Coroner criticised by GPs

Zachary Gravatt died after being suddenly struck down with meningococcal disease. Photo / Supplied

A leading doctors' group has criticised a coroner for his alleged misunderstanding of the health sector when he made recommendations to rectify system failings in the care of Zachary Gravatt.

Following a judge's lifting of name suppression on four blameless health workers who cared for the 22-year-old medical student before he died of meningococcal C disease in 2009, the Herald asked three organisations what they had done to implement coroner Brandt Shortland's recommendations.

The Royal NZ College of General Practitioners said, "... the [college] has had discussions with the coroner's office regarding the difficulties around responding to coroner's [sic] recommendations when they are not based on a clear understanding of the roles played by various organisations in the health sector".

Chief coroner Judge Neil MacLean said he couldn't recall discussing the matter with the college and Mr Shortland hadn't had discussions with the college at all. Judge MacLean said he was confident in Mr Shortland's understanding of the health sector.

"The point needs to be made that the recommendations he made didn't come out of left field. They were the result of involvement and input from both the Gravatt family, who are very well informed medically, and the Auckland District Health Board representing key medical interests."

The recommendations to the DHB, the colleges of GPs and physicians, the ambulance sector and the Health Ministry included writing a protocol to give pre-hospital antibiotics injections when meningococcal disease is suspected, and introducing a simple "tool" to sum the scores from vital signs such as pulse, temperature and breathing rate.

Mr Gravatt's father, Lance, the former head of pharmaceutical company AstraZeneca's New Zealand business, said the scoring tool, which he understood was now used in most hospitals, quickly enabled health workers to detect physiological instability in patients who might look stable.

"This was part of the confusion in Zac's case. The nurses saw he was able to talk to us and he looked all right. If you measured the vital signs and added them up, he was right off the scale of the early warning scoring system."

Dr Gravatt said the DHB had implemented most of the recommendations relating to it, but the other organisations had not told him that they had implemented the others.

"It speaks volumes to me that with everything that's been going on in the last 48 hours with Zac's story and name suppression and the medical community screaming that the focus should be on learning from mistakes rather than naming, that no one has mentioned what they have done to improve things."

The college of GPs said the ministry had responsibility for making recommendations to the primary health sector on managing meningococcal disease and this already included information on antibiotics for suspected cases.

The head of the ambulance services' national clinical working group, Dr Tony Smith, said it had already implemented an ambulance protocol for pre-hospital antibiotics injections. It was exploring the issue of tools for assessing physiological instability, but wasn't aware of any that could be used in pre-hospital care.