A new coroner's inquiry into the 2009 death of an Auckland student from meningococcal disease has begun, with his parents giving a harrowing account of his final hours in hospital.
An anonymous letter, the details of which are suppressed, sparked the second inquest into the death of Zachary Gravatt.
Zachary died 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.
The 22-year-old was killed by septicaemia from the C-strain meningococcal bacteria.
His death was sudden and unexpected.
Parents Lance and Jennifer Gravatt recalled their final hours with Zachary in court today.
"I have never seen Zachary so unwell," Jennifer said.
He was listless, unable to hold a conversation and she recalled wanting to push the red button so he would receive urgent care.
"We were all suspended in an inactive zone."
His blood pressure was dropping to a "disturbingly low level".
She spoke of the moment a group of medical professionals whisked her son away, one managing a breathing bag.
"I was not given the nod to accompany him and sadly I did not."
They disappeared from sight in an elevator.
"We were told they were just getting him settled and then we could go in and see him."
A nurse escorted the family into the whānau room.
"Once there we were told things were not looking good," she said.
They were "recoiling" from that news when a nurse burst in to say they needed to run if they wanted to say goodbye to Zachary.
Looking on through an internal window Jennifer could see they were too late, her son had died, and at first her husband could not bring himself to come into the room.
"I could not see that Zachary was hooked up to any machines," she said.
"There were none that appeared to be turned on or working.
"The nurses with Zachary were crying."
She stayed to talk to her son, stroking his hair while the nurses removed the tubes.
She was asked if they wanted to take a print of her son's hand and was shocked that rigor mortis had already begun to set in but they were able to take a print, she said.
"I remembered thinking he must have died some time ago for this to be the case."
Lance spoke of being "strongly motivated" to go into the hospital first thing in the morning the next day to thank the doctors for everything they had done to try and save him.
In those discussions, he said, staff were surprised at how quickly Zachary had deteriorated and died.
While they were still waiting for the blood result to confirm what infection it was there was suspicion that Zachary had died of meningococcal, Lance said.
"And then we went to the mortuary to say a prayer for Zachary before his autopsy."
In 2013, the DHB gave 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 but neither party would reveal the sum.
Lance previously told the Herald both he and his wife had suffered mental health problems after their son's death.
He had said that he - but not his wife - was still receiving the assistance of mental health services.
The loss still sadden them both and, after speaking to the court, Lance did not feel there was more he could say about his son.
"Not without bursting into tears."