Baby died after sepsis symptoms overlooked – HDC report

A newborn baby who died of sepsis three days after birth had been given appropriate care, despite missed clinical opportunities to detect his deterioration, the Health and Disability Commissioner (HDC) has found, RNZ reported.

The baby boy, born in 2018, was at known risk of infection due to complications during labour and his mother’s positive test for E. coli. He was placed under 24-hour observation after delivery, with early records showing normal vital signs and feeding patterns.

According to a report by RNZ, Deputy Commissioner Rose Wall said the case was “finely balanced,” but concluded Health NZ had not breached the Code of Health and Disability Services Consumers' Rights. She noted that although monitoring was consistent during the baby’s initial hospital stay, opportunities were missed to take observations in the nine hours after his transfer to a community health service.

Before his death, the baby showed concerning signs including difficulty feeding, vomiting blood, and laboured breathing. His parents raised concerns multiple times, but clinicians initially attributed his symptoms to mucus build-up. By the time hospital specialists arrived to assist, the infant had gone into severe respiratory distress and resuscitation attempts failed. A post-mortem confirmed sepsis as the cause of death.

The HDC highlighted systemic issues, recommending Health NZ review staffing levels at community health facilities, strengthen protocols for infant transfers, and provide further staff education on recognising sepsis. Health NZ has since increased midwifery staffing and presented the case as a learning exercise for its workforce, RNZ reported.

The case underscores the dangers of neonatal sepsis, which experts say can cause rapid decline if not treated quickly with antibiotics and intensive care. While most newborns with respiratory distress recover without complications, paediatric specialists stressed that the baby’s early signs, loss of feeding interest and blood-streaked vomit were, in hindsight, warnings of the infection.

Wall also directed Health NZ to issue a written apology to the baby’s parents, acknowledging the missed opportunities and lessons learned.