Toddler died day after being sent home from hospital after seizure

A child who was sent home from hospital after a seizure died from a stroke the following day.

The Health and Disability Commissioner has found a breakdown in communication and his subsequent discharge meant while his death was likely not preventable, sending him home was far more traumatic for his family.

The otherwise healthy three-year-old suffered a sudden seizure at home on 4 September 2021. The report says he "suddenly called out to his mother and fell to the ground unresponsive, stiff, and shaking".

He regained consciousness after 10 minutes but was unable to talk, walk, sit, or stand, and his mother took him to the family doctor, who directed them to the hospital emergency department.

When they arrived at 11.44am, the boy was unable to stand and tests showed his blood pressure was abnormally high - a systolic reading of 135, where normal for his age would be 80-100.

By mid-afternoon, he seemed to be recovering, eating and drinking and walking with support. But his blood pressure was not rechecked before discharge - although an electrocardiogram and blood tests were normal.

The registrar said they were not notified of the initial high systolic reading.

Accounts vary on the boy's condition before he was sent home - hospital staff said he had returned to normal, walking unaided and playing. But his mother said he was still very sick, unable to walk.

Despite this, he was discharged, and the clinical record shows he was retching all evening, walking abnormally, and only ate a small amount of dinner.

His mother said she checked on him several times throughout the night, but he did not wake up.

At approximately 5.45am the next day, she found her son unresponsive, not breathing and without a heartbeat, and called emergency services.

He was given CPR and taken to hospital by ambulance, where he was admitted to the intensive care unit. A CT head scan found he had suffered a posterior cerebral circulation stroke, and had unsurvivable brain swelling. He died surrounded by his family.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell found there had also been a communication breakdown due to a language barrier. The mother's first language was Mandarin, and she was not offered a translator.

The registrar acknowledged that, had a translator been offered, the woman might have been more successfully able to communicate her ongoing concerns.

Health NZ told the commissioner it had made several changes since the incident, including providing more education for paediatric teams on communication and escalating abnormal observations.

It had also updated electronic discharge templates to include a prompt confirming vital observations had been completed within an hour of discharge.