Director of Proceedings v Health New Zealand [2025] NZHRRT 10 (6 March 2025)
The Director of Proceedings filed proceedings by consent against Health New Zealand (“Health NZ”) | Te Whatu Ora (Capital, Coast and Hutt Valley) (formerly the Capital and Coast District Health Board)) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to Mrs A by numerous staff across Wellington Hospital (“the hospital”).
Mrs A was seen by a general practitioner (“GP”) at an urgent care centre after experiencing vomiting bouts and diarrhea, accompanied by a fever, no appetite, severe muscle aches and pain across her lower back.
The GP discussed Mrs A’s presentation with the on-call medical consultant at the hospital, began her on intravenous (IV) fluids, and called an ambulance to take her to the hospital emergency department.
Mrs A was admitted to the Medical Assessment and Planning Unit (“MAPU”). A medical registrar responsible for triaging reviewed Mrs A’s notes and mistakenly believed she had already received antibiotics before her arrival. Consequently, Mrs A was triaged for review after other unwell patients.
An evening shift nurse reviewed Mrs A, took a full set of vital signs, and calculated her Early Warning Score (“EWS”). Mrs A had a fever, fast heart rate, and a low systolic blood pressure (“BP”). The low systolic BP was in the EWS ‘red zone’ which indicated she was likely to deteriorate rapidly. The mandatory escalation pathway required a review by a registrar for any vital signs in the red zone, as well as consideration for referral to the Intensive Care Unit (“ICU”). The evening shift nurse advised a house officer of Mrs A's vitals but did not specify that her BP was in the red zone.
That evening, Mrs A’s BP and temperature were taken however a full set of observations were not. Although Mrs A’s BP had improved slightly, it was still low and considered in the ‘orange zone’. According to the mandatory escalation pathway, any vital sign in the orange zone mandated a house officer review within 60 minutes, and increased frequency of vital sign monitoring. Neither of these actions occurred.
Later that night, Mrs A’s blood test results indicated she may have had an infection. Following receipt of the blood test results, the medical registrar marked Mrs A to be reviewed next and allocated her medical assessment to the house officer. The medical registrar incorrectly relayed to the house officer that Mrs A had already received antibiotics and asked them to undertake a septic screen for suspected gastroenteritis.
Between approximately 9.00 pm and 9.30pm, the house officer began their review of Mrs A. This was the first review of Mrs A by a doctor since her arrival at the hospital, three hours earlier. Mrs A’s systolic BP was once again within the ‘red zone’.
The house officer then discussed the blood test results and examination findings with the medical registrar. The medical registrar directed the house officer to send urine, stool and blood cultures, to add full liver function tests, and to repeat the blood tests in the morning.
The medical registrar then reviewed Mrs A from the end of the bed, noting that Mrs A’s fever had gone but her systolic BP was still low. The medical registrar discussed Mrs A with the on-call medical consultant, who directed the medical registrar to begin treatment with IV cefuroxime and increase fluids. This conversation was not recorded.
The medical registrar then undertook handover to the incoming night shift medical registrar. The medical registrar and the house officer differed in their recollection of the conversation that occurred at handover. The medical registrar recalled that they relayed to the house officer that the on-call medical consultant was concerned about sepsis and IV cefuroxime was to be given overnight. Believing (incorrectly) that Mrs A had already had a dose of cefuroxime earlier in the night, the medical registrar asked the house officer to continue this.
The house officer did not recall being asked to give Mrs A antibiotics. Due to the miscommunication, Mrs A was only prescribed IV fluids and anti-anxiety and anti-nausea medication.
At 12.00am, Mrs A was transferred to the general medical ward. Mrs A’s vital signs were both in the ‘red zone’. Under the escalation pathway, this mandated a review by a registrar and consideration of referral to the ICU. Neither action occurred.
At 1.40am it was discovered that Mrs A had not yet been prescribed or administered any IV antibiotics. She was then given intravenous cefuroxime immediately as well as supplementary oxygen.
Despite these interventions, Mrs A became unresponsive and CPR commenced immediately. Cardiac monitoring showed that Mrs A had suffered a cardiac arrest. After an hour of resuscitation attempts, Mrs A was unable to be revived, and the decision was made to cease CPR.
Sadly, Mrs A passed away shortly afterwards at 3.30am. The cause of death was cardiac arrest secondary to meningococcal septicemia which was confirmed by Mrs A’s blood culture results.
Independent advice provided to the Health and Disability Commissioner advised that the care provided to Mrs A was not reasonable in the circumstances. The advisers noted that multiple existing guidelines and policies were not adhered to, and individual decision making was often not ideal, while poor communication and handover sought to reinforce earlier errors.
Health NZ undertook a Systems Analysis Review into Mrs A’s death. They identified multiple issues including the failure to recognise and respond to sepsis earlier, the failure to escalate Mrs A’s condition to the registrar or for an ICU review when her BP was concerningly low, and the lack of a sepsis pathway in MAPU.
Health NZ accepted that its failings breached the Code of Health and Disability Services Consumer’s Rights (“the Code”). The Tribunal was satisfied that Health NZ failed in the care provided to Mrs A and issued a declaration that it breached Rights 4(1) and 4(5) of the Code.
The Tribunal’s full decision can be found at:
2025-NZHRRT-10-Director-of-Proceedings-v-Health-New-Zealand-Redacted.pdf