DHB criticised for failures in care of premature baby

Vaimoana Tapaleao

A district health board has been slammed for its substandard care of a premature baby who was later diagnosed with kidney problems more than a week after he was born.

The Health and Disability Commissioner, Anthony Hill, has released a report about the baby boy born in the MidCentral District Health Board district about four years ago.

The boy’s father laid a complaint with the commissioner about his son’s care. At 31 weeks’ gestation, the mother had an ultrasound performed by a private radiology service. An abnormality was found with the baby’s renal pelvis dilatation, but was misreported by the radiologist.

The radiologist’s report noted bilateral fetal renal dilation, the report said, “however, the radiologist recorded the degree of dilation as 5mm, when the actual findings were fluctuating measurements of 4.1mm to 9.5mm on the right and 5.1mm to 14mm on the left.” The child was born about a week later.

An investigation showed paediatric staff were told verbally about the results showing bilateral dilation of 5mm. However, a copy of the radiologist’s report was not passed on from the mother’s clinical records to the baby’s records then.

Subsequently, the child developed episodes of high blood pressure and oedema — a build-up of fluid in the body that causes swelling.

Just over a week after the boy was born — on the eighth day — staff carried out a renal ultrasound. As a result, a posterior male urethral valves diagnosis was made, which required surgical management.

The condition is where obstructing membranes in the posterior male urethra prevent normal urine flow from the bladder.

Hill criticised the situation, saying the environment in which the DHB staff were working had contributed “considerably” to the documentation failures in the case.

He was also critical that staff failed to investigate the baby’s worsening high blood pressure and oedema and the fact that the DHB did not receive a copy of the radiologist’s report.

“There was a pattern of suboptimal documentation by multiple staff ... and the environment in which the DHB staff were operating contributed considerably to the documentation failures in this case,” the report said. “The DHB failed to provide services to the baby that complied with relevant standards . . .”

Hill also pointed to what he called a culture at the DHB where nursing staff felt they were not listened to.