"But we have always acknowledged to the Raman family that it's possible she may have survived, had she received earlier treatment. Misdiagnosing meningococcal septicaemia as influenza is every healthcare worker's worst nightmare. In the early stages, 12 to 36 hours, the two illnesses are clinically indistinguishable."
Details emerged this week of another victim's demise with the disease. Northlander Ben Brown, aged 18, died in Whangarei Hospital last Saturday. His father, Darren Brown, said his son had been sent home twice by doctors, before being admitted to hospital. The family felt let down by the health system.
Ben Brown is the fifth person to die of meningococcal disease in New Zealand since late July, but health authorities say the bacterial disease's incidence is not unusually high this year.
In a letter to Mr Raman, of Kelston in West Auckland, Dr Smith and St John's northern regional operations manager, Murray Holt, say "sorry" 10 times.
Mrs Raman, a Work and Income employee and mother of two boys, had a sore neck after attending a conference last September.
The next day a doctor prescribed painkillers. When the pain had spread and worsened by late that night, Mr Raman phoned for an ambulance.
"I told them, 'My wife is in pain'," Mr Raman said. "They told me she's not dying, they can't come."
The St John letter said all ambulances were tied up at that time, and also when Mr Raman called again, at 11.47pm. An ambulance, dispatched at 12.22pm, arrived 33 minutes later.
The call was considered non-urgent because the chief complaint was sore muscles, rarely a life-threatening condition in the absence of other symptoms - but St John apologised for how long the Ramans had to wait.
The crew thought Mrs Raman had influenza and that taking her to hospital was not warranted.
At 2am, Mr Raman and one of the couple's sons took Mrs Raman to Henderson's after-hours medical centre. A doctor there called an ambulance. It arrived at 3.30am and took Mrs Raman to Auckland City Hospital. She had to be resuscitated on the way. She died at 5.30am, of meningococcal blood poisoning.
The letter said the first ambulance crew should have made an electrical recording of her heart and measured her oxygen level. And they missed two subtle aspects of her condition: the absence of a cough and sore throat; and the fact that she was so sore she couldn't walk properly.
It was "highly unlikely" that doing the tests and recognising the subtle signs would have led to the correct diagnosis, but they "may have resulted in them realising that Pushpa did not have influenza".
"We are very sorry that we made the wrong diagnosis and we are very sorry that we did not take Pushpa to hospital."
St John was changing its training and procedures as a result of the case.
Mr Raman said his wife's medical care was unacceptable and others were likely to suffer the same fate. Everyone with flu-like symptoms should be blood-tested for meningococcal disease.
But doctors say this is not the answer because meningococcal bacteria do not always enter the blood and when they do, the culture test takes two days. Nor is a lumbar puncture test always justified, because it can cause complications.
Health and Disability Commissioner Anthony Hill is assessing Mrs Raman's case to decide whether to formally investigate.
