A new hearing has been ordered into the death of an Auckland student from meningococcal disease more than nine years ago.
Deputy Solicitor-General Virginia Hardy has instructed that the inquest into the death of Zachary Gravatt be re-opened because of new evidence which has come to light since a coroner made his findings in 2011.
However the nature of the evidence in this dramatic turn cannot be published yet as details have been suppressed under the Coroners Act.
The Auckland hearing, expected to take five days, starts today before coroner Morag McDowell.
Zachary's parents, Lance and Jennifer, suffered mental health problems following their son's death in July 2009. Lance said yesterday that he - but not his wife - was still receiving the assistance of mental health services.
He said the impact of Zachary's death had been profound, affecting their health, employment and confidence. The great sadness and other emotions had declined over time but hadn't gone.
"We miss Zac just enormously, but we're moving forward.
"This new information that came to light really just turned it all on its head. It was like starting over again. We go through it all - all over again really, with all the same emotions, not knowing what the outcome will be.
"But we just want to know the truth of what happened and what lessons can be learned from it. We feel that that's something that we owe to Zac. It's part of our love for Zac that we feel we need to do."
A fourth-year medical student, Zachary died, aged 22, in Auckland City Hospital on July 8, 2009, just over 15 hours after he woke up with a fever, headache and extreme pain in his right groin.
Zachary was killed by septicaemia from the C-strain meningococcal bacteria. Septicaemia is an extreme immune reaction that occurs after bacteria enter the bloodstream and start multiplying.
Zachary died at the height of the 2009 influenza pandemic and was at first suspected of having influenza.
He had gone to a GP at midday and arrived at hospital by ambulance just after 1.30pm, where he waited for more than an hour and a quarter to be assessed by a doctor - more than twice as long as recommended under triage guidelines.
At 3.30pm a registrar noted the possibility he had influenza but made no comment about a lab report which revealed Zachary had abnormal kidney, liver and blood results, which is consistent with septicaemia.
At 4.15pm he was given an antibiotic, followed by an anti-influenza medication, then a different antibiotic. About 6pm meningococcal was suspected. At 7.15pm, he died.
An independent review found the real cause of Zachary's illness could have been identified earlier if his vital signs had been measured more regularly.
Lance Gravatt said at the time: "The thing we find so hard to live with is he wasn't really given a chance. By the time they did get to treating him, he was really in the last few hours of life and everything was packing down . . . If they had just taken the normal vital signs [more regularly] from the start, the expert evidence is that they would have been alerted to, maybe not definitely meningococcal disease, but probably sepsis pretty early on."
Coroner Brandt Shortland found in 2011 that the delays in recognising and treating meningococcal infection were the fault of the health system and the stress it was under, rather than individual health workers. Partly because of this, he suppressed the names of five health workers involved in Zachary's case.
Lance successfully challenged that in the High Court, allowing three nurses and one doctor to be identified in 2013, although the name of a fifth health worker remained suppressed.
A pharmaceuticals businessman and chemistry PhD, Lance won the backing of the Auckland District Health Board through the inquest to promote nationally the use of an early warning scoring system for upping the care of patients with the kind of instability Zachary had.
The DHB yesterday declined to comment, because the case is before a coroner.
In 2013, the DHB made a second apology to the Gravatts for the shortcomings in its care of Zachary, noting that he might have survived "with different treatment".
The DHB also made a payout - neither party would reveal the sum - that the Gravatts said they would use to help their business, Te Arai BioFarma, which aimed to supply a meningococcal B and C vaccination.
Lance said yesterday that Te Arai was no longer able to supply the vaccine.
Shortland's recommendations backed Lance Gravatt's push for an assessment of state funding of a meningococcal C vaccine.
"The biggest disappointment for me," Lance said yesterday, "has been that we still don't have a meningococcal vaccine for any strain funded in New Zealand."
New Zealand had 132 notified cases of meningococcal disease in 2009. This dropped to 68 to 2013.
Between 2007 and 2014, New Zealand had between 43 and 132 cases of meningococcal disease a year, including between 3 and 13 deaths, with an overall downward trend.