Family accept hospital’s apology over young boy’s death

Victor Talanoa died of meningococcal sepsis. Failings by Oamaru Hospital contributed to his death...
Victor Talanoa died of meningococcal sepsis. Failings by Oamaru Hospital contributed to his death. Photo: supplied
An apology for the death of a 13-month-old boy following several failures at Oamaru Hospital has been accepted by the grieving parents.

In 2019, Victor Talanoa was rushed to the hospital with meningococcal sepsis, but died soon after.

In August, a Health and Disability Commission (HDC) report found a lack of equipment at the hospital and failings by its staff contributed to his death.

Mother Hannah Talanoa said the family had met the hospital following the report to discuss the shortcomings in its care of Victor and the lack of support provided to them after his death.

"We are satisfied that the hospital have implemented all of the recommended changes from the health and disability commissioner and given us a full apology."

Waitaki District Health Services chief executive Keith Marshall said it had "unreservedly apologised" to the family.

"The baby’s illness was clearly an extremely serious one with a high mortality.

"We are heartbroken that more should have been done."

The boy was taken to the hospital in 2019 just after 2am with a fever and vomiting — symptoms of what would later be recognised as meningococcal sepsis.

A nurse discovered a rash on the back of the baby and recommended he be seen right away, but she did not document the recommendation to upgrade the triage score.

The boy had a pulse significantly above normal and was breathing faster than he should have been, but the hospital did not calculate the baby’s paediatric early warning system (Pews) score, used to assess a patient’s risk of deteriorating based on abnormal vital signs.

The on-shift doctor attended, recognised the signs of meningococcal sepsis and instructed the baby be transferred to another hospital.

The boy was sent to another hospital by ambulance, as the doctor calculated it would have been quicker than scheduling a helicopter.

However, the clinical director at the second hospital — which was not named in the report — said the baby would have received monitoring on the way if taken by helicopter and been admitted directly to intensive care.

There were also complications with the transfer.

A nurse at Oamaru Hospital did not specify the suspected illness as meningococcal sepsis; instead she wrote meningitis, which is not as severe.

The portable oxygen monitor inside the ambulance would only work intermittently and a replacement could not be found.

The child’s status deteriorated on the way, but ambulance staff did not radio ahead to notify the hospital.

He was admitted to intensive care at the second hospital under the highest triage category and after being assessed was flown to a children’s hospital, where he died six days later.

The report found the hospital failed to used the Pews chart, had inadequate communication and at the time did not stock the appropriate paediatric fluids.

It also found the doctor’s decision to send the baby by ambulance was inappropriate and he did not document sufficient information, or reassess the baby’s condition.

The HDC made recommendations to the hospital, including training on which ambulance services to use, an audit of paediatric monitoring equipment and an amendment to the Pews chart .

Mr Marshall said the report "made very clear what the shortcomings at Oamaru Hospital were".

It fully accepted the findings and had made changes to clinical practices based on the HDC’s recommendations.

The WDHS was heartened to hear the HDC had also recommended Te Whatu Ora Health New Zealand investigate the establishment of a national transfer desk for urgent-care matters.

"This would make a big difference for patient care in rural hospitals ... and would likely have had an impact in this tragic situation," he said.