A little girl grew sicker and eventually needed to be hospitalised after two GPs overlooked urine tests that showed she had undiagnosed Type 1 diabetes.

Now the doctors have apologised to the family of the youngster for twice not checking the results that pointed to the potentially fatal and lifelong condition.

Their failures meant the 4-year-old girl’s diagnosis and management of the condition, when the body stops producing insulin, was delayed more than two weeks during which time she became more unwell, causing her parents severe stress.

When the diabetes was finally detected, the preschooler was rushed to hospital and needed five days of treatment before she was discharged.

Her father complained to the Health and Disability Commissioner (HDC) who found the two GPs in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable care and skill.

In a decision released today, Deputy Health and Disability Commissioner Dr Vanessa Caldwell also made an adverse comment against the medical centre involved, but did not find the triage nurses at fault.

The names of all involved and the location have been redacted from the decision.

The young girl, Miss A, was first taken to one of two clinics run by the medical centre on November 5, 2020, by her parents after she vomited and complained of abdominal pain.

A triage nurse performed a urine dipstick test which showed glucose (blood sugar) and high levels of ketone, chemicals made in the liver and produced when there is not enough of the hormone insulin.

Glucose, the body’s primary source of energy, and ketones are not usually found in urine and can indicate diabetes, the decision noted.

The nurse decided against a finger prick test for blood sugar levels and the urine findings were added to the girl’s medical notes to go to the GP. She triaged the patient as needing to see a doctor within two hours.

However, at the consultation the GP, identified as Dr C, overlooked the urine findings, diagnosing the girl as having vomiting symptoms and sending her home.

On November 18, Miss A was unwell at daycare and her parents took her to a second clinic run by the centre.

She complained of abdominal pain and had a body rash, was itchy all over, and weak, with her father describing her as being worse than before.

The triage nurse read the nurse’s notes from two weeks earlier and saw the urine test results but noticed Dr C had not made any reference to it.

The nurse told the HDC that together with the girl’s current symptoms and the earlier results she immediately thought of diabetes and did another urine dipstick test.

It showed the same results and she noted it for the GP, triaging the girl as needing to see a doctor within an hour.

A glucometer is used during a finger prick test to check blood sugar levels. Photo / NZME

She did not do a finger prick test because Miss A was crying and upset and said it wasn’t standard practice for nurses to give the results of tests ahead of the doctor’s consultation because it could alarm patients.

The nurse told the HDC the expectation and standard practice was that doctors would read all the triage notes and any test results as part of their consultation.

However, the second GP, Dr B, did not notice the urine test results and there was no mention of it in Dr C’s consultation.

He diagnosed the girl with an itchy skin rash from flea/insect bites, and nappy area redness and itching after her mother said the abdominal pain had resolved.

Both GPs said if they had seen the urine test results they would have followed it up.

Three days later the mother took her daughter back to Clinic 2 because she was not eating properly however the clinic was busy and closing early and the mother was directed to take the girl to Clinic 1 if the girl’s condition was not urgent.

The child was taken again to Clinic 1 the next morning where a third nurse noted a family history of diabetes and a third GP noticed the two earlier urine results.

He ordered a complete blood sugar test for Miss A which showed glucose “exceeding the limits”, and gave a likely diagnosis of Type 1 diabetes, recommending the family go straight to the emergency department at the public hospital.

Miss A was admitted and given intravenous fluids and insulin and discharged on November 27. She now requires insulin three times a day.

In her findings, Caldwell said the accepted practice was for a GP to review triage observations as part of a patient assessment.

“I am critical that both doctors overlooked the urine results during their appointments with the girl. In my view, the doctors’ omissions led to a delay in the girl being diagnosed with Type 1 diabetes.”

The deficiencies in the doctors’ care were individual clinical failures, she noted, however, she made an adverse comment about the company’s triage guidelines.

“I am concerned that the triage guidelines in place at the time were not sufficiently clear to guide nursing staff to appropriately respond to a child at risk,” Caldwell said.

“Nonetheless, guidelines should not replace clinical judgment and critical thinking. Regardless of the adequacy of the guidelines in place at the time, I am most concerned that two doctors at the centre failed to look at the urine test results, despite the results being available for their perusal.”

She recommended both doctors provide a written apology to the family for the breaches in care which had been done.

She also made a number of recommendations to the medical centre, including that it provide HDC updates regarding changes to triage resources and the effectiveness of those changes.

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.