A doctor's evidence about being stuck in bad traffic while rushing back to hospital to attend to a young man who died soon after of meningococcal disease has been slapped down by a coroner.
But Coroner Morag McDowell has also found that even if the doctor had got back to Auckland City Hospital sooner, it would have been unlikely to have changed the outcome for Zachary Gravatt.
A fourth-year medical student, Gravatt, 22, died at the hospital on Wednesday, July 8, 2009. A second inquest into his death was held last October after an anonymous letter which claimed to be from an Auckland District Health Board staffer alleged a "cover up".
The on-call doctor, whose name is suppressed, and a medical colleague from the hospital were at a Japanese restaurant in Ponsonby when he received the first call about Gravatt. The call was said at the inquest to have ended at 6.14pm, 61 minutes before Gravatt died.
Both returned, separately, to the hospital.
In findings issued today, McDowell said there was uncertainty over the timing of the first call and how long it took the doctor to return to the hospital. The range was 35 to 50 minutes.
The doctor had said he was "dead stopped" in traffic in Newton Gully, McDowell wrote. This was the first time during her inquiry that he had identified traffic as the cause of his delayed return. It was surprising he hadn't raised it before giving oral evidence and it was not put to relevant witnesses.
None of those witnesses had independently indicated traffic might have delayed the doctor.
Gravatt's parents, Lance and Jennifer, later provided traffic counts and the doctor's lawyer supplied a Google Maps journey-time estimate, but it wasn't necessary to put any weight on that information.
"There is no support for the proposition that there were extreme traffic delays on the day in question," McDowell said.
"I am not prepared to accept, on the basis of [the doctor's] evidence alone, that there was traffic congestion in Newton Gully and Ponsonby Rd on the relevant night which delayed his return to the hospital."
"... I am satisfied that [the doctor's] return to the hospital was longer than what might be expected of a 2.8km journey; that it was in excess of 20 minutes, and in the range of between 35-50 minutes (approximately)."
The coroner noted that a nurse - name-suppressed - had made a flippant comment about the doctor needing to finish dessert, however "there is no evidence that this was the actual reason for any delay in his return to the hospital".
She also noted Lance and Jennifer Gravatt's suggestion that emergency on-call staff who are off-site should carry a flashing light to put on their vehicles, as provided for in the Land Transport (Road User) Rule 2004. But she was reluctant to make a firm recommendation.
"If Auckland DHB consider there might be value in the use of emergency beacons, it is suggested that it engage in appropriate liaison with the New Zealand Police."
Gravatt had gone to a GP and was taken to hospital by ambulance, arriving shortly before 1.43pm. He was assessed and attended to by several clinicians, during which his condition continued to worsen. At about 6.40pm he was transferred to an intensive care unit, where he died at 7.15pm.
McDowell said the weight of expert evidence supported the findings of an earlier investigation and the first inquest's findings that Gravatt "met the criteria for a Code Red" between 4.15pm and 5pm.
Had a Code Red been called, an intensive care registrar (specialist in training) would have seen Gravatt earlier than occurred.
"... it is therefore likely that the severity of his illness would have been realised earlier and transfer to the Department of Critical Care Medicine [an intensive care unit] would have occurred earlier."
But she also notes expert consensus that there was an "appropriate escalation of care" at around 5pm and that there were "no unreasonable delays" once the intensive care registrar was involved.