New Zealand Police, the Whanganui car park death and discretion

A 16-month-old boy died after being left in a car in Whanganui hospital’s carpark

In January this year a tragic accident occurred wherein a family lost their young child through a series of circumstances that any parent would undoubtedly dread:

Whanganui baby car death: manslaughter charge

22, April 16 2015

A woman has been charged with manslaughter in relation to the death of a toddler who was left in a car in the Whanganui Hospital car park.

Police had been conducting an inquiry into the January 16 death of 16-month-old [redacted].

The woman, 35, appeared before Judge David Cameron in the Whanganui District Court on Thursday. She was granted interim name suppression.

She was remanded at large and will re-appear in the High Court at Whanganui on May 6.

The woman is a Whanganui District Health Board employee.

Board chief executive Julie Patterson said while the DHB understood the decision to lay charges, “we do feel for our colleague and we will continue to support her and her family through the challenging days ahead”.

Patterson acknowledged the thoroughness of the police investigation and thanked police for their sensitive and thoughtful approach when interviewing DHB staff.

“Out of respect for our colleague, and especially given the court suppression orders, the WDHB will not be making any further comment.”

Paediatric Society of New Zealand president Dr David Newman has previously spoken about the dangers of children being left in cars.

An outside temperature of just 21 degrees Celsius meant the inside temperature of a car could reach 49C in just 45 minutes as the sun radiated through the windows, he said.

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“An adult could not survive in that heat and children are far more susceptible to it. They overheat three to five times faster than an adult.”

Younger children have less surface area and fewer fluids, meaning their core body temperature heats up much faster than older children and adults.

Source: Fairfax

Just quite why it was that the police charged the mother in this case defies bekief, although it would seem that the New Zealand police and the country’s prosecutors have a long-held habit of misjudging the appropriateness of their actions. In this case however it would seem that the New Zealand courts may have gone some way to compensating for the polices heavy-handed and seriously inappropriate action in bringing manslaughter charges against a woman in what was clearly a tragic accident, where a third-party may have been morally and circumstantially responsible for the childs untimely death even if not legally culpable.

The High Court has today released two related judgements that we can only assume relate to the tragic death of this particular child. Those judgements are available here and here or in the references below. Suffice to say Justice Simon France of New Zealand’s High Court has seen fit to grant a discharge without conviction and allow permanent name suppression for both parents under section 200 of New Zealand Criminal Procedure Act 2011.

In those judgements France J does briefly note the unique set of circumstance surrounding the childs tragic death, pointing in particular to the long hours defendant, a health professional, had worked as being a significant contributing factor in the accidental death. Now of course it goes without saying that the New Zealand police would also have been aware of these same facts. Given that we find it somewhat significant that they sought to charge the defendant with manslaughter.

[4] The defendant is a health professional who undertakes challenging work. The work is of the type that will often occupy your thoughts even though you have ostensibly left work for the day. Such was the case on this occasion. The defendant had been working long hours for many consecutive days. On the morning of her son’s death she left for work at 7.00 am, having only returned home the previous night at half past midnight.

[5] It was a Friday morning and she put her son in the car to drop him off at day care. He was in his approved car seat, facing towards the back of the car.

[6] Tired, distracted by work, and somewhat on auto-pilot as she describes it, the defendant forgot to turn off at the crèche which is very near her work. Instead she drove straight to work, where she parked the car. Oblivious to the fact her son was still in the car, she went inside and started working.

Source: CRI 2015-083-529 [2015] NZHC 1245

Of course the police are not the only government entity that should be noted on this occasion. The circumstances in this case, as noted by France J, are that the defendant, a health professional was extremely over-tired as a result of having worked consecutive back to back shifts at the whanagnui hospital.

Whanganui District Health Board Chief Executive, Julie Patterson likely knew that the hospital was engaging in cost cutting measures whereby it was foreseable that there was an undue risk of endangerment to either patients or hospital staff.

This then raised the issue of the safety of New Zealand hospitals and the cost cutting measures employed by the country’s hospital boards. Clearly in this case the hospital bears some responsibility for the childs death, a fact that the boards senior managers were no doubt aware of from the outset;

Board chief executive Julie Patterson said while the DHB understood the decision to lay charges, “we do feel for our colleague and we will continue to support her and her family through the challenging days ahead”.

Julie Patterson was also undoubtedly aware of the contribution the hospitals staffing protocols and practices had made leading up to the child’s death. Given this fact questions now need to be asked around the safety of Whanganui Hospital, in particular the level of care afforded it’s staff and just as importantly it’s patients.

Health Board Budget Witnesses Huge Pressure Despite Curbs

A recent assessment made by Whanganui District Health Board Chief Executive, Julie Patterson has revealed that Wanganui’s health board budget is still under high pressure despite introducing severe cuts on its spending.

The assessment report was unleashed at the board’s latest meeting.

Managers have been in plans to introduce a management overhaul, seeking to extend staffing cuts across most of the sections of board’s operation, including some frontline staff.

Such efforts reflect a saving of over $1 million; however, it would immediately initiate mirroring in the board’s financial statements, claimed David Woltman, corporate services general manager.

Mr. Woltman said the process would also affect the mental health division. Changes expected there “would bring us closer in line with our budget”.

But, fall in financial position in highly expected before it starts improving, Mrs Patterson. cited. “We’re not going to see the full impact for another couple of months then we’ve got another six months to pull things back”, she added.

Board Chairwoman, Kate Joblin has claimed that they could not be successful in incurring the savings they sought to get from nursing component alone.

The board is slated to present its financial forecast to the Ministry of Health by October 12.

Source; top news.co.nz

If a loving mother can be so exhausted that it caused her to forget about the location of her own child, resulting in that childs tragic death what then does this say about the additional and quite obvious risks posed to the hospitals patients welfare in a life and death critical environment? The police have been reluctant to disclose the circumstance behind their decision to prosecute but the criminal informations police filed contained the following:

 “omitted without lawful excuse to perform her legal duty to provide that child with necessaries, thereby bringing the death of the child in circumstances where her omission was a major departure from the standard of care expected of a reasonable person to whom that legal duty applied”

This discription could eqaully fit the hospital managements actions leading up to the defendants alleged failures. Have police or crown prosecutor even bothered to look at the hospitals possible culpability in this matter? After all, as aforesaid, it seems to us that there is a good argument for a formal investigation into the hospitals own practices in light of what appears to be an ongoing financial problems and the posibility of dangerous short cuts being taken. For example does Whanganui hospital operate a fatigue risk management system as is the case in most advanced critcal health care institutions. This particular Kiwi hospital has also failed to pass muster, copping serious criticism in past investigations;

Commissioner finds major failings at Whanganui hospital

Health and Disability Commissioner Ron Paterson says that when provincial hospitals face workforce shortages, appointment, supervision and quality control processes must be rigorous.

This follows Mr Paterson’s inquiry into the failed sterilisation of eight women treated at Wanganui Hospital in 2005 and 2006 by Dr Roman Hasil, a doctor from Slovakia.

Six of the women became pregnant despite having had tubal ligations performed by Dr Hasil. Most of the women had their pregnancies terminated.

In a report outlining what he calls “a sorry saga”, Mr Paterson censures the doctor and the Whanganui District Health Board for serious failings in the care of women at the hospital.

His findings include:

• Wanganui Hospital cut corners in the face of endemic workforce shortages
• Inadequate reference checking and credentialling resulted in the recruitment of Dr Hasil, who had a “chequered work and medical registration history” in Australia
• Dr Hasil and his supervisor worked demanding and unsustainable hours in a grossly understaffed department
• A failure to respond adequately to patient complaints and serious staff concerns about Dr Hasil’s competence and alcohol consumption allowed an unsafe situation to continue.

Mr Paterson says: “It is tempting to cut corners when faced with endemic workforce shortages. But a lack of care in appointing staff, and failure to identify problems and act decisively, results in unnecessary harm to all involved – to patients, to doctors and to public confidence in a local hospital.”

He says it is short-sighted for hospitals to struggle on with substandard arrangements in the hope that disaster will be averted and things will get better eventually.

“It may be better to bite the bullet and face potential community outrage if a service is closed rather than muddle on and cause long-term harm to community confidence and a DHB’s committed staff, when patients are harmed and the inevitable external inquiries follow.”

Mr Paterson says the report has national implications. Regional and national service planning is essential. He has again called for increased co-ordination and collaboration across district health boards to protect patient safety.

He says: “Greater coordination and collaboration across DHBs should not be left to serendipity nor should it be forced by a clinical failure or a rushed reaction to adverse publicity.”

The key findings and recommendations from the report are summarised in an executive summary. A copy of the Commissioner’s report is available here.

Source: Health and disability commission

Clearly there now needs to be a full investigation into the circumstances surrounding this case, the contributory factors that were beyond the courts reach in the criminal proceedings but well within the control of the hospital board, senior hospital management and the New Zealand police.

Afterall had this been the death of a hospital patient under the same or similar circumstances, resultant from dangerously fatigued staff, all hell would have broken loose, with the hospital being the focus of a great deal of public anger. In short, LF suspects that there was and remains the ability for police to have charged the hospital, a crown entity, with criminal negligence in this case.

There also now needs to be consideration given to the apparent inability, unwillingness or reluctance of hospital staff to self-report issues such as over chronic tiredness in life critical environments. Again this apparent “reluctance” on the part of staff, be it those creating the rosters or those required to work the obviously unreasonable hours, would indicate that Whanganui hospital has failed to secure anything close to best practice, in fact given the circumstances now accepted by the High Court as fact it would seem that Whanganui hospital has failed in its duty of care to the both the deceased child and the accused, remember this tragic death occured on hospital premises.

As for the CEO’s understanding of the polices actions. well that just speaks volumes around the hospitals desire to obfuscate on some of the more than obvious problems the hospital itself has. They have clearly failed in their duty of care to mitigate risk factors such as fatigue, problems which were in our view not only contributing elements in this childs death but very likely systemic and may well have been unreported contributing factors in the untimely deaths of hospital patients.

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