Over the past few years, hospital emergency departments have emerged from the Covid-19 pandemic into a new crisis. ALEX SPENCE reports on a Hamilton family who alleged they experienced numerous care and communication failures at Waikato Hospital, which has one of the country’s most strained EDs, and their six-month battle to get health authorities to acknowledge what went wrong.
He hated the thought of going back to hospital, but James Wetere had become too weak to resist.
It was Sunday, 22 January 2023. At his home on the rural edge of Hamilton, Jim had been feeling progressively worse for a couple of weeks. Breathing was difficult. His blood pressure was low. He had no energy to get around the property where he and his wife Vivienne lived in a unit next to their son Nathan.
Now he was struggling to stand up. “He was buggered,” Viv recalls.
At 73, Jim’s imposing physical presence had been diminished somewhat by age and illness, but he still possessed an air of quiet authority. The son of a former Māori All Black and Royal Air Force fighter pilot, Jim had for decades been a stalwart in several Waikato communities, commanding respect wherever he went. He sat on the board of Māori Rugby and received a Queen’s Service Medal for running a community centre in Enderley, one of Hamilton’s poorest suburbs.
In retirement, Jim was learning to enjoy a slower existence. He adored his six grandchildren — “Grumpy Old Jimmy,” they lovingly called him — and when he wasn’t spending time with them, he liked watching rugby games and Shortland Street or listening to music. Jim would blast the Rolling Stones through his Bluetooth hearing aid while mowing the lawns and then crack open a cold beer, another of his favourite pleasures, although he had switched to the non-alcoholic versions after a recent heart attack.
Days earlier, Jim had been to his GP for a scheduled diabetes checkup (he had Type 2 diabetes, a chronic disease that limits the body’s ability to control blood sugar levels, which disproportionately affects Māori and Pacific communities). He seemed subdued and “washed out”, according to the doctor’s notes.
Two days later, when Jim hadn’t improved, the GP sent him for a blood test. Jim was called back to the clinic and examined by another doctor, who diagnosed pneumonia, prescribed an antibiotic, and sent Jim home to rest over the weekend. She told him to call back on Monday to arrange a chest X-ray if he deteriorated.
“I feel like s**,’ Jim told his daughter Megan, a 46-year-old marketing executive, that night.
The next day, Viv suggested calling an ambulance, but Jim refused. Three months earlier, he had gone to Waikato Hospital after experiencing heart failure and spent 10 hours waiting in the crowded emergency department before walking out in frustration, the IV catheter still in his hand. He wasn’t eager to go back.
But now, at 10am on Sunday, it was obvious even to Jim that he needed to go to hospital right away.
Nathan insisted again on calling an ambulance, and this time Jim didn’t argue.
“I think you might be right,” he said.
Nathan’s wife dialled 111.
Over the past few years, hospital EDs have emerged from the Covid-19 pandemic into another crisis. Patients are waiting longer to be seen. Staff are burning out and leaving. Incidents of violence and harassment are increasing. And clinicians say the quality and safety of care is being compromised.
Waikato Hospital’s ED is one of the busiest in the country, seeing about 350 people a day according to figures from Te Whatu Ora-Health New Zealand, the national health authority. And it is the most strained, in the view of Health Minister Dr Shane Reti.
Reti revealed in an interview with the Herald during last year’s election campaign that he visited the department during one of 19 night-time rides with ambulance crews and was shocked by the conditions.
“I have never seen an ED that busy,” Reti said.
Do you have information on this subject? Contact the reporter at alex.spence@nzme.co.nz
Six weeks before Reti’s visit, the ED was also over capacity on the Sunday morning that Jim arrived.
According to hospital records, the ED was short-staffed that day because of sickness and vacancies and had an “overload” score of 120-140 (anything above 111 is considered extreme). Patients were experiencing hours-long waits because there were no available beds in inpatient wards to transfer them to, and medical specialists were scrambling to be in several places at once.
Jim died in the ED after waiting for 30 hours. His family was stunned by his death and came to believe that it was avoidable.
The Weteres claim they experienced a cascade of medical and communications failures and spent six months pushing the hospital for a full acknowledgment of those alleged failures. They say their experience raises important questions about accountability processes, communications with bereaved families, and the limitations of the government’s ambitions to make the health system more empathetic to the people it serves.
“I don’t want another family to go through the same pain,” Megan says.
This account is based on multiple interviews and hundreds of pages of documents that the family shared with the Herald. Te Whatu Ora, which operates Waikato Hospital, declined to discuss specific aspects of Jim’s treatment or the family’s experience, despite written consent from his family. “We are not able to share private patient information with the media,” a spokesman said.
Jim arrived at the ED just before 10.30am. He was triaged by a nurse in the ambulance bay, who scribbled on an assessment form: “Pneumonia.”
The nurse circled “2″ on a five-level triage scale that EDs use to determine the urgency of a patient’s illness.
Under Australasian guidelines, this code meant Jim’s condition was “imminently life-threatening” and that he should’ve been examined by a doctor within 10 minutes. However, clinicians say many EDs are now often too busy to meet these guidelines. “The number of patients simply outweighs the capacity of the staff to meet these timeframes,” an internal review of Jim’s care said.
It would be four hours until Jim was first seen by a doctor.
For much of that time, Jim remained in the ambulance triage area, a space the department’s chief doctor later described to the Weteres as “like a bus station”.
While Jim waited, nurses took blood tests and performed an echocardiogram on his heart. They gave him oxygen and intravenous fluids.
An X-ray showed that Jim had fluid in his right lung and that the lung had partially collapsed.
Blood tests revealed an elevated level of lactate in Jim’s blood — 3.7 millimoles per litre (mmol/L) — which could be an indicator of sepsis, an abnormal response to infection that can be fatal. Viv says she and Jim were not informed of this.
At 1.15pm, Jim was moved into a four-person cubicle in the main part of the ED.
Then a registrar, a trainee doctor, arrived to assess Jim.
The doctor looked at Jim’s symptoms, test results, and personal history: James Taui Himiona Wetere. Born May 1949. Married with two children (and a stepson). Former smoker and heavy drinker. Diabetic. Heart attack in 1999. Biventricular heart failure in October 2022. Active gardener. Seemed well after recent cardio discharge.
“Severe pneumonia / chest sepsis,” the registrar wrote.
According to Jim’s medical records, the registrar initiated the hospital’s protocol for treating sepsis patients, ordering blood tests, IV fluids, and IV antibiotics. He informed the ED’s senior medical officers about Jim’s condition and referred Jim to the respiratory team.
Records indicate that the registrar also considered moving Jim to one of the ED’s dedicated resuscitation (“resus”) rooms, where critically ill patients who may need to be revived can be given a higher level of medical and nursing attention.
But the resus rooms were full, so Jim was moved to another cubicle in the main area where he would be more visible to nurses.
Megan arrived to keep her parents company.
At 3.42pm, a nurse noticed Jim’s condition was worsening: His lactate had risen to 4.6 mmol/L, severely elevated, and the amount of haemoglobin in his blood was falling — signs that sepsis was progressing.
Senior staff were informed of the observations, but the Weteres say they remained mostly in the dark. Nobody mentioned sepsis. Nobody warned them it could be perilous given Jim’s existing health problems.
“There was never any conversation about it being life-threatening,” Megan recalls.
At 6.40pm, a respiratory registrar came to assess Jim. Viv had gone to the waiting room to get a drink of water. Megan recalls that Jim seemed exhausted but sat up on the side of the bed while the doctor spoke to him.
The registrar assessed Jim’s pneumonia as severe, assigning a score on a clinical scale that the internal review said implied a 22 per cent mortality risk and may have required admission to the intensive care unit (ICU), where Jim could be put on ventilation, “vasopressor” medication, and organ support.
Again, Megan says the gravity of Jim’s condition was not made clear to the family.
Hospital records show the registrar discussed Jim’s condition with her superior and they decided he could be moved to a respiratory ward instead of the ICU; the doctors concluded he didn’t need intensive care because his blood pressure had responded to IV fluids.
The registrar recommended a chest drain to remove the fluid from Jim’s lungs but thought it would be safer to do it the next morning, when more specialist staff would be available.
Before leaving, the registrar asked Jim whether he wanted to be resuscitated if his heart stopped.
Waikato Hospital has a policy of completing a resuscitation plan for every patient within 24 hours of admission, including documenting whether a patient has said in advance they don’t want to be revived. According to her notes, the registrar believed CPR was “unlikely to have a good outcome” in Jim’s case and wanted to discuss that with the family.
But in Megan’s account, the doctor’s approach came across as “extremely upsetting”. Jim was alarmed when she described CPR breaking his ribs and confused as to why she was bringing it up now.
“I was worried that she made Dad scared,” Megan says, so she asked the registrar to leave.
At around 1am, Jim had still not been transferred to the respiratory ward, so Viv and Megan went home to sleep.
“If we knew what was about to happen, there’s no way we would’ve left him overnight,” Megan says.
The next morning — Monday, 23 January — there was still no inpatient bed.
A nurse noticed Jim’s heart rate had increased and that he was working harder to breathe. The respiratory team advised giving Jim more oxygen and said someone would review him soon.
Viv arrived around 8am and Nathan not long after. Jim refused breakfast but drank water.
Blood tests showed that Jim’s lactate level, although still severely elevated, had fallen to 4.2 mmol/L, which the doctors took as encouraging.
Megan arrived around 9am. She says Jim was awake but struck her as less responsive than the previous night. She chatted to him about a rugby sevens tournament being played in Hamilton, but Jim didn’t say much.
For long periods, the Weteres waited for something to happen.
“Still awaiting bed on ward,” a nurse scribbled on an assessment form at 11.30am.
By then, Jim had been in the ED for 24 hours.
Then it was 25.
Then 26.
Still mistakenly believing that Jim was merely fighting pneumonia, the Weteres fixated on the chest drain as the crucial intervention. “Get that fluid off his chest and he’ll be sweet,” Megan thought.
At 2.55pm, Jim was given a blood transfusion. He had to give written consent to receive blood but was so weak he could barely hold a pen.
Then a senior nurse confronted Viv, Megan and Nathan.
Why were there three visitors in the cubicle? It was against ED rules. They would have to leave.
Megan pushed back. Jim had now been waiting nearly 29 hours. They weren’t leaving him again until he moved to the respiratory ward.
Nathan, trying to keep the peace, said he would come back later when the chest drain was done.
Then the atmosphere changed, Megan says.
Perhaps the senior nurse went away and examined Jim’s chart for the first time, Megan figured, because she returned with a new sense of urgency.
Orderlies arrived and adjusted the bed to make Jim more comfortable. Then a pair of doctors came to examine Jim.
Jim was moved to a resuscitation room.
One of the doctors recorded that Jim’s blood pressure, oxygen level, and responsiveness to stimulation had gotten worse.
“Deterioration, likely terminal,” the registrar wrote.
The young doctor took Viv and Megan aside in the hallway and told them Jim probably wouldn’t survive.
It was the first time in 30 hours they were told Jim had sepsis, let alone that it was likely to be fatal.
“You might as well have hit us with a truck,” Megan says.
Megan phoned Nathan and told him to come back to the ED right away. He arrived just in time. Megan called her daughters and Jim’s sister and told them to come too. They would have been there already if they’d known Jim’s life was at risk.
Jim was given more IV fluids, but his blood pressure kept falling. His lactate had shot up to 9.3 mmol/L.
His breathing became “extremely slow and erratic”, a nurse observed.
“Entering last moments of life,” a registrar noted at 4.15pm.
Monitors and IV pumps were switched off. Jim’s breathing stopped. His heart stopped. With the family’s agreement, there was no attempt to resuscitate him.
“Rest in peace,” the registrar wrote. “Time of certification: 16:26.”
Jim Wetere’s death wasn’t just a shock to his family.
On Friday, 27 January — the same day that an unprecedented downpour devastated Auckland — a crowd of mourners filed into the Suburbs Rugby Club, where Jim had been a constant presence, for his funeral.
Draped in rugby shirts from the local Suburbs and Tainui Waka clubs, Jim’s coffin was carried past the bar where he’d spent many hours socialising over the years, and placed in front of the club’s honour board. Nathan read the eulogy and then others came forward to give tributes:
“You were the backbone of the whānau,” said one of his granddaughters.
“Hell of a man,” said the Suburbs chairman.
“I’m honoured just to have walked in his life,” said a woman who worked with him in Enderley.
At the end of the ceremony, a montage of family photographs was played to the sound of the Rolling Stones’ You Can’t Always Get What You Want: Jim in his wedding suit. Jim with the grandkids. Jim with his dog Poppy. Jim wearing an All Blacks jersey. Jim holding a beer. Jim in the garden. Jim at Disneyland. Jim dressed as Santa Claus.
In the weeks that followed, the Weteres struggled to make sense of what happened.
It was hard enough to accept the loss of such a monumental figure in their lives, but the family’s grief was compounded by the disorienting circumstances.
Their shock was mingled with anger and guilt. They had spent so many hours waiting with Jim without realising he was dying; should they have pushed harder for something to be done?
For Megan, it was especially heartbreaking that her daughters had not been there to say goodbye. Jim had helped raise them as if he was their father.
Megan obtained copies of Jim’s medical records and began digging through the charts, test results, and clinical assessments. A friend who had been a senior nurse at the ED helped decipher the terminology and figure out what to ask.
At the end of June, Megan sent the hospital management a five-page email detailing numerous alleged flaws.
Her concerns fell under three main themes.
First, there was the medical care: the four hours it took for Jim to be seen by a doctor after he was triaged as code 2; that he wasn’t immediately moved to a resuscitation room or ICU where he would’ve got closer attention; the long periods when it seemed nobody had a handle on Jim’s condition.
“There was no urgency in his care,” she wrote.
Second, the lack of communication about how sick Jim was and the allegedly insensitive interactions with the respiratory registrar and senior nurse.
Finally, Megan also claimed there had been cultural failings. The family wasn’t offered assistance from the hospital’s Kaitiaki Māori liaison service until after Jim died, and she alleged that tikanga (Māori death custom) wasn’t followed because Jim’s body was left unaccompanied shortly after his death.
The hospital opened an internal review, treating Jim’s case as a “SAC 1″ incident — an unexpected death that may not have happened naturally.
In July, an operations manager informed Megan that the hospital had “identified that there are abnormalities in your father’s care plan and acknowledge that these should have been picked up earlier”, although she did not identify the abnormalities. The manager said the hospital aimed to complete the investigation within four weeks.
Later that month, the Weteres met the staff conducting the review to discuss their complaint. Megan says they seemed sympathetic and promised to keep her in the loop and share their findings when they were ready.
Weeks went by. Megan pushed for updates.
Finally, the document arrived in her inbox in November.
Megan was crushed.
“It has been ascertained through completing this review that Mr W was provided with the appropriate level of care by the nurses and medical staff,” the review said.
It found that Jim had been given the appropriate triage code, diagnosis, and treatment plans and there was no clinical indication that he needed to be sent to a higher level of care until late on Monday afternoon. Staff followed the correct path for sepsis and Jim responded to treatment. Jim’s observations were “stable and managed” until he suddenly deteriorated; he didn’t need to be seen by a senior doctor; and another course of treatment was unlikely to have had a different outcome.
Near the end of the report were two paragraphs acknowledging “communication issues.
“It is clearly evident that communication between the nurses and medical staff did not meet the expectations of Mr W’s whānau,” it stated. “They were absolutely shocked when Mr W deteriorated on 23 January 2023 and the whānau were informed he was unlikely to survive. Because of this, the whānau feel they were robbed of precious time with their husband, father, and loved one.”
The report said the miscommunication was a “learning opportunity” for the staff who were part of Jim’s “journey”.
After reading the document, Megan says she regretted participating in the process. She hadn’t expected it to substantiate all the family’s complaints, but as she saw it the 13-page document — written in passive, impersonal clinical and bureaucratic language — minimised their experience, left many of their questions unanswered, and was insufficiently critical of the service that had been provided.
It felt as if the hospital had strung them along for months and then deflected responsibility.
Megan sent back another long email with a point-by-point rebuttal.
“Waikato ED failed to provide Jim with the care he required,” she wrote.
In early December, a hospital representative wrote back apologising that the review was traumatic and didn’t “provide the peace and resolution that you are seeking.
“I acknowledge the report exposes gaps in Jim’s care that do not meet the standards we would expect,” the manager said, without elaborating on those gaps, and invited the Weteres to another meeting to discuss the findings.
Viv refused, her trust in the system exhausted. Megan was also sceptical, but having pushed it this far decided to see the process to the end. She and Nathan agreed to meet.
A week before Christmas, they arrived at a hospital building across the road from the ED. It was unnerving to be back.
Entering the room where five hospital staff waited, including the clinical leaders of the emergency and respiratory departments, Megan says they were braced for an awkward, defensive conversation — but were surprised.
The staff struck her as empathetic and conciliatory, and they went beyond what had been said in the report.
Dr Harry Gallagher, head of the respiratory department, said it seemed from Jim’s clinical notes that he had been triaged correctly but “then there’s a real lack of apparent urgency around treatment being given.
“So then you naturally arrive at some uncomfortable conclusions,” Gallagher said. “And it may not have been the case, but with the lack of urgency comes the perceived lack of care.”
Dr Greg Stevens, head of the ED, said Jim waited too long to be seen by a doctor after being triaged. “There’s no way that a four-hour delay is acceptable. I’m not hiding that one. Unfortunately, that’s a common occurrence in our department because we have so many sick patients coming through.”
Stevens pointed out that nurses had begun treating Jim while he waited for a doctor, with IV fluids being the most important intervention. Someone in Jim’s condition would also usually be given IV antibiotics immediately, Stevens said, and he wasn’t sure why that hadn’t happened with Jim.
“Would that have made a difference? I don’t know.”
Stevens pointed out that Jim’s heart condition was severe, which complicated the sepsis treatment and diminished his body’s natural ability to fight the illness.
Stevens apologised for the long delays and said the ED is “working really hard” to cut waiting times.
They discussed Jim’s lactate level.
“As you’re aware, monitoring lactate is an important part of how we gauge our fluid resuscitation,” Gallagher said. “That wasn’t checked frequently overnight.”
Although Jim’s lactate had decreased slightly on Monday morning, which the internal review cited as evidence that he was responding to treatment, Gallagher now said: “You can reasonably say that that’s an inadequate response, and that it actually hadn’t come down enough.
“And that should’ve probably raised alarm bells to say that we’re possibly under-treating your Dad with regard to sepsis management. So I think that’s a clear shortcoming.”
Gallagher apologised that Jim’s lactate hadn’t been checked more often and his treatment reviewed overnight.
Megan choked up.
It wasn’t a definitive answer to the question that haunted her most: Would Jim still be alive if things had been done differently? Megan knew that emergency medicine was too fraught with uncertainty for the doctors to go that far, but it was a relief to hear their apologies.
The staff also apologised for communication failures.
“Communication was a huge issue that we didn’t deliver on,” said Melody Mitchell, operations director for medicine.
“I could pick up from your feedback one insult after another when it came to lack of communication, lack of respect, and that’s something that weighs on us hugely because it’s a common trend. We get it right sometimes and sometimes when we get it wrong, we get it really wrong.
“And I think in your Dad’s case, in your family’s case, we got it really wrong.”
Hemi Curtis, a cultural adviser, spoke up.
“You hit the nail on the head, Megan, with your first letter [in June], and it was around empathy, compassion, and communication,” Curtis said.
He said reading the internal review was “like getting slapped in the face by a cold fish.
“Where are you in that review? You’re not there,” Curtis said. “All you see are the processes, procedures, and protocols that are in place.”
Curtis thanked the doctors for fronting up. He thanked Megan for holding the hospital accountable. “Ever since I read your first letter it’s been in the back of my mind.”
“I’m in quite a lot of these types of cases,” he said.
After the meeting, Megan didn’t feel that the family’s complaints had been resolved, exactly, but it was vindicating — and now they could start to move on.
Megan spent six months pursuing the complaint with unusual doggedness, out of love and respect for her father but also because she believed that is what Jim would have done. It had been exhausting, and it had also prevented her from properly grieving.
“It just feels like this unfillable hole,” she says of losing her father. “You’ll be fine for a while, for a day or two. Then you’ll be driving somewhere and pow, it just comes over you.”
She intends to keep pushing the hospital to make meaningful changes so that other families don’t endure a similar experience — a Te Whatu Ora spokesman says there are “a number of existing initiatives” under way that are relevant to Jim’s case — and she plans to complain to the Health and Disability Commissioner, which would conduct a fuller investigation of Jim’s care, although that is likely to take years.
For now, though, Megan is concentrating on celebrating Jim’s life as it deserves to be.
Next week, a year to the day after Jim was buried, the Weteres plan to unveil a headstone at his grave at Hamilton Park Cemetery. They have had a korowai, a Māori cloak, specially made to drape over the headstone. After the ceremony, they will go back to Jim’s home and throw the party he would’ve wanted as a send-off. They will put on the Rolling Stones and turn it up loud.
Alex Spence is an investigative reporter and feature writer who tends to focus on social issues such as health and mental health. He joined the Herald in 2020 after 17 years in London where he worked for The Times, Politico, and BuzzFeed News. He can be reached at alex.spence@nzme.co.nz or by text or secure Signal messaging on 0272358834.