Health New Zealand has apologised and says it's a top priority to make sure a case of mistaken identity never happens again.
Police mistook an 11-year-old for a distressed woman in her 20s - and she was restrained and given drugs meant for adults at a Waikato mental health facility.
Chief clinical officer Richard Sullivan says it's clear human error was a factor - and they need to learn from this.
"What's clear here is - our staff were doing everything in good faith, working hard, there's no doubt some human error occurred here. But we just need to learn from that."
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Episode Transcript
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Speaker 1 (00:00):
Health Inded's report into this case of mistaken identity is
out today. This is the eleven year old autistic girl
who was mistaken for a twenty year old woman somehow.
Doctor Richard Sullivan is Healthing deed's chief Medical officeries with
me this evening. Hello, Hi Ryan, Yeah, good, thank you.
So does anyone get fired over this or want?
Speaker 2 (00:22):
Ryan? So, look, you know, this has obviously been a
very event that just should never happen our health system.
And as you're probably read, we've done to full reports
on that, one around the event and one around the escalation.
And I think what's clear here is that our staff
we're doing everything in that faith. We're working hard. There's
(00:45):
no doubt there's some human error curred here, but we
just need to learn from that. Related to the escalation,
you'll see one of the best advice in that recommendation
is to look into an HR process to see what
you know, what shall be undertaken and what further action
should be taken from that. But that's a piece of.
Speaker 1 (01:05):
Works, right, that's the fact that you didn't tell the
Minister's on time, right or in time?
Speaker 2 (01:09):
That's right?
Speaker 1 (01:10):
Okay, So coming back to this young girl, how do
you go from so staff she comes in staff saying, oh,
she doesn't she looks like a child, she doesn't look
like an adult, to then administering adult medications, anti psycholic
adult medications.
Speaker 2 (01:26):
Yeah. So the background of that, which again you're seeing
the report, is that, as you say, you know, the
police brought her in, she was in the ED initially,
and the staff team who are looking outter there, you know,
they's exactly as you've described. Within a short period of time.
Then the misidentification, if I put it that way, from
the best came through confirming it was as somebody else.
(01:50):
And so the team then, which was a different team
than the one that's seeing you earlier, then talked that
as the identification. There's no other means to identify you. Unfortunately,
again you'll see in the report, and that comes down
to some of the recommendations we've made. And so from
then on the team provided that, you know, with the
best information they had recognizing them that.
Speaker 1 (02:13):
Well, well you could argue the best information they had
was actually from the ED staff who said this is
a child.
Speaker 2 (02:19):
I don't think they said this as a child. I
think there was a Yeah, I was going to say
there was there was. There was no questions raised as
to you know, you have an undidentified patient in the ED.
The questions are raised as to who is this? And
there was as you say, commentary or type the child okay,
and that's I cares. That's what we call them out
of the fine.
Speaker 1 (02:37):
She refused the oral medication that she was off of,
this young girl, and then you injected her with meds
adult meds anyway? Is that common? I mean, can you
just inject anybody who does who refuses medication?
Speaker 2 (02:52):
So I'd probably look at it slightly differently. So this
they believed they were treating a patient who had significant
help billing, who was under the Mental Health Act, and
so they were providing care based on that patient's history,
and so they were delivering therapy that they would normally
deliver the patient so ill they thought she had.
Speaker 1 (03:13):
If you're under the Act, then that can be done.
But for your average Joe Blogs is not under the Act.
There's no way that you could walk into to a
hospital and be injected with something you didn't want to
be injected with. Right, So it was the mistaken identity
that led to the injection. Indeed, okay, what was she
doing that required anti muscular drugs.
Speaker 2 (03:36):
So she was one of the challenges with you know,
how people present through to our health systems is that
different people, as different illness can come in the next
other situations. So her symptoms were mimicking, you know, what
you would see with somebody who had an underlying mental
health illness. And so you know, again the staff, based
on what they knew, you know, with bus information, they
(03:59):
had treating her with somebody who they believe had the
mental help illness, who, as you're seeing the report, had
a history of symptoms escalating, and so they were treating
with that leanings rather than knowing that it was somebody different.
Speaker 1 (04:12):
Can you give it to some plain language. What was
she doing like convulsing or punching or being angry? What?
Speaker 2 (04:17):
No, just just just just demonstrating, you know, symptoms of
somebody who you know could have an underlaying mental health illness.
Speaker 1 (04:25):
But what are the symptoms?
Speaker 2 (04:28):
I probably you wouldn't want to go into too much detail,
but you know, she was stressed, you know that when
you could imagine she was stressed because she was identified
as somebody that she wasn't, so that they were doing
that to kind of manage her in the environment.
Speaker 1 (04:42):
But what I guess what I mean, people will be
wondering how stressed was she, you know, like, was she aggressive,
was she violent? Was she throwing her hands around? Was
there a need for her to have anti muscular drugs?
Or do you just sedate people because they're under a
section and it's easier to do.
Speaker 2 (04:58):
Yeah, Look, I don't I don't from what I understand,
I don't believe she was what you've described. But as
I say that, I think that now the issue here
is that she was presented. They believe she was somebody else.
They were following their normal protocols and pathways when they're
providing that care, and as I said, I think that
you know, this is human era. The staff and good
(05:19):
faith were delivering care, and obviously it wasn't until later
that day when the police appropriately identified her that obviously
we discovered that the care she had had was not okay.
And I think that's really important to be clear. Ryan,
you know, it's not okay that this happened, and you know,
you know, we're going to do everything we can to
(05:39):
make sure this doesn't happen again in our system.
Speaker 1 (05:42):
All Right, I appreciate your time, doctor, Richard Sullivan, Chief
Medical Officer, Health and said, I should say, and a
lot of people are texting in where were the parents?
We don't know the answer. You know, the caregiver or
the parents to this young girl. We don't know the
answer to that. I don't know the answer to that
because I don't know who she is, because Health and
Said doesn't say because it's confident, private patient information, which
(06:03):
you can understand too. So I understand why people ask
the question. I've asked the question too, but I just
don't have the answer for you. For more from Heather
Duplessy Allen Drive, listen live to news talks it'd be
from four pm weekdays, or follow the podcast on iHeartRadio
Health Inded's report into this case of mistaken identity is
out today. This is the eleven year old autistic girl
who was mistaken for a twenty year old woman somehow.
Doctor Richard Sullivan is Healthing deed's chief Medical officeries with
me this evening. Hello, Hi Ryan, Yeah, good, thank you.
So does anyone get fired over this or want?
Speaker 2 (00:22):
Ryan? So, look, you know, this has obviously been a
very event that just should never happen our health system.
And as you're probably read, we've done to full reports
on that, one around the event and one around the escalation.
And I think what's clear here is that our staff
we're doing everything in that faith. We're working hard. There's
(00:45):
no doubt there's some human error curred here, but we
just need to learn from that. Related to the escalation,
you'll see one of the best advice in that recommendation
is to look into an HR process to see what
you know, what shall be undertaken and what further action
should be taken from that. But that's a piece of.
Speaker 1 (01:05):
Works, right, that's the fact that you didn't tell the
Minister's on time, right or in time?
Speaker 2 (01:09):
That's right?
Speaker 1 (01:10):
Okay, So coming back to this young girl, how do
you go from so staff she comes in staff saying, oh,
she doesn't she looks like a child, she doesn't look
like an adult, to then administering adult medications, anti psycholic
adult medications.
Speaker 2 (01:26):
Yeah. So the background of that, which again you're seeing
the report, is that, as you say, you know, the
police brought her in, she was in the ED initially,
and the staff team who are looking outter there, you know,
they's exactly as you've described. Within a short period of time.
Then the misidentification, if I put it that way, from
the best came through confirming it was as somebody else.
(01:50):
And so the team then, which was a different team
than the one that's seeing you earlier, then talked that
as the identification. There's no other means to identify you. Unfortunately,
again you'll see in the report, and that comes down
to some of the recommendations we've made. And so from
then on the team provided that, you know, with the
best information they had recognizing them that.
Speaker 1 (02:13):
Well, well you could argue the best information they had
was actually from the ED staff who said this is
a child.
Speaker 2 (02:19):
I don't think they said this as a child. I
think there was a Yeah, I was going to say
there was there was. There was no questions raised as
to you know, you have an undidentified patient in the ED.
The questions are raised as to who is this? And
there was as you say, commentary or type the child okay,
and that's I cares. That's what we call them out
of the fine.
Speaker 1 (02:37):
She refused the oral medication that she was off of,
this young girl, and then you injected her with meds
adult meds anyway? Is that common? I mean, can you
just inject anybody who does who refuses medication?
Speaker 2 (02:52):
So I'd probably look at it slightly differently. So this
they believed they were treating a patient who had significant
help billing, who was under the Mental Health Act, and
so they were providing care based on that patient's history,
and so they were delivering therapy that they would normally
deliver the patient so ill they thought she had.
Speaker 1 (03:13):
If you're under the Act, then that can be done.
But for your average Joe Blogs is not under the Act.
There's no way that you could walk into to a
hospital and be injected with something you didn't want to
be injected with. Right, So it was the mistaken identity
that led to the injection. Indeed, okay, what was she
doing that required anti muscular drugs.
Speaker 2 (03:36):
So she was one of the challenges with you know,
how people present through to our health systems is that
different people, as different illness can come in the next
other situations. So her symptoms were mimicking, you know, what
you would see with somebody who had an underlying mental
health illness. And so you know, again the staff, based
on what they knew, you know, with bus information, they
(03:59):
had treating her with somebody who they believe had the
mental help illness, who, as you're seeing the report, had
a history of symptoms escalating, and so they were treating
with that leanings rather than knowing that it was somebody different.
Speaker 1 (04:12):
Can you give it to some plain language. What was
she doing like convulsing or punching or being angry? What?
Speaker 2 (04:17):
No, just just just just demonstrating, you know, symptoms of
somebody who you know could have an underlaying mental health illness.
Speaker 1 (04:25):
But what are the symptoms?
Speaker 2 (04:28):
I probably you wouldn't want to go into too much detail,
but you know, she was stressed, you know that when
you could imagine she was stressed because she was identified
as somebody that she wasn't, so that they were doing
that to kind of manage her in the environment.
Speaker 1 (04:42):
But what I guess what I mean, people will be
wondering how stressed was she, you know, like, was she aggressive,
was she violent? Was she throwing her hands around? Was
there a need for her to have anti muscular drugs?
Or do you just sedate people because they're under a
section and it's easier to do.
Speaker 2 (04:58):
Yeah, Look, I don't I don't from what I understand,
I don't believe she was what you've described. But as
I say that, I think that now the issue here
is that she was presented. They believe she was somebody else.
They were following their normal protocols and pathways when they're
providing that care, and as I said, I think that
you know, this is human era. The staff and good
(05:19):
faith were delivering care, and obviously it wasn't until later
that day when the police appropriately identified her that obviously
we discovered that the care she had had was not okay.
And I think that's really important to be clear. Ryan,
you know, it's not okay that this happened, and you know,
you know, we're going to do everything we can to
(05:39):
make sure this doesn't happen again in our system.
Speaker 1 (05:42):
All Right, I appreciate your time, doctor, Richard Sullivan, Chief
Medical Officer, Health and said, I should say, and a
lot of people are texting in where were the parents?
We don't know the answer. You know, the caregiver or
the parents to this young girl. We don't know the
answer to that. I don't know the answer to that
because I don't know who she is, because Health and
Said doesn't say because it's confident, private patient information, which
(06:03):
you can understand too. So I understand why people ask
the question. I've asked the question too, but I just
don't have the answer for you. For more from Heather
Duplessy Allen Drive, listen live to news talks it'd be
from four pm weekdays, or follow the podcast on iHeartRadio
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