‘They missed warning signs’
Series of treatment failures at Auckland Hospital cited by ACC investigation.
Illuminated bikes, scooters and wheelchairs lit up Silo Park in Auckland’s Wynyard Quarter last night for the annual InMotion Matariki parade.
The event kicked off with a haka fusion performance in the perfect spot to view the Vector Lights for Matariki on the Harbour Bridge.
The disability-friendly parade, part of Auckland Council’s Matariki Festival, included lantern sculptures of golden snapper and colourful floats of kereru¯ in flight.
Participants wrapped up warmly on the chilly night and enjoyed performances by dancers, music groups and fire poi artists that lined the parade route to The Cloud.
Inside The Cloud, Touch Compass, a performance company for people with and without disability, put on an aerial display for the crowd.
It was the second year the parade has been held.
Atoddler’s cardiac arrest which left her with a brain injury could have been avoided if not for several treatment failures at Auckland City Hospital, an ACC investigation has found.
There have been a handful of investigations into Jeanette Queensell-Logan’s case which was referred to the Director-General of Health — a rare move when there could be a risk of harm to the public.
The Auckland pre-schooler, who turns 4 next month, is now confined to a wheelchair and is having to relearn basics like how to walk, talk and swallow.
At just 3 months old, Jeanette was diagnosed with D-Transposition of the arteries, a birth defect in which the large arteries of the heart are not connected properly. She had several holes in her heart and, at 16 months, had a pacemaker inserted.
A month before she turned 2, she was rushed to Auckland City Hospital after a runny nose, cough and breathing problems failed to clear.
ACC investigator Neil Waldman wrote in a report that she initially received good care.
Heart failure was first suspected as the cause but an x-ray did not reflect that. Two doctors failed to appreciate the signs and did not consider another diagnosis, Waldman wrote. “The failure to recognise that she had ongoing severe respiratory distress and shock was a mistake.”
An arterial blood gas test should have been done and would have shown sooner that she was suffering from incidental hyperkalemia — high levels of potassium in the body.
“The involvement of so many doctors and teams seems to have delayed critical care that was necessary to stabilise Jeanette,” Waldman said. “No IV access and no blood samples were obtained for over an hour, which was too long for a critically ill child in shock.”
Jeanette’s cardiac arrest and brain injury has left her needing round-theclock care. Major modifications are needed for the three-bedroom Glen Eden home she shares with her father Stephen, mother Mele and five siblings.
“Jeanette is a baby again,” said Stephen Logan. “She is crawling like a caterpillar, rolling over and over on the floor. She grunts and nods.”
A review of ACC’s decision to provide cover for the family concluded there was a “failure in the provision of treatment up until the cardiac arrest”.
In its own review, seen by the Herald on Sunday, senior ADHB medical clinicians noted her resuscitation and stabilisation were challenging due to difficulties obtaining intravenous access. This caused a delay in Jeanette being treated.
They disputed Jeanette’s cardiac arrest was avoidable and systemic improvements did not need to be made, but said it noted “some areas to look into to see if there were opportunities for improvements”.
Dr Margaret Wilsher, chief ADHB medical officer, said there was nothing that could be done to prevent Jeanette’s outcome.
“She was actively and appropriately treated in children’s ED by a highly experienced team, personally directed by a senior paediatric emergency medicine Specialist.”
The ADHB released its review to the Logan family in December and met them in January at the request of Jeanette’s father, who wanted answers. “Put it this way, we both agreed to disagree, ” he said.
“I think her condition was not assessed correctly soon enough. There were so many warning signs there that they didn’t pick up and they failed to respond to. Meanwhile, she was going downhill and no one is taking any overall responsibility.”
ACC filed a risk of harm report to the Director-General of Health because there was a “a failure to provide treatment, or to provide treatment in a timely manner”.
Doctors expect Jeanette will eventually regain some mobility. She’s learning to talk and swallow again before she can begin eating.
HWatch the video at nzherald.co.nz
‘Nothing fazes our bubbly little angel’, Review P24-25
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