Two coroner's inquests were held into the death of Zachary Gravatt, who died from meningococcal disease in 2009. Video / Jason Oxenham
Two Auckland doctors have asked a judge to suppress their identities after concerns were raised and two inquests held over the care given to a young medical student dying of meningococcal disease.
Zachary Gravatt went to his GP with fevers, rigors, headaches and groin pain at about lunchtime on July 8, 2009, before being admitted to hospital at 1.43pm.
Despite quickly deteriorating over the afternoon he was not transferred to the Department of Critical Care Medicine until 6.40pm. He died 35 minutes later - killed by septicaemia from the C-strain meningococcal bacteria.
Two inquests have been held over the 22-year-old's death at Auckland City Hospital, after he was admitted on the suspicion he had swine flu.
The second inquest, held in October 2018, was ordered by the Deputy Solicitor-General Virginia Hardy after an anonymous letter which claimed to be from an Auckland District Health Board (ADHB) staffer alleged a "cover up".
Today and yesterday, the High Court heard a judicial review and the applications of two doctors associated with Gravatt's care who wished to have their identities permanently suppressed.
During the second inquest, the on-call doctor's evidence was that he was stuck in traffic when attempting to return from a Ponsonby restaurant to hospital to treat Gravatt. It was a claim the coroner later said had "no support for the proposition".
Today, Justice Paul Davison acknowledged Gravatt's parents, Jennifer and Lance, who were seated in the courtroom's gallery, and said "it's clear he was a very fine young man".
The judge added the sudden death of their son was a profound loss not only for his family but also the community, given he was a talented fourth-year medical student.
When reserving his decision, Justice Davison said the hearing had "thrown up some issues which are going to need to be given some careful thought".
His judgment will be released in writing at a later date.
The on-call doctor and a colleague from the hospital were at a Japanese restaurant in Ponsonby when he received the first call about Gravatt's worsening condition. The inquest heard the call ended at 6.14pm, 61 minutes before Gravatt died.
The coroner also noted that a nurse had made a flippant comment about the doctor needing to finish dessert, however, "there is no evidence that this was the actual reason for any delay in his return to the hospital".
But she found that even if the doctor had returned to hospital sooner, it would have been unlikely to have changed the outcome for Gravatt.
Lance and Jennifer Gravatt's son Zachary died of meningococcal disease in 2009 at Auckland City Hospital. Photo / Jason Oxenham
Ultimately, she said the weight of expert evidence supported the findings of an earlier investigation and those in 2011 from the first inquest which said Gravatt "met the criteria for a Code Red" between 4.15pm and 5pm.
Had a Code Red been called, an intensive-care registrar would have seen Gravatt earlier than occurred.
"... it is therefore likely that the severity of his illness would have been realised earlier and transfer to the Department of Critical Care Medicine [an intensive-care unit] would have occurred earlier."
The coroner recommended several improvements, some of which are being implemented.
Dr Lance Gravatt has told the Herald it was upsetting to read if the health care was better it would have lessened his son's suffering, but if health providers implemented the coroner's recommendations, it would be "a good legacy for Zac".
In 2013, the ADHB apologised to the Gravatts for the shortcomings in its care, noting that Gravatt might have survived "with different treatment". The DHB also made a payout but neither party would reveal the sum.
