A baby too weak to suck from a bottle, with a high temperature and losing weight rapidly, was sent home three times by doctors in the two weeks before she died.
A New Zealand coroner has found that the last doctor who saw three-month-old Skylah Vaimalu should have sent her to hospital.
But he is powerless to make any recommendations against Dr Huu Hoai Nam Nguyen because Dr Nguyen is now practising in Australia.
Skylah died at her home in Arawhata Street, Porirua, on September 1, 2007. Wellington coroner Ian Smith's long-awaited findings into her death have just been released.
Born in May that year, the fourth daughter of Travilla Pupuke and Mosa Vaimalu, Skylah was a bubbly baby. "She was a very happy baby," her mother said yesterday.
Shortly after Skylah received her vaccination injections in August 2007 she developed flu-like symptoms. Ms Pupuke gave her Pamol but, by August 19, her cough had a high pitch and she had diarrhoea.
The next day she took Skylah to Waitangirua Health Centre, where the baby was diagnosed as having bronchiolitis and continued paracetamol was prescribed.
Later that afternoon, she developed a high temperature and was bleeding from the nose. Her mother took her to the emergency department at Kenepuru Hospital, but the doctor was not concerned, again diagnosing bronchiolitis.
In the following days, Skylah remained very sick and continued to lose weight. On August 29, Ms Pupuke again took her to Waitangirua Health Centre, where she was seen by locum Dr Nguyen. Skylah was dehydrated, had severe diarrhoea, was pale and losing weight.
Dr Nguyen again diagnosed bronchiolitis, prescribing Histafen. He told Ms Pupuke that, if Skylah would not take a bottle, she should feed her with a syringe. "Ms Pupuke felt that her concerns for her daughter's health were being ignored," Mr Smith says in his findings.
On August 31, the family continued to monitor Skylah and give her medication. By this time her breathing was heavy, her skin was pale and she had trouble sleeping.
At 1.45am on September 1, she was given formula with a syringe.
He is powerless to make any recommendations because Dr Nguyen is now practising in Australia
"Ms Pupuke was now exhausted and fell asleep but, when she awoke between 7.30am and 8am, she found her daughter deceased."
Pathologist Jane Zuccollo found Skylah lost 1.5kg in 10 days, from 7kg to 5.5kg. The coroner concluded she died from sudden unexpected death in infancy after suffering bronchopneumonia.
Wellington Hospital general and community paediatrician Nikki Blair completed a review of the medical care Skylah received. In a statement, she told the court that Skylah should have gone to hospital.
"Dr Blair was also critical of Dr Nguyen's suggestion of providing a syringe for feeding as being inadequate for a baby too weak to suck," Mr Smith said.
"Had Dr Nguyen still been practising in New Zealand, I would have recommended that he receive more formal training in paediatric medicine, but I understand that he now resides and practises in Australia."
Ms Pupuke, who has since also moved to Australia, said: "It's very hard to understand that Mr Nguyen, being the last doctor that saw her, did not admit her. I feel strongly that her health and wellbeing was not much of a concern for them. I do feel I've been let down – me and my family, but mostly my daughter."
The Medical Council issued Dr Nguyen with a certificate of good standing before he left, unaware of this case until contacted by The Dominion Post yesterday. Spokesman George Symmes said it would hold a complaints hearing next week.
Waitangirua Health Centre chairman Logan McLennan said there had been no concerns about Dr Nguyen's performance.