A young child who was discharged from the hospital following a seizure passed away from a stroke the next day.
The Health and Disability Commissioner reported that a communication failure and his subsequent discharge increased the trauma for his family, although his death was likely unavoidable.
The three-year-old, previously in good health, experienced an unexpected seizure at home on September 4, 2021. The report details that he “suddenly called out to his mother and fell to the ground unresponsive, stiff and shaking.”
He became conscious again after 10 minutes but could not speak, walk, sit, or stand, prompting his mother to take him to their family doctor, who referred them to the hospital’s emergency department.
Upon their arrival at 11:44 a.m., the boy was unable to stand, and tests revealed his blood pressure was unusually high, with a systolic reading of 135, whereas a normal range for his age would be between 80 and 100.
By the afternoon, he appeared to be improving, able to eat, drink, and walk with assistance. However, his blood pressure was not rechecked before he was discharged, though both an electrocardiogram and blood tests were normal.
The registrar noted they were not informed about the initial high systolic blood pressure reading.
There are differing accounts regarding the boy’s condition before discharge. Hospital staff claimed he returned to normal, walking unaided and playing, but his mother insisted he was still quite ill and unable to walk.
Despite these concerns, he was sent home, and the clinical record indicates he vomited throughout the evening, walked abnormally, and consumed only a small dinner.
His mother monitored him several times during the night, but he did not wake up.
At around 5:45 a.m. the following day, she discovered her son unresponsive, not breathing, and without a heartbeat, leading her to call emergency services.
He received CPR and was transported to the hospital by ambulance, where he was admitted to the intensive care unit. A CT scan of his head revealed a posterior cerebral circulation stroke and unsustainable brain swelling.
He passed away surrounded by his family.
Deputy Health and Disability Commissioner Dr. Vanessa Caldwell also identified a communication issue due to a language barrier. The mother, whose first language is Mandarin, was not provided with a translator.
The registrar admitted that offering a translator could have enabled the mother to more effectively express her ongoing concerns.
Health NZ informed the commissioner of several changes made since the incident, which include enhancing education for pediatric teams on communication and the escalation of abnormal observations.
Additionally, electronic discharge templates have been updated to include a prompt to confirm that essential observations have been completed within an hour of discharge.
