Director of Proceedings v Southern District Health Board  NZHRRT 8, (6 March 2020)
The Director of Proceedings filed proceedings by consent against Southern District Health Board (“SDHB”) in the Human Rights Review Tribunal (“the Tribunal”) regarding services that the SDHB provided to Master A.
Master A was 17 months old when his mother took him to Southland Hospital four times because he was not weight-bearing on his left leg. Eventually, Master A was diagnosed with a spiral tibial fracture. Despite a number of warning signs in his presentations, a diagnosis of non-accidental injury was not considered adequately across multiple presentations to hospital, resulting in a delayed diagnosis. Sadly, Master A sustained further injuries following discharge from hospital, and was found deceased on 13 October 2015.
SDHB acknowledged that a series of failings within teams and across services in the assessment, communication, documentation, and coordination of care, together with a failure by numerous staff to adhere to policies and procedures around family violence screening and non-accidental injury, prevented earlier diagnosis of Master A’s spiral tibial fracture and non-accidental injuries. The inadequate documentation (of social history, cause of injury, and family violence screening) led to an incomplete clinical picture, critically as to risk of harm being passed on between different teams and departments, and this contributed to a delay in Master A’s diagnosis. SDHB accepted that it is responsible for the operation of the services it provides and that there was a systemic failing on its part with tragic outcomes for Master A and his family.
SDHB accepted that its failures in care amounted to a breach of the Code of Health and Disability Services Consumers’ Rights (“the Code”), and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that SDHB failed to provide services to Master A with reasonable care and skill, and failed to provide co-operation among providers to ensure quality and continuity of services, and issued a declaration that SDHB breached Right 4(1) and Right 4(5) of the Code.
The Tribunal’s full decision can be found at:
 A spiral tibial fracture, also known as a toddler’s fracture, is a spiral fracture of the shaft of the tibia (the shinbone in the leg) with an intact fibula (the calf bone in the leg).