HDC finds care failures after four-year-old dies of sepsis
Monday 12 October 2026 · 4 outlets · 3 reports · updated In this story Health New Zealand, Health and Disability Commissioner
The Health and Disability Commissioner found deficiencies in the care of a four-year-old boy who died from sepsis at Wellington Hospital in September 2022. Following a bike accident, clinicians failed to recognise warning signs and did not place the child on a paediatric sepsis pathway.
Key facts
4 facts
- Four-year-old boy died of Group A streptococcal sepsis and toxic shock syndrome in September 2022
- HDC found Health New Zealand | Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights
- The boy had tested positive for Covid-19 during his hospital admission
- Wellington Hospital has since implemented a Paediatric Early Warning System and a paediatric sepsis pathway
The full story
1 min read · 3 outlets
The Health and Disability Commissioner (HDC) has found that Health New Zealand | Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights in the care of a four-year-old boy who died in September 2022. Deputy Commissioner Vanessa Caldwell found that multiple deficiencies in the boy's care at Wellington Hospital amounted to a failure to provide services with reasonable care and skill. While it is unknown if earlier intervention could have changed the outcome, Caldwell noted there were "missed opportunities" to identify the child's deterioration and start the paediatric sepsis pathway.
The boy first visited a local medical centre with fever and neck pain two days after falling from his bike at kindy. He was diagnosed with a viral illness and sent home with painkillers. Four days later, he was taken to the Wellington Hospital emergency department (ED) where he had also tested positive for Covid-19.
Upon arrival at the ED, the boy was described as lethargic, in pain, and unable to bear weight. An expert review found that although an ED registrar saw him within 60 minutes, sepsis was not considered as a diagnosis. Independent adviser Dr Philip Moore stated, "Sepsis was not considered at this point. In my opinion, it should have been".
The HDC identified several failures, including a five-hour delay in obtaining intravenous access and blood samples, and a nearly three-hour gap in recorded vital signs. After a paediatric registrar reviewed the case at 5.30pm, the boy received antibiotics after 6pm but died at 7.24pm. Caldwell noted these issues reflected system-level problems rather than individual clinician failures.
Where reports differ
- One report states the boy was not feverish upon arrival at the ED, while another notes he had a low temperature on admission
Compiled from reports by Stuff, NZ Herald and Otago Daily Times.