A baby boy who hit his head on his cot and cut his lip spent a month in hospital with severe sepsis after Waikato DHB emergency department staff misdiagnosed him and sent him home three times.
The incident has left the boy with a partially paralysed facial nerve and a crooked smile, his mother says.
In a finding released today, Health and Disability Commissioner Anthony Hill said Waikato DHB and one of the doctors involved had breached the baby's rights by failing to provide services with "reasonable care and skill".
The six-month-old's mother brought him to an emergency department on November 29 2015 after he knocked his head on his cot, cutting his lip. He presented with flu-like symptoms and was diagnosed with a viral illness.
He was sent home only to return on December 1 and December 4 with new symptoms including fever, a rash, bleeding nose and bleeding gum. His face also became increasingly swollen.
On December 5, at 2am, his worried mother brought him back to the ED, with a swollen face and lip, crying inconsolably and refusing food.
Doctors examined the baby and decided to transfer him to a paediatric department in a hospital in another city some 100km away. His distressed mother was told no ambulance was available so she drove him there herself at 3am.
The paediatric service at the second hospital found the baby had a fever and a "grossly" swollen cheek and jaw. Lab tests came back positive for Staphylococcus aureus - a bacterial infection.
The baby was already on antibiotics but had to be intubated, ventilated and transferred to the intensive care unit as the swelling was making it hard to breathe.
On December 7 he was transferred to a third hospital with severe sepsis, and required a four-week course of antibiotics while under observation.
He was discharged on January 5, but it was noted he would have partial paralysis or weakness of his facial nerve and an area of exposed bone in his mouth.
"[His mother] stated that the effect is that although Baby A is a good-looking boy, he looks crooked when he cries or smiles, and nothing can be done to remedy the condition until he is about 10 years old," the HDC decision said.
The HDC found serious issues with Waikato DHB's processes, with observation not properly completed or repeated on three occasions and imperfect use of the Child Emergency Assessment Chart.
Repeated presentations of a baby at an ED were a "red flag", the commissioner said. [He] was also concerned about how the mother was spoken to and that she was told to drive to another city in the middle of the night, in some distress, with a sick baby.
Waikato DHB has since changed its emergency assessment chart for children, including making elevated respiratory rate a "red flag", and now ensures that if a child comes to the ED twice their case will be discussed with the second hospital's paediatric service at the second hospital.
Both the hospital and the doctor who treated the baby on his third ED visit were required to write apologies to the mother. If the doctor involved were to return to medical practice, his competence should be reviewed, the commissioner said.
'Extremely concerned': Woman may have been jabbed with used syringe
In another case published by the HDC today, a woman was jabbed with an empty flu shot syringe that may have already been used.
Before administering the vaccine on May 8 2018, the GP did not look at the syringe to check it was full.
The woman said after jabbing her, the doctor said "Oh it's empty! Oh God," before leaving the room.
He later explained to the woman that either the injection may have been faulty, or it had already been used on an earlier patient.
Medical staff discussing the incident the next day were adamant they would not have returned a used needle to the fridge as it was standard practice to immediately put them in a sharps container for disposal.
But Commissioner Hill said he could not determine whether the empty syringe was the result of a manufacturer error, or whether a staff member had put a used syringe back in the box.
"If the latter, I would be extremely concerned," he said.
The practice - which administered about 1100 flu vaccines each year - had reviewed its processes to make sure faulty syringes would be recognised and that all vaccine barrels would be double-checked.
The doctor involved had also accepted there were deficiencies in his care and apologised.
But the patient said she was still "very disappointed" with how she had been treated, with nothing done about the anxiety and stress the incident had caused her.