Korina Mullins in front of a photo of her parents Koro and Mavis Mullins. Her father died in a botched surgical procedure in Wellington Hospital in 2019. Photo / Warren Buckland
A coroner says a health authority investigation into a surgical mistake that caused the death of prominent shearing identity Koro Mullins “obfuscated the search for the truth” and “added to the trauma” of his whānau.
Mullins, from Dannevirke, died in Wellington Hospital on September 16, 2019, after a fatal injection of air into one of his arteries at the start of what was supposed to have been a routine stent procedure.
His Hastings-based daughter Korina, in the hours after her father’s death, questioned staff and received an admission that there had been a mistake and that a full investigation would follow.
But an inquest into the death in November and December last year heard that there wasn’t a “full investigation”, which annoyed deputy chief coroner Brigitte Windley.
In findings released publicly today, Windley says the manner in which the Capital & Coast DHB conducted itself throughout the investigation was “largely unhelpful, obfuscated the search for the truth and served only to add to the trauma they [the Mullins family] had already suffered”.
Korina told Hawke’s Bay Today the report made her fear that her father’s death was not a unique event in New Zealand and that there was the potential for medical procedure mistakes to be kept quiet to protect the interests of hospitals, health service providers and staff.
She said the whānau had consistent concerns about why there was cleaning or disposal of medical equipment after the fatal surgery, and why a foreign national among the surgical team was able to leave the country shortly afterwards without being interviewed.
Capital, Coast and Hutt Valley, now a division of Te Whatu Ora, acknowledged it “failed” Mullins and his whānau and that there were shortcomings in the review process into his death.
It said it had implemented several changes to ensure such an incident did not happen again.
In her 71-page report, Windley says what happened before and after Mullins’ death was “not an outcome that should ever sit easily with the medical professionals involved” and that, in addition to the family, it would continue to affect the theatre clinicians.
Windley noted her jurisdiction did not encompass “an examination of the manner in which the Capital & Coast DHB, its review panel and its clinicians engaged with the Mullins whānau following Koro’s death, in particular relation to the hospital’s systems analysis review process”.
Korina Mullins, a nurse who has recently moved into a new job involving privacy and legal issues in health, sparked in part by her experiences of the past four years, said she wondered what would have happened if she had not asked questions on the tragic afternoon in Wellington.
“We wouldn’t be here,” she said as she again pored over her folders of documents at her home in Hastings.
Expert evidence at the inquest said it was the first time such an event had occurred in the New Zealand health system.
Korina had a simple question for those experts: “How would we know?”
The events that led to Koro Mullins’ death began after he went to the Palmerston North Hospital emergency department on August 20, 2019, concerned about chest and back pains.
After a brief examination, he was sent home with relief for musculoskeletal back pain and referred to an accelerated diagnostic chest pain pathway (ADCPP). Given his profile as a male Māori aged over 65, he should have been given a more comprehensive analysis, including a follow-up with a cardiologist within 72 hours.
But that never happened and, in evidence at the inquest, expert witness and Christchurch clinician Dr David Smyth said that, in the MidCentral DHB, this analysis was “mythical”.
There was no follow-up and in the meantime Mullins travelled to Fiji with his wife Mavis for a presentation she was making at a conference.
He returned to the hospital on September 11, reporting intensified pain and a fall while working on the family dairy farm just east of Dannevirke.
He was diagnosed as having had a heart attack with damage to the heart muscle and was admitted to hospital. A stent procedure was scheduled in Wellington five days later.
Smyth noted at the inquest that many others presenting in similar circumstances in the scope of MidCentral Health had died without even that opportunity.
An audit he recommended found that, while the pathway was supposed to include the follow-up within 72 hours, the average patient wait for those presenting at Palmerston North Hospital was 129.6 days, and that 38 people had died while waiting for follow-ups that never happened.
He said the death or severe adverse event rate for those referred to the ADCPP at Palmerston North was 6.77 per cent, compared with just 0.5 per cent at Christchurch, and that such a difference “should not occur”.
Windley’s report says there was “inadequate” assessment at Palmerston North Hospital’s emergency department, there was “inadequate” resourcing of Mid Central DHB’s outpatient cardiac investigations, and “iatrogenic/human error” in the theatre in Wellington. “Iatrogenic” refers to any illness caused by medical examination or treatment.
The names of clinicians involved are subject to interim non-publication orders.
Windley said: “I find, on balance, that multiple failures caused or contributed to Koro’s death.”
She then specified:
(a) Inadequate assessment and characterisation of Koro’s presenting complaint and history by (Dr M) together with communication between (Dr M and Dr A) about Koro’s recent medical history. Those inadequacies meant that the significance of Koro’s history of recent chest pain and near-syncopal episode was not fully recognised and factored into the clinical decision-making at the time of Koro’s first presentation to ED on 20 August, 2019, in particular the decision to discharge him home.
(b) Inadequate resourcing (as at August 2019) of urgent outpatient cardiac investigations by MidCentral DHB which meant that, following discharge, Koro’s underlying cardiac condition was not investigated in a timely manner, which led to a consequent failure to initiate the appropriate treatment to reduce the chances of a subsequent acute coronary event, which eventuated three weeks later. That in turn compromised, at least to some degree, Koro’s cardiac resilience to the air embolism complication which eventuated in the PCI procedure, albeit the evidence suggests the volume of the air embolism was such that, even without that recent compromise, it was likely to have been fatal to Koro, and
(c) Iatrogenic/human error by (Dr Z) and or (Ms M) in the performance of the PCI procedure techniques and/or visual checks relied upon to mitigate the risk and detect any air in the tubing connected to the automated contrast injector, as a result of which a significant air embolism entered Koro’s arteries and rapidly resulted in his cardiac arrest and, despite resuscitative efforts, his death.
The Mullins family had developed a global reputation in the shearing industry, as employers in the shearing contracting enterprise Paewai Mullins in the Tararua district, as well as in shearing sports.
Koro Mullins, originally from Rotorua, was described as a strong, physical man. In a lengthy shearing career was 6th in the 1993 Golden Shears Open final, won by shearing legend Sir David Fagan, and went on to become an internationally recognised competitions arena commentator.
Mavis Mullins won the Golden Shears Open woolhandling final in 1987 and 1993 and became a woolhandling competitions judge, the first female president of the Golden Shears International Shearing Championships Society, a top businesswoman at the board table with induction to the New Zealand Business Hall of fame, and the first woman on the board of the Hawke’s Bay Rugby Union, of which she is now president.
While Korina Mullins veered away from a career in the shearing industry, her sister Aria and brothers Tuma and Punga all had winning careers in shearing or woolhandling competition, with Tuma now in a senior arena commentating role and Aria running the shearing contracting.
Korina told Hawke’s Bay Today she wondered whether “people will be thinking we’re all psychos” for raising so much concern about her father’s death.
She said she did not want “heads on sticks” or compensation. Instead, the whānau wanted accountability and, most of all, change that would mean “this does not happen to anyone else”.
Coroner Windley said that, at the inquest, the whānau “expressly recognised the effort of the clinicians to be present ‘kanohi ki te kanohi’ at the inquest opening, where Mavis Mullins spoke of the symbolism of the kawakawa and olive branches that were brought to the inquest as representations of strength and fortitude and coming to the inquiry in peace, with respect, and in looking for solutions to make our community a better place”.
“I am hopeful that those who had a role in the review process, and more importantly Te Whatu Ora, in an organisational sense, have reflected on the approach taken in this case, and have identified measures to engage early, honestly and constructively with whanau who lose a loved one in circumstances where iatrogenic error is at least implicated.”
Capital & Coast and MidCentral were among 21 district health boards established on January 1, 2001. They ceased to operate at the end of June last year with the establishment of national agency Te Whatu Ora.
The care of Koro Mullins began with his presentation on August 20, 2019, at Palmerston North, which was under the management of the MidCentral DHB, and ended with his death soon after entering theatre less than a month later, on September 16, at Wellington Hospital, which was under the management of the Capital & Coast.
At the start of a percutaneous coronary intervention process (PCI), otherwise known as stent replacement, oxygen was inadvertently introduced intravenously to his blood system, causing death by iatrogenic embolism.
Te Whatu Ora central region director Russell Simpson said: “On behalf of Te Whatu Ora – Health New Zealand I would like to take this opportunity to apologise further to Mr Mullins’ whānau for his death and for the subsequent pain and suffering they have experienced.
“While we recognise how distressing it can be to lose a loved one in difficult circumstances, we cannot begin to imagine the mamae [pain] and pāpōuri [grief] they have gone through – and continue to go through – as a result of this tragic outcome.
“No harm or distress to a patient under our care, or to their whānau, is acceptable. We take patient safety and whānau support extremely seriously and acknowledge that we failed the patient and whānau in this instance.
“We recognise that we could have done better for Mr Mullins’ whānau in the wake of this death and there were shortcomings in the review process undertaken at that time.”
Capital, Coast and Hutt Valley
Simpson continued: “Since this tragic event, Capital, Coast and Hutt Valley has implemented a number of changes to ensure that such an incident does not happen again.
“Wellington Regional Hospital has implemented a new three-person stop-check process step in percutaneous coronary intervention procedures. This will help mitigate the risk of an air embolism complication and has been named after Mr Mullins with his whānau’s endorsement.
“We have also purchased and installed new contrast injectors which avoid the need for extra connections. The contrast injectors have an automated air detection system that reduces the risk of air embolism.
“CHV is also proposing to include explicit reference to the circumstances of Mr Mullins’ death in the protocols required when using the new contrast injectors.”
MidCentral
The former MidCentral DHB is now Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral. It had accepted and would implement the coroner’s recommendations, Simpson said.
“Implementation of the recommendations will support the identification of issues within clinical pathways, enable patients to make informed decisions to explore alternative treatment providers if they wish and ensure that both junior doctors and SMOs are reminded of the importance of information from primary care in informing clinical decisions.
“MidCentral continues to strengthen the cardiology services with its Spire (surgical procedural interventional recovery expansion) project. This includes a cardiac catheter lab to provide a local interventional cardiology service.
“Two interventional cardiologists have been recruited and other staff recruitment is underway. This will improve access to these services for the wider region.
“Across Aotearoa, Te Whatu Ora – Health New Zealand continues to look at all our services to understand what works well and what can be done better. We remain committed to delivering safe care and support for the patients, whānau, and communities we serve.”
Hawke’s Bay
Hawke’s Bay health authorities were not involved or implicated in the circumstances of Mullins’ death, but Hawke’s Bay Today asked Te Whatu Ora Te Matau a Maui Hawke’s Bay for information about its procedures.
Chief medical and dental officer Dr Robin Whyman replied that Hawke’s Bay Hospital had an ADCPP in place in 2019.
Best practice guidelines were routinely reviewed and updated, and best practice updates to the ADCPP were “going live” in January this year.
Patients with risk factors and chest pain are triaged to the front of the queue with an assessment, ECG and care commenced within 10 minutes of arrival, in line with the Australasian Triage Scale prescribed by the Australasian College of Emergency Medicine.
The Ministry of Health audits emergency department triage guidelines across all presentations (the status of the patients’ triage score and the time to care).
Additionally, the Ministry of Health and the Health Quality Safety Commission support and provide guidance toward quality improvement and faster care across specialities.
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