The parents of Greymouth teenager Matt Gunter, who died after an operation to remove his appendix in November 2012, are frustrated with the coroner's decision to withhold the names of the medical staff involved with his care.
Matt, 15, had surgery on November 16, 2012, at Grey Base Hospital but his condition deteriorated and he was transferred to Christchurch Hospital, where he died three days later.
Yesterday, Coroner David Crerar closed the file on the case and suppressed all the names of the staff involved.
Matt's mother, Heather Gunter - a nurse at Grey Base Hospital - told the Greymouth Star today that none of the staff involved with Matt's care had shown any insight into what had happened.
"None of them have ever said, 'Yes, I understand what I did', which means they have not learned from what happened or changed their practice," Mrs Gunter said.
Two of the nurses had been referred to the Nurses Council and an anaesthetist to the Medical Council, she said.
Mrs Gunter wrote to both councils asking what, if anything, had come of the referrals but she had not heard back.
Throughout the whole process, none of the staff involved had been stood down.
"They have all been working the whole time, as far as I am aware.
"If a policeman shoots someone, they would have been stood down and there would have been consequences."
Mrs Gunter said: "When you build a house, you Google a good builder to make sure you get the best. With health care you have no idea what you are getting. People's lives are being affected and we should have the right to know."
She said she was "disappointed" with the legal and health systems, which she felt had failed her family.
"We are frustrated and disappointed with the Medical Council and the Nurses Council. There have been no consequences for anyone. How are they supposed to understand what happened and avoid something like this happening again? This is what really bothers me."
Mrs Gunter has since taken a different stance in an effort to help Grey Base Hospital staff to avoid a similar tragedy.
"I have filmed a video called 'Matt's Story' and it is being shown to everyone who works at the hospital and is being used as a learning story."
In the video, she speaks about her experience, patient advocates and how everyone who goes to hospital should be treated as an individual.
"I believe it is mandatory for all staff, including new staff, to watch," Mrs Gunter said.
The West Coast District Health Board had accepted that mistakes had been made during Matt's care and had apologised and supported the family over the past three years.
"The hospital did not fail us - it is the process used in dealing with what happened which has failed."