Coroner Bridgette Windley said the inquest wasn’t about blame, but accountability and finding where the system needed strengthening to give protection to people in the future.
“[I] ask [to] keep firmly focused on the reason we are here, that reason is Koro,” she said.
Mullins died on September 16, 2019, during a percutaneous coronary intervention procedure at Wellington Hospital to clear clogged coronary arteries. He had just turned 65.
The inquest will have a “dual focus” - establishing past facts and looking towards preventing further harm.
Mavis Mullins said it has felt like David up against a Goliath, the New Zealand health care system, in the three years since Koro died.
“We have felt isolated, disconnected and abandoned by the medical staff,” she said.
“Since Koro’s passing, we have not felt heard, seen or respected.”
Images of Mullins and his loved ones were displayed at the front of the courtroom, some taken just weeks before his death.
The photo frames were adorned with kawakawa leaves, a symbol of strength and fortitude, and olive branches, a symbol of peace, respect, and of the solutions that may arise from the inquest process.
A number of witnesses will give evidence during the inquest, including Palmerston North Hospital staff who saw Mullins in the months before he died and staff from Wellington Hospital involved in his care before his death.
Mullins was a strong, physical man who had worked hard in the farming industry. His wife described him as community man, recognised and well-liked.
He was a legend in the shearing community and had earned international respect for his contribution to it.
Mullins was making nervous jokes and hugging his family in the hours leading up to the surgery. He was told he was a low risk but felt anxious about the procedure that ultimately claimed his life.
When Mavis Mullins next saw her husband, he had died. He was still warm when the family came in to see him in the operating theatre where a “heavy air of silence” was present.
“I was traumatised but I knew I had to be calm and coherent.”
She says her husband died of a venous air embolism when air entered the IV line during surgery.
“They knew what went wrong, they knew they had made a mistake,” she said.
She had hoped they would “own it” and the family could grieve, forgive, and Mullins could finally rest in peace.
“Three years three months later that is not what has happened.”
He is still yet to have his unveiling because of the inquest process and the questions that still linger.
In the three years and three months since his death, Mullins’ family has tried to find answers to do with his death. Paperwork, reports, and numerous emails haven’t given any sense of closure.
They were questioned by the police after Mullins died. Mavis Mullins asked why a similar treatment was not given to the healthcare workers who were operating on her husband that day.
She said the level of scrutiny she felt she was under was starkly different from what she has seen of the surgeons.
A hospital worker who saw Mullins in Palmerston North a month before he died told the inquest today that had she known about any chest issues, she would have wanted him to be admitted to hospital for further checks.
He was instead discharged with muscular-skeletal back pain.
The worker said she was focusing on back pain when she saw Mullins, but now believes his condition was a “ticking time bomb” and that he should have been seen sooner for follow-up tests.
“People shouldn’t be waiting, it’s just very very disappointing and a dangerous situation ... it’s a risk to have patients like this in the community,” she said.
She also said communication between healthcare providers and clinicians needed to be a priority in a patient’s care so symptoms aren’t missed.
When Mullins died he left behind his shearing contracting business, Paewai Mullins, his whanau, and a community that adored him.
His death was a shock to all those who knew him.
He had been a part of the world-famous Golden Shears for decades and was a commentator, presenter, and interviewer for the competition.
Mullins was highly regarded by the international shearing community and at the time of his death colleagues from overseas expressed their deepest condolences to the media.
Welsh commentator Huw Condron said Mullins was one of the “voices of shearing”.
The inquest continues.
