The father an 18-year-old Whangarei man who died of meningococcal disease after being sent home from Whangarei Hospital with medication, wants to know why it took the death of his son for the Northland District Health Board to act on major failings in its emergency department and intensive care units.

Coroner Brandt Shortland yesterday reserved his findings after hearing evidence into the coronal inquest into Ben Brown's death in August 2011. Mr Shortland said the importance of his decision was such that he would release it within three months.

In his evidence to the hearing, NDHB CEO Nick Chamberlain acknowledged the DHB had made significant errors that contributed to Mr Brown's death - including full results of a CT scan not being read for 36 hours, poor communication and note taking.

Dr Chamberlain said NDHB was deeply remorseful for the shortcomings and had conducted two independent reviews after Mr Brown's death, covering the actions of the Emergency Department and ICU, acting on every recommendation made .


"We have done all we can to try to ensure this does not happen again," he said.

He said meningococcal was difficult to diagnose and the DHB had made 16 significant changes to the way it dealt with patients at ED and ICU, including a new blood test that had an 88 per cent chance of identifying meningococcal disease.

Mr Brown's father Darren Brown said he was saddened his son died before problems in the two departments were identified and acted on.

"Does it take a death to know that your communication is poor; to learn that a CT scan with vital information that if seen earlier might have saved Ben wasn't read for 36 hours?" Mr Brown said.

"One of the worst things is that nobody has been held accountable for this."

On August 22, 2011, Mr Brown fell suddenly sick after work.

He was taken to White Cross accident and medical clinic, but sent home with a meningitis leaflet, a script for oral antibiotics for tonsillitis, and paracetamol. On deteriorating, he went by ambulance to Whangarei Hospital, but was discharged.

The oral antibiotics, although not sufficient to destroy the meningococcal bacteria, masked the real cause of his illness.

The following afternoon Mr Brown's worsened and he was admitted to the intensive care unit (ICU). He later died.