Pleas for dying son unheard, mother claims

Reef Steiner was admitted to hospital with what was diagnosed as moderately severe asthma. Photo / Supplied

A mother has described how she spent hours beside her dying 2-year-old son's hospital bed pleading with doctors to save him but feeling like she was not being heard.

Reef Steiner died of brain damage connected to an asthma attack in the children's ward of Tauranga Hospital in 2007.

In a report released yesterday, Health and Disability Commissioner Ron Paterson criticised the hospital and a junior doctor in charge of the children's ward for providing inadequate asthma care.

Jade Steiner said her son "went floppy in her arms" while staff battled to revive him. Reef, who had had asthma for about 11 months, was admitted to hospital suffering from what was diagnosed as moderately severe asthma.

He was treated in the emergency department in the afternoon and transferred to a paediatric ward. He was given inhaled asthma medications, steroids, antibiotics and paracetamol. His condition improved but then deteriorated.

Mrs Steiner said when he was first admitted, emergency department doctors at Tauranga Hospital "seemed to have no urgency and not know what they were doing".

When he was admitted to the ward, the junior doctor, referred to as Doctor B in the report, did not immediately respond to her pleas for help. She said Reef would only sleep on a nebuliser and would become distressed as soon as it ran out.

He would often be waiting up to 30 minutes for the next one.

Around 4.30 the next morning, Reef's heart and breathing stopped.

"I watched my little man take his final breath and go floppy in my arms while the nurses were fumbling for oxygen."

Reef was resuscitated but his heart and breathing stopped three more times. Later in the morning he was flown to Starship children's hospital in Auckland, where it was found he had suffered severe brain damage.

Life support was withdrawn and he died at 10pm the following night in his father Quentin Steiner's arms.

"We were praying non-stop, as were lots of other people, for a miracle," Mrs Steiner said.

"You can imagine our shock and horror at what had happened to our little guy, all because of the staff on that night at the Tauranga Hospital. Due to their incompetence and non-urgent attitudes our baby was taken from us."

Northland paediatrician Dr Roger Tuck, who conducted an independent review of the case for the Bay of Plenty District Health Board, told the Herald yesterday that if the severity had been noted earlier, Reef's life probably could have been saved.

Mr Paterson found that the British-trained junior doctor had failed to provide care of the appropriate standard, breached the code of patients' rights and was over-confident.

He also found the employer, the Bay of Plenty District Health Board, was vicariously liable.

Dr B was employed as a second-year house officer, but the board told Mr Paterson that junior recruits who presented as second-year doctors from Britain - where a medical degree typically took five years rather than the six in New Zealand - "are now recognised as being equivalent to New Zealand first-year house officers".

The board employed Dr B after an interview by a junior doctor, without any input from senior paediatric staff. This has now changed and senior paediatric staff are involved in employment of junior doctors.

The commissioner's decision says that when Dr B first spoke to the paediatric consultant by phone about Reef at 3.30am he did not inform her that he had treated him with a nebulised asthma reliever medication - something he later acknowledged he should have done.

Mr Paterson said he had decided not to refer to the case for consideration of disciplinary proceedings because the health board had placed out of his depth, he had striven to address his shortcomings and he was no longer in New Zealand, having returned to Britain.

The doctor had apologised in writing to Reef's family but Mrs Steiner said it wasn't enough.

"I haven't got to the point of forgiveness. Someone needs to be held liable. We've been left in the dark. If somebody kills somebody on the road they get charged."

She said she believed Dr B went back to Britain because of the way her son was treated.

"His name is mud over here. They had trouble trying to find an independent commissioner that didn't know about the case."

She was considering taking legal action and was looking for legal representation.