Two coroner's inquests were held into the death of Zachary Gravatt, who died from meningococcal disease in 2009. Video / Jason Oxenham
Zachary Gravatt's parents say all their questions have been answered in a coroner's findings following a second inquest into their son's death.
Lance Gravatt said it was upsetting to read Coroner Morag McDowell's findings, especially when they touched on health care which, if done better, would have lessened his son's suffering.
But he said that If health providers implemented the coroner's recommendations and suggestions, it would be "a good legacy for Zac".
An Auckland coroner's findings into the death of Zachary Gravatt from meningococcal disease in 2009 have been issued today following a second inquest. Photo / supplied
"There were so many questions that we didn't have answers to. It was our way of showing Zac that he still mattered and that we still love him. I think we have achieved that. In that sense, we have got out of this what we wanted."
A fourth-year medical student, Zachary died aged 22 at Auckland City Hospital at 7.15pm on Wednesday, July 8, 2009, of meningococcal disease. The second inquest into his death was ordered last October by Deputy Solicitor-General Virginia Hardy after an anonymous letter which claimed to be from an Auckland District Health Board staffer mentioning an alleged a "cover up".
Jennifer and Lance Gravatt, whose son Zachary died of meningogoccal disease at Auckland City Hospital in 2009. Photo / Jason Oxenham
In her findings, issued today, McDowell slapped down an on-call doctor's evidence about being stuck in bad traffic while rushing back to the hospital to attend to Zachary. He was in a Ponsonby restaurant when he received the first call about Zachary, about an hour before he died.
"There is no support for the proposition that there were extreme traffic delays on the day in question," McDowell said.
"I am not prepared to accept, on the basis of [the doctor's] evidence alone, that there was traffic congestion in Newton Gully and Ponsonby Road on the relevant night which delayed his return to the hospital."
"... I am satisfied that [the doctor's] return to the hospital was longer than what might be expected of a 2.8km journey; that it was in excess of 20 minutes, and in the range of between 35-50 minutes (approximately)."
The coroner noted that a name-suppressed 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".
She also found that even if the doctor had got back to the hospital sooner, it would have been unlikely to have changed the outcome for Zachary.
Lance Gravatt said the second inquest focused on the later hours of Zachary's hospital stay. He believed that his son might have survived if better care had been provided earlier on.
The recommendations or suggestions he highlighted as important were support for greater national consistency on antibiotic use, the inclusion of health workers' private notes in a patient's clinical records, and the extension of an early warning scoring (EWS) system based on vital signs to ambulance services.
McDowell wrote: "The family identified that had the EWS been applied in Zachary's case, with reference to the recordings taken in the ambulance, escalation of care would have been triggered, including the possibility of antibiotics being administered early."
Auckland DHB said in a statement, "We have great sympathy for the family of Zachary Gravatt. Auckland DHB will consider the recommendation and suggestions contained in the Coroner's findings."
