Director of Proceedings v Health New Zealand [2025] NZHRRT 15
(13 May 2025)
The Director of Proceedings filed proceedings by consent against Health New Zealand | Te Whatu Ora (“Health NZ”) (formerly Taranaki District Health Board (“TDHB”)) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to Mrs A.
On 15 February 2019, Mrs A presented to Hawera Emergency Department (“Hawera ED”) with suspected kidney stones. She was transferred by ambulance to Taranaki Base Emergency Department (“Base ED”) for further investigation and treatment. A CT scan confirmed an obstructing kidney stone which was blocking the part of the ureter that drained to the bladder. Mrs A was admitted to the General Surgery ward.
On 16 February 2019, Mrs A underwent surgery to place a left ureteric stent to bypass the blockage. A referral was then made to the Taranaki Base Hospital booking office for a follow up lithotripsy to break up the kidney stones. The referral priority was “routine” which meant that the timeframe for surgery was to be within four weeks. Mrs A was discharged from Taranaki Base Hospital on 18 February 2019. Her place on the elective surgery waitlist was confirmed on 19 February 2019.
On 24 April 2019, Mrs A’s general practitioner (“GP”) sent an urgent urology referral to TDHB as Mrs A had not yet received a date for her surgery, despite it being almost 10 weeks since her stent placement.
On 26 April 2019, Mrs A presented at Hawera ED with abdominal pain and was admitted overnight for pain relief. She was discharged the following day with an appointment at the urology clinic on 1 May 2019. The lithotripsy had not been scheduled due to capacity issues.
On 1 May 2019, Mrs A was reviewed by the surgical registrar at the urology clinic. They noted that Mrs A was having significant pain and irritation with her stent. She was advised that the stent had to remain at this stage, as she had an infected stone and taking the stent out would cause further problems. The surgical registrar emailed the booking clerk to expedite the date for surgery.
A week later, Mrs A presented at Hawera ED with abdominal pain. She was admitted overnight, given pain relief, and was discharged the next day.
On 13 May 2019, Mrs A presented at Base ED with abdominal pain, stinging on urination, nausea, and hot/cold sweats. She was admitted under the urology team and given pain relief. The severity of her illness at this time prompted a diagnostic investigation which indicated the need for acute surgery.
On 14 May 2019, Mrs A underwent the lithotripsy. Her ureter was very inflamed, multiple stones were found and fragmented, and the stent was also replaced.
After the surgery, Mrs A was cared for by the urology team. She was monitored using an Early Warning Score (“EWS”). At 4.15pm, a house officer reviewed Mrs A, after nurses raised concerns about her pain level. The house officer identified (among other things) early sepsis as a possible diagnosis, however no blood cultures were taken. The house officer confirmed with the urology registrar that they would continue to provide Mrs A with pain relief and would notify the night house surgeon if Mrs A's pain became unmanageable.
Mrs A was reviewed at 4.40pm and 4.50pm. At both reviews, Mrs A’s EWS was calculated as 10 as per TDHB’s EWS Mandatory Escalation Pathway (“EWS Pathway”) which indicated an “immediately life-threatening critical illness” and mandated that a 777 or “pre-arrest” call should be made. This was not done.
At 5.05pm, the house officer reviewed Mrs A again. Her EWS was at 8 and 9 (at 5.00pm and 5.15pm, respectively). As per the EWS Pathway, the requirement for an EWS of 8–9 was for a registrar to undertake a review within 20 minutes and for the ICU outreach team to be informed. The house officer contacted a locum urology registrar who advised them to take the aggrieved person’s bloods, give pain relief, and that they would review Mrs A later. The ICU outreach team was not contacted.
At 6.20pm an on-call surgical house officer reviewed Mrs A. They noted that despite regular doses of morphine, Mrs A’s pain levels continued to increase. She was then given fentanyl and the surgical house officer planned to review her again in an hour.
At 6.45pm, Mrs A had an EWS of 8. The EWS Pathway was not followed: neither a registrar nor the ICU outreach team were called. Instead, the surgical house officer reviewed Mrs A and noted that her blood pressure (“BP”) had improved, her pain was controlled, and she no longer required supplemental oxygen.
Between 8.50pm and 10.30pm, Mrs A’s observations were taken every 15 minutes and her EWS stayed around 7. At 10.30pm, Mrs A’s heart rate increased, and she required two litres of oxygen to achieve a normal oxygen saturation level. A nurse asked the surgical house officer whether Mrs A should be considered for the High Dependency Unit (“HDU”). This was declined by the surgical house officer on the basis that Mrs A's EWS was 5. However, the surgical house officer noted that Mrs A was confused and incoherent, with no objective power in her left upper and lower limbs. They contacted the on-call medical registrar who advised that an urgent CT scan be completed.
Shortly after 10.30pm, it was observed that Mrs A had a raised temperature of 38.5 degrees and her EWS was 9. For the third time, the EWS Pathway was not followed.
At 11.30pm, Mrs A had a sudden drop in systolic BP. This put her in the “blue zone” and a 777 call was placed. The medical registrar responded to the call, reviewed Mrs A, planned to manage her symptoms as sepsis, and transferred her to the HDU.
In the HDU, the anaesthetic registrar determined that as Mrs A was still early in her fluid resuscitation, she should be resuscitated with IV fluids first. If her BP remained low, she would be reviewed again. They requested ongoing BP monitoring and a phenylephrine infusion be initiated. Initially Mrs A improved, however her diastolic BP was not responding well and the results of an arterial blood gas sample showed the development of a mild metabolic acidosis. At approximately 3.30am, the anaesthetic registrar contacted the ICU senior medical officer who advised them to insert a central line and start a noradrenaline infusion. This was completed before 5.00am.
On 16 May 2019, Mrs A’s blood cultures were returned, with a diagnosis of fungaemia (the presence of fungi or yeasts in the blood). Initially, Mrs A was treated with antifungal medication, and she was sedated, incubated, and ventilated. Mrs A continued to deteriorate and, sadly, died in hospital on 9 June 2019.
Independent expert advice was provided to HDC from a consultant urological surgeon and an ICU Clinical Nurse Specialist. They noted the length of time Mrs A had to wait for her lithotripsy was far beyond the 4 weeks scheduled and beyond a reasonable tolerance of 8 weeks. They also noted the missed opportunities to trigger escalation to the ICU despite Mrs A having an EWS of 10 as early as 4.40pm.
They also stated that there was confusion among staff regarding who was meant to place the 777 calls and a lack of awareness as to when the call was necessary. Overall, they advised that the lack of EWS escalation and failure to follow the policy in this case was a significant deviation from the standard of care and the fault of all team members involved.
Health NZ accepted that it failed to provide services to Mrs A with reasonable care and skill and, accordingly, breached Right 4(1) of the Code.
The Tribunal’s full decision can be found at:
2025-NZHRRT-15-Director-of-Proceedings-v-Health-New-Zealand-REDACTED.pdf.