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Fears, frustrations and critical risks highlighted in report on Hawke’s Bay hospital



Doctors have been grappling with mistrust around information entered into the IT systems at Hawke’s Bay hospital, including what it tells them about patients and critical scan results.

A newly released report has revealed 15 critical risks that assessors found in late June, before suspending the radiology department’s international accreditation in July.

It described reporting gaps which critical results about patient health had slipped through.

“The uncertainty of the delivery of [scan] reports was of particular concern for the radiologists, adding to their stress.”

“Mistrust” and frustration are mentioned five times in the short report by International Accreditation, or IANZ, released to RNZ.

Read the report: IANZ – Hawke’s Bay Surveillance Assessment, June 2023 (964K)
“There was an inherent mistrust of the system” among senior doctors, it said.

Staff “were overworked, tired and frustrated, and they have become fearful not of ‘if’, but ‘when’, a major incident of patient harm will occur”, it said – and indeed, there were documented cases of harm, it added.

One failing was that the radiology IT system and the clinical IT were not able to share critical results.

They were “not integrated” and “therefore reports are not automatically sent out”.

“Critical results are sent out via a manual process or a phone call if the referrer can be identified.”

But the system often failed to show which doctor had made a referral.

“There is no way to easily identify the referrer and unnecessary time is spent doing so.”

Referrals by GPs for a scan were having to be typed into the system.

The system was stabilised in May but problems persisted, it said.

Doctors were being forced to work after-hours to get scan reporting done.

Te Whatu Ora: two reviews into patient records
Te Whatu Ora was now randomly going through patient records in Hawke’s Bay to find any harm that had gone unreported.

The agency said a review of a risk register “did not find a significant number of harm events logged, and those which had been are all being investigated”.

But this was during a period of low reporting, it said, so it had begun a second review, this one of random patient records, to find unreported events of harm, or potential harm

Cases would be managed as they were found.

And once it had looked through a large enough sample, it would be in a better position to assess the rate of harm.

It said the concerns of the local community and radiology staff had been heard.

“Substantial work has been in place for some time to stabilise and enhance the reporting system, and this work will continue under a governance group,” it said in a statement.

Latest IANZ report adds to issues raised in earlier review and report
But poor reporting had harmed patients, IANZ said. At least four events were being investigated in August; RNZ has asked Te Whatu Ora for an update.

The IANZ report comes on top of a scathing external review in April of the district’s radiology, which Te Whatu Ora had kept under wraps for months.

Once it was forced to release the report in August, the agency then told the public all the risks were being dealt with.

The Minister of Health echoed this, saying the “immediate safety risks” at Hastings hospital (Hawke’s Bay hospital) had been addressed. She added the way IT was set up there, “is not present in other hospitals”.

However, an internal agency report last September about radiology reporting problems across the whole central region – from Hastings to Wellington to Whanganui – stated:

“The risks are alarming to read considering the serious nature and length of time they have been present.

“… these risks have been present for a long time in many districts in the region … The risks are present and we must address them.”

It listed failings that echoed Hawke’s Bay’s, including:

A “missing clinical result” from a scan; “delayed or missed communication of clinical result”; “reduced capacity/clinical capability due to lack of integration”; and “unavailability/poor performance of system”.

Hastings’ radiology system was upgraded in May 2023 and had been “stabilised” – and new rooms were being built for it – but the problems remained “unresolved” as of late June.

Similarly, Hutt Hospital’s radiology IT had just been upgraded, but was rated as “high risk” just last month by IANZ. Counties Manukau’s system was, too.

The mid-2023 IANZ assessment at Hastings said problems with its clinical IT portal “were common across other hospital services including Medical Laboratory and Cardiology”.

“Discussion with key staff indicated they were frustrated by the system and the lack of perceived engagement from IT to resolve the issues.”

On top of that, Hawke’s Bay was short of doctors and medical technicians, with vacancies worst for radiologists, the assessment said.

Cyclone Gabrielle’s impacts had made trying to recruit harder, the hospital told IANZ, when it pleaded in May 2023 for the assessment to be postponed. “We … cannot stress enough the impact that Cyclone Gabrielle has had,” it said.

IANZ went ahead anyway, finding that the staff shortages and IT woes had combined to present “several recognised and documented critical risk of patient harm issues … which remain critical even after controls were applied”.

The problems have added to the long wait lists for scans.

Routine scans have a six-week target to get done, but at Hastings this had blown out by midyear to:

2-6 months to get a CT scan
MR 2 months
Nuclear medicine 3-4 months
Community-referred ultrasound 3-4 months
Steroid injections up to a year
Fine-needle aspirations up to 5 months
The hospital continues to deliver radiology services.

Te Whatu Ora has repeatedly told the public that the “tireless work of our clinical staff” ensured the services were safe.

But the assessors in June reported back that “discussion with key staff identified low morale, staff were overworked and frustrated with inefficient workflow”.

The health agency did not mention frustration or mistrust in its media release about Hawke’s Bay’s suspension in July, though these featured in IANZ’s findings.

Te Whatu Ora was due to report back to IANZ last week on what safeguards it had put in place. RNZ asked for an update.

If it does not fix things properly within a year, Hastings will have its accreditation formally withdrawn, as happened recently to Palmerston North Hospital.



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Christchurch terror attack inquest: ‘Significant blind spot’ relating to St John’s specialist paramedics – coroner



A woman who was forced to leave the side of her bleeding husband following the terror attack at Christchurch’s Linwood Islamic Centre only discovered he had died the following day after seeking help from then-prime minister Jacinda Ardern.

Saira Patel’s husband Musa Patel was one of seven people who died after being shot at the Linwood Islamic Centre, following the massacre at nearby Al Noor Mosque on 15 March 2019.

Supported by her son, Patel told the inquest into the deaths that she and her husband were praying in separate parts of the mosque on the day of the attack.

Patel said she thought a tyre had blown when she heard a loud bang. A baby began to cry, and she could soon smell gunpowder.

She yelled, “Someone is shooting, someone is shooting” as people ran to escape.

When Patel found her bleeding husband, she told the Coroners Court she could hear him saying his “last prayer” as if he knew he was about to die.

Imam Hafiz Musa Patel

Musa Patel died at Linwood Islamic Centre on 15 March 2019. Photo: Facebook/ US Embassy Suva

She said she was forced to leave when police arrived and started treating Musa Patel, an order that distressed her to this day.

“I think any dying person who is about to leave this world would be very desperately craving and needing to be close to their loved ones. My presence during his final moments would have made a big difference in my life and I think maybe his last moments of departing this world,” she said.

She did not know her husband had died until the following day, when she approached then-prime minister Jacinda Ardern, who led her to a counsellor.

Patel said the counsellor showed her a photo of an unidentified man in hospital who was not her husband.

“I knew then that my husband was dead. There was no-one else who could have identified him, and this last unidentified man was my last hope,” she said.

Patel thanked the doctors and paramedics who did everything they could to console her husband in his final moments.

“I would like to thank them from the bottom of my heart,” she said.

“I was trying to be with him in that last moment but maybe they were chosen to be with him.”

Dr Alison Wooding from nearby Piki Te Ora Medical Centre was one of the doctors who treated Musa Patel when staff went to the mosque to help the injured.

She told the court he was meant to be the first victim taken to hospital but realised he had died after he was moved onto a stretcher.

Wooding said she and others were talking to Musa Patel the entire time they cared for him, but she did not recall him ever responding.

Police officers gave evidence on Tuesday saying Musa Patel had been able to communicate with them at first but his condition deteriorated over time.

Wooding told the court she felt apprehensive and worried about the situation at the mosque, but safe and protected between armed and vigilant police officers.

29th November 2023 Iain McGregor/The Press/Pool Christchurch Masjidain Attack Coronial hearing. Coroner Brigitte Windley.

Deputy chief coroner Brigitte Windley. Photo: The Press / Iain McGregor

‘Significant blind spot’ relating to St John emergency response team – coroner

The coroner has queried a “significant blind spot” in the way St John ambulance officers work with specialist paramedics trained to work in dangerous situations.

Deputy chief coroner Brigitte Windley questioned St John duty manager Bruce Chubb about the organisation’s response massacre.

Two Special Emergency Response Team (SERT) paramedics were among ambulance officers who went to the scene of the shooting in Linwood Avenue.

No-one from St John attended the Al Noor scene in a SERT capacity.

Chubb told the Coroners Court that SERT teams worked under police and it was not uncommon for St John not to know when they had been requested, where they were, or what they were doing.

In response, coroner Windley said: “My concern is that that creates a significant blind spot for St John, doesn’t it?”

“Isn’t it that these are critical resources in terms of closing that care gap for people who are dying and injured and being able to get a response in, and you’ve got no visibility about where they are and even if in fact they’ve been deployed?”

041223 CHRIS SKELTON Witness, Bruce Chubb from St John command and control during the Christchurch terror attack inquest held at the Christchurch Justice precinct.

St John’s Bruce Chubb. Photo: Stuff / Chris Skelton

Chubb said he was not suggesting it was “okay” that St John did not know where SERT officers were but said it was the practice at the time.

He was not aware of any changes to the SERT policy since the terror attack.

Chubb told the coroner he thought it was “always nice to know” where resources were, to which she replied, “I would suggest it’s more than nice to know. I would suggest that St John needs to know”.

Chubb earlier told the inquest that he believed general ambulance officers should not have entered either mosque immediately after the shootings because of the safety risk.

Windley said the court was concerned St John ambulance officers had to breach the organisation’s policy in order to get an emergency response in place.

“Do you agree that that’s fundamentally a problem?” she asked.

“Yes,” Chubb replied.

Earlier on Tuesday, Chubb told counsel for families Kathryn Dalziel that the terror attack was a catastrophic event that he did not expect and was never prepared for.

“I don’t believe any of my colleagues were either, so it was fundamentally overwhelming,” he said.

The inquest will examine the following 10 issues over seven weeks:

  • Events of 15 March 2019 from the commencement of the attack until the terrorist’s formal interview by police
  • Response times and entry processes of police and ambulance officers at each mosque
  • Triage and medical response at each mosque
  • The steps that were taken to apprehend the offender
  • The role of, and processes undertaken by, Christchurch Hospital in responding to the attack
  • Coordination between emergency services and first responders
  • Whether the terrorist had any direct assistance from any other person on 15 March 2019
  • If raised by immediate family, and to the extent it can be ascertained, the final movements and time of death for each of the deceased
  • The cause of death for each of the victims and whether any deaths could have been avoided
  • Whether Al Noor Mosque emergency exit door in the southeast corner of the main prayer room failed to function during the attack and, if so, why?

The inquest continues.


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Protests raise questions about next year’s Waitangi day



In the wake of protests over the new government’s policies on co-governance and the Treaty, the head of the Waitangi National Trust Board says it is important Treaty partners front up and have a conversation on 6 February.

Prime Minister Christopher Luxon says he intends to visit for Waitangi Day, as does ACT’s David Seymour.

The protests taking place across New Zealand on Tuesday were part of a “National Māori Action Day”, led by Te Pāti Māori and iwi, to challenge the government over its policies on the Treaty of Waitangi, and other policies affecting Māori.

Waitangi National Trust Board chairperson Pita Tipene expected for that sentiment to flow through on Waitangi Day.

“Clearly, the Māori people see it as an attack on the Treaty of Waitangi and the constitutional basis of this country,” Tipene said.

These include switching from Māori to English names on various government departments, rewriting legislation to make mentions of the principles of the Treaty more specific, and progressing an ACT bill calling for the principles to be set down under its own prescription, rather than decades of jurisprudence.


Ngāti Hine leader Pita Tipene

Ngāti Hine leader Pita Tipene Photo: RNZ

Tipene told Checkpoint there was no invite list for politicians per se, and the doors of the Trust were open for all to come along.

“Given that it is a Waitangi Day commemorations period, it’s really important that the Treaty of Waitangi is the focus, and therefore the Treaty partners should front up and have a conversation.”

He would be disappointed, but not surprised, if parties in government were not represented there on the day.

“It has happened before where governments or political parties have chosen not to front up at Waitangi.”


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Te Pāti Māori protests – Day of action focuses on new government’s Māori policies



Police says protesters are causing widespread delays at key transport networks around the North Island, but there have been no arrests so far.

A police spokesperson says commuters should allow travel time this morning, with Te Pāti Māori’s planned protests disrupting travel routes.

There are large gatherings in Tāmaki Makaurau and central Wellington, along with a number of other cities and towns.

The spokesperson says Auckland motorists are advised there are heavy delays on parts of the motorway network this morning.

The demonstrations are in response to Te Pāti Māori’s call for action against the new government’s policies on co-governance and the Treaty.


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