Koro Mullins was known as a strong and fit man, as shown when aged over 60 shearing in a veterans event at the Golden Shears. Photo / Pete Nikolaison
Koro Mullins was known as a strong and fit man, as shown when aged over 60 shearing in a veterans event at the Golden Shears. Photo / Pete Nikolaison
Koropiko Tumatahi Mullins (Ngāti Pikao), the fit active 65-year-old hailed as ‘the voice of shearing’ died four years ago during a stent procedure.
“What happened to Mr Mullins is for the interventional community like a crash of a 747. This is as bad as it gets.”
That was the searing comment made by one expert witness during the inquiry into Mullins’ unexpected death held in the Wellington District Court at the end of 2022.
Deputy Coroner Brigette Windley.
In her findings released last weekend, Deputy Coroner Brigette Windley found “on balance” that Mr Mullin’s death on 16 September 2019 was a “consequence of multiple failures”.
Last night on Te Ao with Moana, Mavis Mullins (Rangitāne) spoke exclusively about the circumstances around her husband’s death and why her whānau have delayed his hura kohatū.
“When I’ve felt like this is just too much, can’t do it, the kids would say, ‘Dad wouldn’t give up if that was you, Mum!’ He wouldn’t and they’re right. So, this has never been an opt-out.”
Te Ao with Moana began filming the Mullins family five months after their husband and father died as they tried to find out how air had entered into one of his arteries. Last night’s story tracked their frustrations with a system that the coroner described “obfuscated the search for the truth”.
The whānau were acutely aware that Māori are more than twice as likely to die from cardiovascular disease and 1.5 times as likely to be hospitalised for cardiovascular disease than non-Māori. Māori are also twice as likely to die from ischaemic heart disease and 1.3 times as likely to be hospitalised for ischaemic heart disease, 1.5 times more likely to die from a stroke, and 1.5 times more likely to be hospitalised from a stroke.
“One thing with dad was like, if there was any sign of trouble with his body, the first thing he’d do is go to the doctor,” recounts Punga Mullins. “No mucking around.”
In her findings, the coroner described a series of inadequacies at the Palmerston North Hospital Emergency Department (managed by Mid Central DHB at the time) which saw Mullins discharged into an accelerated chest pain pathway. An audit of the outpatient diagnostic programme found it to be severely under-resourced, compromising patient safety.
After his discharge, Mullins suffered a heart attack which experts at the inquiry all agreed made his heart less resilient to the acute air embolism that occurred during his stent procedure at Wellington Hospital (managed by Capital & Coast DHB). When advised by two doctors that her husband was dead, Mavis Mullins describes her shock.
“I just recall ending up on the floor trying to absorb what the hell had gone on?”
Koropiko Tumatahi Mullins. Photo / Te Ao with Moana
The coroner found that the large volume of air injected into Mr Mullin’s heart was due to human error.
She recommended: “That Te Whatu Ora include in its new OCT/ACIT protocol and procedure manuals express reference to both the circumstances of Koro’s death and that his death has been a significant driver in the development of improved safety measures in catheter labs at Wellington Hospital.”
The coroner also recommended that those changes be championed to the rest of the medical community. All clinicians were granted interim non publication orders, including the doctor responsible for the immediate safety checks, and protocols in the lab during the procedure. She left New Zealand straight after Mullins’ death and refused to engage in the inquiry - a decision the coroner described as “deeply disappointing”.
In her report, Coroner Windley acknowledged that while it was outside her jurisdiction to examine the engagement between the Capital Coast DHB, its review panel and clinicians with the Mullins whānau, she described it as “largely unhelpful, obfuscated the search for truth and served only to add to the trauma they had already suffered”.
Both Mid-Central and Capital & Coast DHBs ceased to operate in June 2022 when they were absorbed into Te Whatu Ora.
Te Ao with Moana received a statement attributable to Russell Simpson, regional director, Central Region
STATEMENT
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.
Since this tragic event, Capital Coast 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.
CCHV is also proposing to include explicit reference to the circumstances of Mr Mullins’ death in the protocols required when using the new contrast injectors.
Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral accepts and will implement the recommendations made by the coroner related to Mr Mullins’ care prior to his surgery.
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.
