Delays, missed treatment opportunities in boy's death at Wellington Hospital ED, review finds
Tuesday, 30 June 2026
Pre-schooler Sebby Chua died of probable sepsis in Wellington Hospital’s emergency department after “significant delays” in diagnostic tests and missed opportunities for potentially life-saving treatment, a review has found.
Four-year-old Sebby died eight hours after arriving at ED at 11am on September 26, 2022, groaning in pain, in distress with swollen limbs and reduced, dark urine. The sepsis that likely killed him went undiagnosed for more than five hours.
Sepsis happens when the immune system goes into overdrive trying to fight infection, and instead damages the body’s own tissues and organs. If caught early, it can be treated with antibiotics, but if undiagnosed it can rapidly progress to organ failure and death.
By the time Sebby’s risk was identified, and antibiotics given, his body was so overwhelmed, he could not be saved.
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The serious event review into Sebby’s death, obtained under the Official Information Act, found “significant delays” in obtaining a blood sample which could have identified the Group A streptococcus bacteria causing the fatal infection, and “potential opportunities for treatment missed”.
“If Sebby’s blood results had been obtained earlier it may have triggered earlier antibiotic treatment,” the reviewers found.
While the reviewers could not say whether earlier antibiotics would have saved Sebby, the hospital apologised for the testing delays and failure to suspect sepsis. They also apologised for not taking Sebby’s parents’ concerns seriously enough, and for shutting Sebby’s father Arvin out of the ED because of a one-parent visitor policy.
“We are deeply apologetic that we did not diagnose Sebby’s condition and for the tremendous ongoing grief and distress this has caused you and your family,” the hospital wrote.
The review also revealed that, despite mandatory reporting requirements for unexpected patient harm, Sebby’s death was not reported or investigated until after his father lodged a complaint more than a week later.
With new research showing sepsis-related hospitalisations spiked 78% from 2000 to 2019, the Sepsis Trust has called for doctors and the public to be more aware of the condition.
The review into Sebby’s death catalogued a timeline of missed opportunities to diagnose sepsis, and give potentially life-saving antibiotics.
He had been treated four days earlier at Kenepuru Accident and Medical Clinic for fever, a cough and racing heart. The doctor there did not swab his throat for Group A streptococcus, which causes 15-30% of child sore throats, instead concluding the cause was viral. The reviewers found that diagnosis was reasonable.
At Wellington ED, Sebby’s diagnosis was complicated by his pain and distress, and the fact he had tested positive for Covid two days earlier.
Because the doctors did not suspect sepsis ‒ and therefore did not consider Sebby’s condition urgent ‒ they put off a planned blood test until they could reduce his pain.
However, Sebby deteriorated through the day, and by the time a blood sample was taken, and the results were reported at 5.17pm, his heart and breathing were so laboured he was already at risk of death.
While antibiotics were eventually given at 6.07pm, they could not save Sebby. He died at 7.25pm.
Wellington Hospital said it had completed all the review recommendations, which included presenting the report to a new sepsis management working group, training paediatric registrars in “recognition of unwell child and difficult IV access techniques” and updating the visitor policy to allow more than one parent to support a child in ED.
Asked why Sebby’s death was not reported or investigated until after his father complained, Health NZ failed to respond by deadline.
Infectious disease specialist and Sepsis Trust co-founder Paul Huggan said with rising sepsis rates, the condition needed greater focus, investment and research.
While new national screening tools should help doctors spot sepsis red flags, Huggan advocated for a funded awareness campaign to boost public understanding.
He also called for action to prevent infections that lead to sepsis, which are often linked to poverty, poor access to GPs and dentists, and health inequalities. That included mouth infections after people tried to pull their own teeth.
“We can do what we can in the healthcare system to treat sepsis, but if there's nothing done upstream to reduce the risk factors that lead to it, then we will be seeing people coming to harm.
“On a human level, it's extremely distressing, particularly when it's something that could easily be prevented … Those are the cases that make you hug your children a bit closer in the evening.”