A toddler who was taken to hospital twice and had symptoms including fever and an increased heart rate died of a brain disorder linked to a major infection.
The mismanagement of the girl's care has led Health and Disability Commissioner Anthony Hill to rule that her rights were breached by the Southern District Health Board, a senior doctor, and a nurse employed by a tele-health service.
The SDHB team had sufficient information to provide [the girl] with appropriate care. However, a series of judgement and communication failures meant that it did not do so.
An autopsy found group A streptococcal bacteria were widespread in the girl's body and she had pneumonia. The bacteria had caused sepsis, an inflammatory reaction. The girl, aged nearly two years and 11 months, was also found to have underlying acute myeloid leukaemia.
The cause of her death was cerebellar herniation, a movement of brain tissue from increased pressure within the skull resulting from the sepsis.
She had had a worsening cough and runny nose over five days in 2013. Her mother took her to a hospital emergency department in the early hours of a Friday morning after she woke with a fever. Staff there got her high temperature and increased heart rate to reduce and she was discharged.
A doctor asked the paediatric department to call the family to follow up but this did not happen.
The girl was lethargic, slept a lot, refused food, had diarrhoea and was wheezing. On the Saturday night, her mother took her back to the ED, where a viral illness was suspected. Again the girl was discharged.
On the Sunday morning, the girl's temperature reached 40.2C and her mother called the ED for advice. She was transferred to a telehealth service.
"[The girl's] breathing can be heard throughout the call," Mr Hill says in his decision on the case, made public today. The mother, "Ms A", told the registered nurse, "RN D" her daughter's temperature and that they had been to the ED twice.
"Ms A ended the call after 3 minutes and 12 seconds, telling RN D that she was 'going to go'. RN D did not call back Ms A or contact the telehealth service's resource nurse for advice."
The girl stopped breathing at around 1pm, six hours after the telehealth conversation. An ambulance took her to the ED, where attempts to resuscitate her were unsuccessful.
An ED consultant had breached the code of patients' rights by discharging the girl home on the Saturday without sufficient investigation of her symptoms, Mr Hill said.
Another doctor, a house officer, received the lesser criticism of "adverse comment" over the inadequacy of both his investigation and his medical records.
The DHB itself was found in breach of the code for the failings of its staff over inadequacies of their investigation and discharge information, and weak paediatric follow-up systems.
"... SDHB failed to encourage a culture where staff felt comfortable questioning or challenging decisions ..."
"The SDHB team had sufficient information to provide [the girl] with appropriate care. However, a series of judgement and communication failures meant that it did not do so."
Mr Hill called for an audit of all unplanned re-representations of children under 5 to the ED within 48 hours of discharge to measure compliance with requirements including an assessment by an emergency consultant or senior registrar before being discharged.
Richard Bunton, the DHB's medical director of patient services, said the DHB had formally apologised to the girl's family over the failure to deliver the care they were entitled to.
"Such events are, fortunately, rare, and weigh heavily upon all involved. Any learnings that can be taken from this situation are welcome, and an opportunity for us to continue to improve our processes to take the greatest possible care to our patients.
"Southern DHB accepts the commissioner's recommendations and is taking steps to implement them."