminimal support to Master A\u2019s wh\u0101nau, failed to think critically, and failed to seek advice from the paediatric service at Gisborne Hospital\u201d.<\/p>\n

She said an independent reviewer had found that Dr B failed to understand how sick the boy was, failed to consult appropriately with specialists and did not consider transport options. <\/p>\n

She found that Dr B failed to provide Master A with reasonable care and skill, in breach of the Code of Health and Disability Services Consumers\u2019 Rights. <\/p>\n

She said that Health NZ Tair\u0101whiti breached the code through failures by multiple staff members, and a lack of awareness in relation to the difficulties faced by patients from remote areas.<\/p>\n

\u201cThis is reflective of systemic and organisational issues at Health NZ,\u201d she said. <\/p>\n

Caldwell recommended that Health NZ Tair\u0101whiti, the primary healthcare provider and Dr B each separately apologise to the family.<\/p>\n

Health NZ responds<\/p>\n

John Swiatczak, Health New Zealand group director of operations Tair\u0101whiti, said the agency extended its \u201cheartfelt aroha and deepest apologies\u201d to the child\u2019s wh\u0101nau.<\/p>\n

\u201cWe are truly sorry for the loss they have suffered and the pain this has caused,\u201d he said. <\/p>\n

\u201cWe acknowledge the profound impact this has had on the wh\u0101nau and the wider community who loved and supported this child.\u201d<\/p>\n

Swiatczak said Health NZ took the safety and wellbeing of every person in its care extremely seriously, \u201cbut in this instance, we failed to meet the standard of care that every wh\u0101nau deserves\u201d.<\/p>\n

\u201cFor that, we offer our sincere and unreserved apology,\u201d Swiatczak said.<\/p>\n

\u201cAll wh\u0101nau who entrust us with their health have the right to feel safe, supported and respected. We are committed to learning from this event and taking every step necessary to ensure it does not happen again.\u201d<\/p>\n

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME\u2019s Open Justice team in 2022 and is based in Hawke\u2019s Bay. <\/b><\/p>\n","protected":false},"excerpt":{"rendered":"That doctor, identified only as Dr B, and Health NZ Tair\u0101whiti, which runs hospitals and health services in…\n","protected":false},"author":2,"featured_media":357695,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4316],"tags":[125918,125917,14120,23364,125914,30636,125919,97067,8557,390,34677,3576,125915,125913,105,4348,1867,51345,125916,17289,13649,11615,97609,16,15],"class_list":{"0":"post-357694","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthcare","8":"tag-23monthold","9":"tag-adequate","10":"tag-after","11":"tag-before","12":"tag-censure","13":"tag-days","14":"tag-died","15":"tag-dies","16":"tag-doctor","17":"tag-family","18":"tag-five","19":"tag-for","20":"tag-gisborne","21":"tag-hdc","22":"tag-health","23":"tag-healthcare","24":"tag-hospital","25":"tag-sick","26":"tag-spent","27":"tag-their","28":"tag-toddler","29":"tag-treatment","30":"tag-trying","31":"tag-uk","32":"tag-united-kingdom"},"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@uk\/115057451639700690","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts\/357694","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/comments?post=357694"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/posts\/357694\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/media\/357695"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/media?parent=357694"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/categories?post=357694"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/uk\/wp-json\/wp\/v2\/tags?post=357694"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}