A sick baby may still be alive today if he was admitted to hospital for further observation, rather than discharged after a half-hour emergency department consultation.
Jayzhan Singh Goraya, who was born prematurely at 26 weeks' gestation, was four-months-old when he died at his foster parents' Northland home on December 20, 2017 - two days after being released from Kaitaia Hospital's ED.
In a Coroner's report released this month, an emergency medicine specialist said it was possible Jayzhan may have survived had he been admitted to hospital or observed for 24 hours with this illness.
At the time of his death Oranga Tamariki noted Jayzhan was "well cared for and very much loved" by his foster family.
On December 18 they took him to Kaitaia Hospital where he presented with bronchiolitis. After a 30-minute consultation, hospital staff were happy for Jayzhan to go home and advised his caregivers to keep him upright to help ease his nasal congestion.
On the morning of December 20, Jayzhan was wrapped in a blanket and put in his pram to sleep. Later, he made an unusual-sounding cough and then stopped breathing.
An ambulance was called but he couldn't be resuscitated.
A post-mortem concluded that Jayzhan's death was due to extensive bronchopneumonia in the setting of extreme prematurity. Jayzhan's lungs were heavy and congested and extensive bronchopneumonia was evident throughout, perinatal pathologist Dr Jane Zuccollo said.
Jayzhan's foster mother later commented in an interview with a Sudden Unexplained Death of Infant (SUDI) liaison officer that she felt uneasy at the brevity of the examination at Kaitaia Hospital and the subsequent discharge and advice given.
Jayzhan's death was referred to the coroner because of her concern and because he was under the care of Oranga Tamariki. Deaths of people in official care and custody are required by law to be referred to the coroner.
At the outset of her findings, coroner Erin Woolley acknowledged the lengthy delay in finalising the report into Jayzhan's death and apologised for it.
The delay in the findings was a reflection of a recognised and ongoing nationwide problem with wait times for coronial inquiries.
In examining the cause of death, Woolley sought advice from Dr Louise Finnel, an emergency medicine specialist at Middlemore Hospital.
Dr Finnel said the care, diagnosis, and medication given to Jayzhan on December 18 at Kaitaia Hospital were all appropriate.
But the decision to discharge him after only half an hour at the emergency department was not.
Dr Finnel said given Jayzhan's age and several risk factors predisposing him to develop more severe bronchiolitis, Jayzhan needed to be kept under observation in hospital longer.
In her opinion, it was possible Jayzhan may have survived had he been admitted or observed for 24 hours with this illness, as any deterioration in his health would have been actioned immediately.
The doctor was also critical about the quality of the discharge advice given to the caregivers by the hospital. It was non-specific about when Jayzhan should be returned to the hospital, with no documented information about his social set-up in case he was urgently returned.
His caregivers should have been given a written list of signs to watch out for and told to return if any of those occurred.
The hospital's advice to the caregivers was to have Jayzhan reviewed by his GP two to three days later but he should have been reviewed within a day, Dr Finnel said.
The coroner said she agreed with Dr Finnel's observation that had Jayzhan's carers been told specifically what symptoms to look for, they would likely have taken him back to hospital the night before he died when they noticed him looking lethargic, less active, and yellow.
The foster father said he regretted not acting on his observation but the coroner said he should not in any way blame himself for the outcome in this case.
The coroner's preliminary findings were referred to the Northland District Health Board (NDHB), which acknowledged the sad outcome and accepted there were red flags, and that more could have been done in terms of documentation and offering admission. However, because Jayzhan had been presented so early in the course of his illness, the NDHB felt that the whānau would not have stayed in hospital.
Woolley said the offer should have been made regardless.
She recommended the NDHB adopt the use of Starship Children's Hospital Bronchiolitis Guidelines, a paediatric vital signs reference chart, and that it develops a standard written patient advice sheet for common paediatric presentations such as bronchiolitis.
She commended the NDHB for having already proactively made these changes following its internal reviews.