KEY POINTS:
The family of Folole Muliaga have not ruled out taking legal action against Mercury Energy and Counties Manukau Health Board after a report concluding a power cut that stopped oxygen therapy contributed to her death.
Mrs Muliaga, 44, was receiving oxygen at her Mangere home when the power was cut on May 29 last year because of unpaid bills.
Olinda Woodroffe, lawyer for Mrs Muliaga's husband, Lopaavea Muliaga, told the Herald she invited the two organisations to talk to the family about a "fair and reasonable monetary settlement".
"I think there are strong legal grounds for compensation," she said.
Family spokesman Brenden Sheehan agreed, but also said Mrs Muliaga's children and husband were trying to get on with their lives.
"They're pleased they've finally been given some answers, but it's disappointing that some simple procedures weren't followed.
"Her death was quite preventable."
Mr Sheehan said the family would have made different arrangements if they had known how sick Mrs Muliaga was.
"Not to know the nature of her condition is frightening."
Ms Woodroffe said Mr Muliaga always believed that cutting the power contributed to his wife's death.
In his report, Coroner Gordon Matenga said he agreed with the testimony of two of the four doctors who gave evidence during the inquest that the disconnection of power to Mrs Muliaga's oxygen supply contributed to her death from morbid obesity.
"The contribution of the cessation of oxygen therapy and therefore the effects of the power being disconnected cannot be ignored or set to one side," Mr Matenga said.
He accepted that the stress of the power being cut also contributed to her death.
The report said Mercury Energy acknowledged it was not fully compliant with guidelines that identified vulnerable customers, but had made changes since Mrs Muliaga's death.
Mr Muliaga rang the company and told them his wife, who was the account holder, was in hospital and tried to arrange part payment of the outstanding bill.
Mr Muliaga did not advise the call centre of the nature of his wife's illness, but the call taker at Mercury Energy also never made inquiries about it.
Mr Matenga said this highlighted a failure in Mercury Energy's systems.
But he went on to say power disconnection was not foreign to the couple and they were aware of the "ramifications" if their bills went unpaid.
The contractor, who has name suppression, was widely blamed immediately after Mrs Muliaga died for being uncaring in cutting off the power and even received death threats.
But he escaped blame in yesterday's findings.
Mr Matenga said that although the contractor must have walked over the oxygen machine's tubing on the floor it was accepted he did not notice it.
The coroner said his impression of the contractor was that he was open, honest, frank and careful in giving evidence.
He was not seeking to "embellish or justify himself" and his evidence was credible.
The contractor's failure to ask if Mrs Muliaga needed the oxygen was balanced against her and her son's failure to advise she needed it, he said.
Mr Matenga said Counties Manukau health board staff did not follow board policy when it was decided to make a non-resuscitation order on Mrs Muliaga. No plan of care was recorded, and the order was not discussed with her family.
"That is not good enough."
The report said it was not certain Mrs Muliaga's family were fully informed about the seriousness of her health and her care requirements.
Mr Matenga recommended the board make discharge letters more informative on these issues.
"I am happy that the changes made at Mercury Energy are appropriate, that staff have been adequately trained and, in the end, will go a long way towards avoiding similar deaths in the future," he said.
Mr Muliaga told One News last night that the coroner's finding brought some closure.
"It's a good answer for me and my kids. That's why I am very happy."
He said his family were still grieving but also starting to move on with their lives.
THE CORONER'S FINDINGS
MERCURY ENERGY
* Was not fully compliant with guidelines. The company did not provide customers with information that could assist "vulnerable" customers who couldn't pay their bills.
* A call taker at Mercury's call centre told Mr Muliaga she could not discuss his account because Mrs Muliaga was the account holder - even though Mr Muliaga said she was in hospital.
"This should have been sufficient to the call taker ... to refer the call to her credit manager for further inquiry."
* "In light of the Electricity Commission Guidelines which were in force at this time this highlights a failure in Mercury Energy's systems."
THE CONTRACTOR
Known only as Mr A, he has permanent name suppression.
* Coroner accepts the contractor did not notice the tube on the ground even though he must have walked over it.
* His impression of the contractor was that he was open, honest and frank in giving his evidence.
COUNTIES MANUKAU DHB
* Staff did not follow own policy when decision about Mrs Muliaga's non-resuscitation order was made.
* A decision was recorded on clinical records but no plan of care was noted.
* No informed discussion took place with Mrs Muliaga or her family.
* "The hospital could have done much better to improve it's communication with Mrs Muliaga."
THE MULIAGA FAMILY
* The children did not understand, or fully understand the extent of their mother's illness.
* The coroner was satisfied the family struggled with their finances.
* Power being disconnected was not "foreign" to Mr or Mrs Muliaga and they were "acutely aware" of the ramifications of allowing the power bill to go into arrears.