Health reporter Martin Johnston talks to departing health and disability commissioner Ron Paterson about his efforts to lift medical and legal veils of secrecy
Among the heavyweight reports on death, misdiagnosis and mistreatment, Ron Paterson reaches for a small painting that symbolises what his job is all about.
The departing Health and Disability Commissioner was given the tapa cloth painting by the family of a Wellington man whose early evidence of lung cancer was not acted on by doctors, leaving him no hope of survival by the time the disease became more obvious.
Aged 68, Afano Sua had gone to Wellington Hospital with a bowel obstruction in 2004, a condition that resolved while he was there. A routine chest X-ray showed an abnormality on his right lung, but the finding was never reported to him nor to his GP. Surgery to remove the tumour may have been possible at the time.
Nearly three years later, he returned to the hospital with severe pneumonia. Terminal lung cancer was diagnosed and Sua died in 2008.
Paterson found that - like a number of other patients in the "hundreds" of investigations he has completed in his decade as commissioner - Sua "fell through the cracks" of the health system.
"To its credit, the [Capital and Coast] District Health Board had openly disclosed what had happened. They revealed to the family that this finding had been there but not reported and they and the hospital made important changes to its system for radiology reporting but also helped the family with its ACC claim.
"Very unusually, the family later presented me with a painting ... which meant a lot for me because, ultimately, the job is all about serving the people."
The gift was formalised at a farewell for Paterson at Parliament on Wednesday when it was re-presented by Sua's daughters, Temu Sua and Lesa Sue-Larsen. They said their family was honoured when Paterson visited their family's Porirua home in 2007 and was touched by his personal approach.
Says Paterson: "Inevitably you end up having a lot more contact with providers and professional groups because they are the ones you see. But you are there to be an impartial decision-maker and to speak up for the rights of consumers."
"Consumers" are the patients, the clients of health and disability services who are at the heart of all of his office's investigations, whether of complaints concerning individual health practitioners or the major inquiries like those into North Shore Hospital, Gisborne Hospital or the Southland District Health Board's mental health services.
A frequent critic of failings in New Zealand's public health system, yet also one of its staunch advocates, Paterson, 54, is widely credited with getting New Zealand's relatively new health commissioner system on track after it experienced problems in its first five years.
The commissioner's role - to protect patients' rights and resolve complaints - was created on the recommendation of the Cartwright inquiry into National Women's Hospital in the late 1980s.
Before the mid-1990s, complaints about doctors were handled in-house by their profession, a situation that persisted for dentists, nurses and other registered health workers until the early 2000s.
The first commissioner, Robyn Stent, was appointed by the Government in December 1994.
Paterson took over in 2000, after a career as a legal academic - to which he will return shortly, as professor of law at Auckland University - and a short stint at the Ministry of Health as the deputy director-general in charge of safety and regulation.
As commissioner, he landed in the developing cyclone of public discontent over the handling of health complaints, a storm stirred by the Gisborne inquiry into misreading of cervical smears by pathologist Dr Michael Bottrill and finally unleashed by the case against the Northland obstetrician and gynaecologist Dr Graham Parry.
A flood of complaints from aggrieved former patients engulfed Parry. They led to four more disciplinary cases and even a parliamentary inquiry. However, after a legal siege he was cleared of all disciplinary charges except the first, which was of disgraceful conduct in his mismanagement of Colleen Poutsma, who died of cervical cancer. This charge arose from a commissioner investigation.
Stent took more than 18 months to complete her investigation of Poutsma's complaint, lodged just as Stent was completing a major inquiry into Christchurch Hospital. When she announced she was stepping down as commissioner in 1999, the backlog of complaints stood at more than 500 and Stent complained of having too little help.
Early in his tenure, Paterson apologised to Poutsma for the "inexcusable" delay and made changes to ensure similar cases were dealt with urgently. In the years since, his annual reports have detailed the progress in clearing the backlog.
The latest report, last June, put the number of open files then at 274 and said 96 per cent of the around 1300 complaints received annually were closed within a year.
Doctors felt under attack from Stent and the media attention on medical misadventure after the opening of medical disciplinary hearings to the public in 1996.
Paterson has trod a careful line on the outing of errant health workers or services, grumping at times about "trial by media" prior to formal proceedings, yet widely circulating the findings of many of his investigations.
His reports, however, almost never name the individual parties - to protect the privacy of patients and their families, and to foster a culture of openness among health workers about mistakes so everyone can learn and avoid repetition.
"It is in everybody's interest that practitioners co-operate with complaint and investigations processes," Paterson says. "They are less likely to do so if the stakes are suddenly much higher [from facing the spotlight of publicity]."
But because many mistakes arise from faults embedded in hospital and health systems, he has taken to naming clinics, hospitals and DHBs he finds have breached the Code of Health and Disability Services Consumers' Rights.
He describes this as his attempt "to lift the veil of secrecy [from] the medico-legal system".
Dr Pippa MacKay, chairwoman of the Medical Association at the time of Paterson's appointment, recalls a marked improvement after he took over.
"He streamlined activities and caught a huge backlog of cases up.
"Ron has always treated doctors with fairness. Most of us have felt we can trust him. Some doctors found guilty are going to feel hard done by. I think he has made that organisation something that I think doctors can be reasonably comfortable they will get a fair hearing from, whereas before then, that wasn't the case.
"I think he's done a good job. Robyn Stent, to her credit, set up the organisation and put the code in place."
The association's current chairman, Dr Peter Foley, echoed MacKay's assessment of Paterson.
"I think he has been a good commissioner. He has tried to be open with the profession.
"All the involvement he's had dealing with complaints he's tried to make them learning exercises, which is really important as we move into more open disclosure of problems in the health sector. He helped to set the frame for that."
Foley is referring to the Health Ministry's league tables, ranking district health boards and primary health organisations on lists of health targets like immunisation rates - and DHBs' annual release of an outline of all their "serious and sentinel" medical mistakes.
Paterson says, "I have pushed the agenda of putting more information about the quality of healthcare before the public. From day one, I have said we needed to have better comparative information. I'm very pleased that that has come to pass."
He says the public have a right to the information and there is evidence that publishing it leads to services improving their performance.
But after 10 years in the job, does he see the same kinds of errors happening over and over again?
"Yes. That's why we started grouping decisions," he says, referring first to a clutch of three cases he reported on in October 2008 in which the patients suffered serious setbacks - the loss of an eye, a serious stroke and the spread of prostate cancer - after their referrals were lost between DHBs.
Two months later, in a report on five cases including three deaths, he concluded patients were being put at risk by DHBs running their emergency departments with too few staff. This report coincided with pressure from emergency physicians and the ministry which is now paying off in improved ED performance.
Though Paterson has had some success in influencing the quality of health care, his office lost its campaign to hold the line on the sexual restrictions on doctors.
Is he disappointed that former Medical Association chairman Dr Anton Wiles was in 2001 acquitted of disgraceful conduct by a disciplinary tribunal, a decision endorsed on appeal to the District Court, after becoming intimately involved with a patient?
"No. I look back on that case and other more recent cases and I'm pleased to see the Medical Council and HDC [his own office] have continued to act in a clear and consistent way, that sex with patients current or recent is unethical and inappropriate.
"What the disciplinary tribunal and courts decide to do about that is ultimately up to them. I remain of the view that a very clear line in this area is for the benefit of, not only patients, but for doctors themselves."
Paterson leaves the job next Wednesday, two years into a five-year re-appointment made in 2008 under the Labour Government. But there is no apparent animosity between him and National's Health Minister Tony Ryall. The minister hosted the farewell at Parliament.
"I said I wouldn't necessarily stay for the full term," Paterson says. "I regarded it as a personal goal to complete 10 years in the job. As it happened, the chair was advertised at the University of Auckland and it felt like the right time to make a change."
His first project there will be an international investigation into whether New Zealand's "fairly light-handed" regulation of doctors needs to be beefed up.
After Paterson's probing the depths of medical misadventure and dysfunction for a decade, it might be thought he would be wary of putting himself in the hands of doctors and nurses. But it's a suggestion he dismisses with a flourish.
"I feel very comfortable going into any public hospital in New Zealand."
THE BIG INQUIRIES
Gisborne Hospital
Report 2000
* Anaesthetist faulted for re-using syringes.
* 117 men had to repeat prostate cancer blood tests after laboratory error produced incorrect results.
* Tairawhiti Healthcare had breached patient rights by failing to address problems in laboratory.
Southland District Health Board
Report 2002
* Mark Burton killed his mother in Queenstown in 2001, hours after he was discharged from Southland Hospital mental health unit. Found not guilty of murder, by reason of insanity.
* Report faults DHB, two managers, six clinical staff.
* Severely critical of mental health unit.
* "The overall picture is one of sloppy care that was lax and laissez-faire. Mr Trevor Burton [Mark's father] and his family have every right to feel that the health system failed them."
* Dr Peter Fisher later found guilty of professional misconduct.
North Shore Hospital
Report 2009
* Acute services "overwhelmed" in winter 2007.
* Inquiry into care of five elderly patients in the emergency department and two medical wards.
* Medical care reasonable, but nurses did not have time to care.
* Delays and omissions in care. Deficient communication with patients and families.
* Waitemata DHB had tried to deal with overcrowding but acted too slowly, too late.
Whanganui DHB
Report February 2008
* Sterilisation surgery by Dr Roman Hasil failed on eight of 32 women in 2005/06.
* Six became pregnant. Most had abortions.
* Hasil made basic surgical mistakes.
* DHB "hesitated too long" in dealing with him despite information that patients may be at risk.
* Hasil fled New Zealand after DHB began investigation.
* DHB's safety systems not followed, so failed to pick up his failures.
* Regional co-operation vital to overcome financial and workforce pressures on small hospitals
