medical malpractice cover up in new zealand courts
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Medical Malpractice, Judicial Corruption, New Zealand, Ultra ViresTRANSCRIPT
IN THE SUPREME COURT OF NEW ZEALAND
[2013] NZSC 98/2013
SC 23/2013
CIV 2011-404-006634
CA723/2012
BETWEEN PAULINE JANICE HARRISON
Sister and Inquest Representative for
MALCOLM ARMSTRONG HARRISON
(Victim)
First Appellant (Plaintiff)
AND ANGELA JANICE HARRISON
Niece and Inquest Representative for
MALCOLM ARMSTRONG HARRISON
(Victim)
Second Appellant (Plaintiff)
AND AUCKLAND DISTRICT HEALTH BOARD
First Respondent (Defendant)
AND ANNE O’CALLAGHAN
Second Respondent (Defendant)
AND KATHERINE JANE RIX-TROTT
Third Respondent (Defendant)
AND AROHA WAAKA
Fourth Respondent (Defendant)
AND HEALTH AND DISABILITY
COMMISSIONER
Fifth Respondent (Defendant)
AND CORONIAL SERVICES UNIT
Sixth Respondent (Defendant)
SUBMISSIONS OF APPELLANTS
27 NOVEMBER 2013
APPLICATION FOR RECALL OF DECISION
JUDGES MCGRATH, WILLIAM YOUNG, GLAZEBROOK JJ
Filed by Appellants in person. Address for service: 38 Damien Place, Bromley, Christchurch 8062
Facsimile (03) 942-6557, email [email protected]
1
SUBMISSIONS FOR RECALL OF DECISION DATED 15 OCTOBER 2013 OF
MCGRATH, WILLIAM YOUNG AND GLAZEBROOK JJ
Copy United Nations Human Rights Council
Counsel for respondents 5
The appellants are concerned that it has been observed that some judges are not
thoroughly reading the appellants documents and are either skimming the contents
which is impacting on the quality of the decision making or they are not bothering to
read them at all and brushing off serious important prima facie court proceedings 10
which truth, justice and equity under the law require to proceed to substantive trial for
truth, justice and equity to be meaningfully realised and for core inalienable human and
individual rights protected and preserved in the Rule of Law to be upheld and it is a
serious and important public interest when human and individual rights are being
obstructed and denied. 15
RESPONSIBILITY OF SUPREME COURT – JUSTICIABLE PROCEEDINGS FOR
ENFORCEMENT OF VIOLATED FUNDAMENTAL HUMAN AND INDIVIDUAL
RIGHTS EMBODIED IN THE RULE OF LAW
20
Human Rights are inherent, inalienable and universal and are being treated as relics. Human
Rights are inherent, in that they belong to everyone because of their common humanity.
This is a case of public interest importance to uphold the victim’s Rights and to safeguard
against repetition of dangerous practices in a metropolitan hospital funded out of the public
purse which are capable of being repeated again and have been since the wrongful death of 25
Mr Malcolm Armstrong Harrison. The substantive prima facie case is being interfered with
by obstruction of court officers and the respondents to stop it from getting to the inalienable
Right of a fair trial and this obstruction is inequitable, unfair and unjust, against the core
principles of Rule of Law. Human Rights are inalienable, in that people cannot give them up
or be deprived of them by governments. In the separation of powers the Judiciary is a 30
branch of the Government. Human Rights are universal, in that they apply regardless of race,
sex, language or religion or other distinctions.
2
The provisions of statute Law and Equity under the Rule of Law preserve and protect the
victim Mr Malcolm Armstrong Harrison’s Rights, the Rights of his family who care, and the 35
Rights of the public at large who are entitled to the natural confidence of medical safety
standards and guidelines being adhered to. These are fundamental Rights under the
International Covenant on Civil and Political Rights which was ratified by New Zealand on
28 December 1978 which the Ministry of Justice is responsible for administering.
40
INCONSISTENCY - It is offensive to the appellants that Nicholas REEKIE, convicted child
molester and serial rapist has exploiting this moral high ground case for his own benefit and
we do not approve. It has come to the Appellants attention that recently Leave to Appeal
against Security for Costs has been granted to a convicted child molester and serial rapist
Nicholas REEKIE by the same judges of the Supreme Court who have perversely and 45
inconsistently declined an Application for Leave to Appeal against Security for Costs made
by the Appellants who are fighting for the inalienable Rights of Mr Malcolm Armstrong
Harrison an innocent victim of lethal malpractice proven by solid evidence and backed by the
Rule of Law and for the inalienable Rights of the public at large, and this fight is justified as
demonstrated by the wrongful deaths of Mrs Shirley Curtis in 2011 after Metoprolol overdose 50
at North Shore Hospital and Mr Zachary Gravatt in 2009 from suboptimal care at Auckland
City Hospital which happened subsequent to the Appellants drawing genuine concerns to the
notice of Auckland District Health Board Management, the Coronial Services Unit, the
Health and Disability Commissioner, and the Attorney-General, none of whom would take
notice. Waitemata District Health Board owned up about Mrs Curtis. This is contrasted with 55
Auckland District Health Board who make it hard for the families of victims of malpractice
as shown by this case and the case of the family of Mr Zachary Gravatt.
It has been proven that the lethal malpractice is capable of repetition, as evidenced by at least
two more deaths from malpractice since cover up of the truth of the lethal malpractice to 60
Mr Malcolm Armstrong Harrison. These successive deaths from malpractice disprove the
words of McGrath, William Young and Glazebrook JJ. This case is a serious and important
public interest case. The victim’s and public’s Right to safety cannot be diminished and
undermined as these judges are doing. To diminish and undermine inalienable human and
individual rights is repugnant to the Rule of Law. Human and individual Rights are 65
inseparable from the Rule of Law. Obstruction of justice is not an option under the Law.
3
This is an important human rights case with serious issues. Truth, justice and equity require
it be brought to a fair trial.
MEDICAL INSURANCE INDEMNITY - The second, third and fourth respondents are 70
fully indemnified with medical liability insurance which they did not disclose to the
appellants or to the Court until faced. Information from the New Zealand Nurses
Organisation for instance shows that nurses are covered up to $500,000.00 for each claim, to
a total of $1,000,000 per year. NZNO pays any excess under the indemnity insurance policy,
so nurses doesn’t have to. The NZNO recognises that nurses can be “sued” for their actions, 75
as do the indemnifiers of doctors. The respondents have been less than honest in this regard.
The appellants have no desire for blood money from the respondents and bring the
substantive case for human rights on moral high ground, and the facts and merits of the
serious and important issues of this case which cannot be ignored.
80
Auckland District Health Board and the second, third and fourth defendants breached their
duty of safe standard of care when they cast aside accepted medical and pharmaceutical
standards and guidelines and caused unbearable anguish and a tortured wrongful death and
did not provide services of an appropriate standard because of a battery of sub-optimal
processes and practices in Ward 81 and Ward 34 which have never been brought to account 85
and the risk of danger continues to other unsuspecting patients and their families. The fifth
and sixth defendants have monstrously covered up in the face of solid evidence and their
duty, responsibility and obligation to victims under the Acts which bind them.
It is unfair, unjust and inequitable that the same judges who refused Leave to Appeal in this 90
principled human and individual rights prima facie case with strong merits and solid facts and
the Rule of Law, on the other hand perversely inconsistently granted Leave to Appeal to
convicted child molester and serial rapist Nicholas REEKIE in Reekie v Attorney-General &
Ors in [2013] NZSC74, 25 July 2013 who has reportedly as published publicly been up to
things like smearing faeces over one prisoner’s cell window and told another “he looked like 95
an 11-year-old boy and he would love to rape him”, has ruined innocent people's lives and
comes to the Court to claw money out of the Crown for himself. If anything is a perversity,
that inconsistency is. In good conscience and principle such perverse inconsistency doesn’t
speak of justice and equity at all when these same judges refuse Leave to Appeal for a
principled and moral high ground case and grant largess to Mr Reekie who, on reading his 100
4
application, simply made a bare request for leave and got it. The decision is delinquent
against the Rule of Law and against human and individual rights which are inseparable and
has a strong Barabbas taint.
McGrath, William Young and Glazebrook JJ have no legal authorities to rely on in their 105
Decision. The law and the evidence and equity back this case.
Paragraph [2] of the Decision is erroneous against the Victims’ Rights Act 2002 on standing.
The paragraph also fails to acknowledge that human rights are inalienable meaning that no
executor is entitled to overrule inherent human Rights of a victim which these judges are 110
erroneously suggesting. Section 4 and the whole Victim’s Rights Act 2002 recognises a
victim’s family has standing and becomes victims also. The erroneous paragraph in the
decision also ignores the Rule of Law Argument. It would be repugnant to the Rule of Law if
judges encouraged perpetrators of wrongful death to walk free.
115
The Decision has not addressed the elements of the Application for Appeal in the Court’s
case summary Case Number SC 23/2013: Civil Appeal – Bill of Rights Act 1990, s 27 –
Medical malpractice – Whether the Associate Judge had jurisdiction to strike out the claim or
acted ultra vires in doing so – Whether the Associate Judge was correct to hold that the
statement of claim disclosed no reasonable cause of action against the defendants – Whether 120
the Associate Judge was correct to hold that the statement of claim was vexatious and an
abuse of process – Whether the Court of Appeal erred in refusing to dispense with security
for costs. CA 723/2012.
Paragraph [6] of McGrath, William Young and Glazebrook JJ’s decision loses more 125
momentum through their incongruous assumption about Parliament when their comment in
paragraph [6] of their decision is weighed against the actual reasons why the Privy Council
was replaced with the Supreme Court and the work that went behind the scenes to establish
what was intended by Parliament to be improved accessibility to New Zealand’s highest
court. The aversion by these three judges to exercise their conferred power to uphold section 130
3 and section 7 of the Supreme Court Act 2003 for the purpose of improved access to
New Zealand’s highest court spoils the law.
5
The intention for the Supreme Court replacing the Privy Council is further explicitly shown
in the Foreward of Margaret Wilson, Attorney-General and Associate Minister of Justice, in 135
the Report of the Advisory Group first published in April 2002 by the Office of the Attorney-
General Parliament Buildings,1 entitled:
REPLACING THE PRIVY COUNCIL
A NEW SUPREME COURT 140
The Report of the Advisory Group is in accordance with the purpose and scope of the
Supreme Court Act 2003 which followed afterwards, and in particular sections 3, 5 and 7 of
the Act. The Foreward of the Report states: (emphasis added with bold text)
145
The Advisory Group chaired by the Solicitor-General, Mr Terence Arnold
QC, and comprised senior legal practitioners – experienced in a wide range
of the law, including commercial and litigation practice – and leaders of the
Māori community. In addition, Sir Ivor Richardson, President of the Court
of Appeal, shared his considerable knowledge of appellate Court processes, 150 as a Special Advisor.
On 13 March 2002 I received the Advisory Group’s report. The Advisory
Group has carefully examined the issues and has achieved a remarkable
degree of unity in its conclusions. In particular I note the Advisory Group’s 155 conclusion that
If recommendations of the type made in this report are implemented, the
Advisory Group believes that replacing the Privy Council with the Supreme
Court should: 160
improve accessibility to New Zealand’s highest court;
increase the range of matters considered by New Zealand’s highest court;
improve the understanding of local conditions by judges on
New Zealand’s highest court. 165
MORE INCONSISTENCY
Paragraph [6] of the decision further pales with inconsistency. Glazebrook J inconsistently
argues against section 7 of the Act to inhibit the clear robustness and scope of the Act, while 170
1 ISBN 0-478-20172-9
6
on the other hand Glazebrook J argues for section 7 of the Act in Vincent Ross Siemer v
Solicitor-General [SC 37/2-12 [2013] NZSC Trans 2 by inconsistently postulating that she
wouldn’t have thought that the right to a fair trial is one that is other than a total right. The
key word being “total”. See screenshot:
175
The preponderance of authority clearly establishes the intention of Parliament to improve
accessibility and increase the range of matters considered by New Zealand’s highest court,
not inhibit as these judges decision demonstrates. McGrath, William Young and Glazebrook
JJ’s decision is ultra vires of the purpose and scope of the Act made by Parliament.
180
McGrath, William Young and Glazebrook JJ unilaterally and arbitrarily erroneously
postulated that Parliament cannot have envisaged that this jurisdiction would extend to
decisions by a Registrar which are reviewable by, and subsumed in the decision of, a Court of
Appeal Judge.
185
McGrath, William Young and Glazebrook JJ’s suggestion is without substance and is
repugnant to the purpose and scope which are set out in the Act significantly to “improve”
access to justice in section 3, and to “increase” the range of matters as set out in section 7
which unequivocally says “any decision”, and section 5 of the Act binds the Crown which
requires courts to uphold the provisions of the statute. 190
The decision is also utterly void of a preponderance of authority, which is not good enough
from New Zealand’s highest court by legal, equitable, moral, and ethical standards.
The inattention to equity and the strong merits and weight of facts and law which the
substantive case is based on is disrespectful to the seriousness and importance of this prima 195
facie case where an innocent victim was caused to scream out in anguish from being refused
the necessaries of life and subjected to a constellation of inexcusable gross departures from
universal safety standards and guidelines causing tortured wrongful death, and these serious
7
breaches of safety are capable of repetition because of judges who don’t show responsibility
to care. This prima facie case is a matter of serious and important public interest for safety 200
and this fact is underscored epidemiologically. A Report prepared for the New Zealand
Ministry of Health by Rebecca McDowell, Jeff Fowles and David Phillips in April 2003
entitled Surveillance of Chemical Induced Mortality in New Zealand from Coronial
Services Office data states that death from chemical injury in New Zealand is not negligible,
in particular Methadone and drug combinations causing mortality. 205
It is against good conscience for anyone, particularly the courts, to cast aside the Rule of Law
by fobbing off imperative human and individual rights which are public interest importance.
GENERAL APPEAL 210
The Report of the Advisory Group to the Attorney-General and Associate Minister of Justice
entitled REPLACING THE PRIVY COUNCIL: A NEW SUPREME COURT dated
April 2002 further says on page 11 at paragraph 11.1:
215
Given that the Supreme Court will have an error correction role, appeals to the Court
should, in principle, be available on issues of fact as well as law.
The unsupported ‘Reasons’ in the decision of McGrath, William Young and Glazebrook JJ
are inconsistent with the intention and purpose of the law and are legally and morally 220
impotent against the serious and important issues of public interest importance of gross lethal
medical malpractice capable of repetition. and violated individual and human rights which
are protected and preserved under the Rule of Law.
A COURT OF COMPETENT JURISDICTION 225
Access to Justice is a democratic safeguard guaranteed by various Charter prerogatives in line
with principles of Fundamental Justice which the courts cannot deny for reasons involving
budgetary concerns. Section 24 subsection 1 of the Canadian Charter of Rights and
Freedoms reads: 230
8
Anyone whose rights or freedoms, as guaranteed by this Charter, have been
infringed or denied may apply to a court of competent jurisdiction to obtain
such remedy as the court considers appropriate and just in the circumstances.
A judicial dilemma arises when courts acting under the Rule of Law fail to guarantee access 235
to Justice to applicants seeking appeal of erroneous lower court decisions.
The Supreme Court should perform error correction and it is failing its responsibility by
obstructing prima facie appeals.
240
JUSTICE AND THE NEW ZEALAND CONSTITUTION
No branch of Government2 may act unconstitutionally. No branch is above the Law.
No public official may act arbitrarily or unilaterally outside the Law (ultra vires). No written
law may be enforced by the branches unless it conforms with the unwritten, universal 245
principles of FAIRNESS, MORALITY, and JUSTICE which transcend human legal
systems.
FUNDAMENTAL JUSTICE
250
The more a person’s rights or interests are adversely affected, the more procedural or
substantive protections must be afforded to that victim in order to respect the principles of
fundamental justice.
The New Zealand Bill of Rights Act, adopted in 1990, also recognises the importance of 255
fundamental justice. Specifically section 8 of the Act which enshrines the right to life, states
in full that “No one shall be deprived of life except on such grounds as are established by law
and are consistent with the principles of fundamental justice.”
260
2 Branches of the Government: Judiciary, Legislature and Executive
9
Justice the three branches of Government to meaningfully uphold the core fundamental
principles of the RULE OF LAW and Equity.3 The Human and individual Rights are
inseparable from the Rule of Law. Justice denied is lawless and makes Anarchy.
265 PURPOSE OF THE NEW ZEALAND SUPREME COURT
The Supreme Court Act 2003 is unequivocally clear in its Purpose to improve the public’s
access to justice:
3 Purpose 270
(1) The purpose of this Act is—
(a) to establish within New Zealand a new court of final appeal
comprising New Zealand judges—
(i) to recognise that New Zealand is an independent nation
with its own history and traditions; and 275 (ii) to enable important legal matters, including legal
matters relating to the Treaty of Waitangi, to be resolved
with an understanding of New Zealand conditions, history,
and traditions; and
(iii) to improve access to justice; and 280 (b) to provide for the court's jurisdiction and related matters; and
(c) to end appeals to the Judicial Committee of the Privy Council
from decisions of New Zealand courts; and
(d) to make related amendments to certain enactments relating to
courts or judicial proceedings. 285 (2) Nothing in this Act affects New Zealand's continuing commitment to
the rule of law and the sovereignty of Parliament.
Paragraph [6] of McGrath, William Young and Glazebrook JJs decision departs from the
clearly articulated Purpose of the Principal Act set out in section 7. It is obvious from clearly 290
articulated words in section 7 formed by the Legislature branch of Government that this part
of Legislation was indeed carefully considered and that the Legislature have succeeded in
conveying their clear intention and purpose of the Act. Section 7 of the Principal Act says
precisely what it means. “Any decision” is the key and should not be undermined or skewed
which would be in conflict with the Rule of Law which the statute embodies with access to 295
justice. The decision of McGrath, William Young and Glazebrook JJ conveys an apparent
aversion and recalcitrance towards this fundamental provision in statute which binds the
Crown.
3 Section 99 Judicature Act 1908
10
ESTABLISHMENT AND JURISDICTION OF SUPREME COURT
The robust Appeal provision is clear in section 7 of the Supreme Court Act 2003: 300
7 Appeals against decisions of Court of Appeal in civil proceedings
The Supreme Court can hear and determine an appeal by a party to a civil proceeding
in the Court of Appeal against any decision made in the proceeding, unless—
(a) an enactment other than this Act makes provision to the effect that there is no
right of appeal against the decision; or 305 (b) the decision is a refusal to give leave or special leave to appeal to the
Court of Appeal. [emphasis added to “any decision”]
NEW ZEALAND MINISTRY OF JUSTICE SPEAK ON THE RULE OF LAW
310
The RULE OF LAW is a significant part of the New Zealand constitution. The Ministry of
Justice says it is the Judges’ role to apply the law to every case that comes before the Court
and act fairly and within their powers.4 It is not the intention or purpose of the Law for
perpetrators of acts of illegality to evade accountability and walk free. Wrongdoing is
accountable under the Law. The RULE OF LAW encompasses: 315
Powers are based on legal authority
There are minimum standards of justice to which the law must conform including that
laws affecting individual liberty should be reasonably certain and clear
320
The law should have safeguards against the abuse of wide discretionary powers
Unfair discrimination should not be allowed by the law
A person should not be deprived of his or her liberty, status or other substantial interest
without the opportunity of a fair hearing before an impartial court or tribunal5
325
The Ministry of Justice is responsible for administering the International Covenant on Civil
and Political Rights which was ratified by New Zealand on 28 December 1978.
The RULE OF LAW means no one, including the three branches of Government, is above
the Law; where laws protect fundamental rights; and where justice is accessible to all.6 330
4 The New Zealand Legal System – Ministry of Justice, New Zealand at
http://www.justice.govt.nz/publications/global-publications/t/the-new-zealand-legal-system 5 Ibid 6 The World Justice Project on universal principles and why the Rule of Law matters to everyone
11
INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIGHTS
New Zealand Parliament Legislature has incorporated the International Covenant on Civil
and Political Rights into New Zealand domestic law. The ‘Covenant’ states: 335
Preamble
The States Parties to the present Covenant,
Considering that, in accordance with the principles proclaimed in the Charter of the United Nations, recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and 340 peace in the world,
Recognizing that these rights derive from the inherent dignity of the human person,
Recognizing that, in accordance with the Universal Declaration of Human Rights, the ideal of free human beings enjoying civil and political freedom and freedom from fear
and want can only be achieved if conditions are created whereby everyone may enjoy 345 his civil and political rights, as well as his economic, social and cultural rights,
Considering the obligation of States under the Charter of the United Nations to promote universal respect for, and observance of, human rights and freedoms,
Realizing that the individual, having duties to other individuals and to the community to which he belongs, is under a responsibility to strive for the promotion and 350 observance of the rights recognized in the present Covenant,
Agree upon the following articles:
PART II
Article 2
1. Each State Party to the present Covenant undertakes to respect and to ensure to all 355 individuals within its territory and subject to its jurisdiction the rights recognized in the present Covenant, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.
2. Where not already provided for by existing legislative or other measures, each State 360 Party to the present Covenant undertakes to take the necessary steps, in accordance with its constitutional processes and with the provisions of the present Covenant, to adopt such laws or other measures as may be necessary to give effect to the rights recognized in the present Covenant.
3. Each State Party to the present Covenant undertakes: 365
(a) To ensure that any person whose rights or freedoms as herein recognized are violated shall have an effective remedy, notwithstanding that the violation has been committed by persons acting in an official capacity;
(b) To ensure that any person claiming such a remedy shall have his right thereto determined by competent judicial, administrative or legislative authorities, or by any 370 other competent authority provided for by the legal system of the State, and to develop the possibilities of judicial remedy;
(c) To ensure that the competent authorities shall enforce such remedies when granted.
12
PART III 375
Article 6
1. Every human being has the inherent right to life. This right shall be protected by law. No one shall be arbitrarily deprived of his life.
Article 7
No one shall be subjected to torture or to cruel, inhuman or degrading treatment or 380 punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation.
Article 23
1. The family is the natural and fundamental group unit of society and is entitled to protection by society and the State. 385
Article 26
All persons are equal before the law and are entitled without any discrimination to the equal protection of the law. In this respect, the law shall prohibit any discrimination
and guarantee to all persons equal and effective protection against discrimination on any ground such as race, colour, sex, language, religion, political or other opinion, 390 national or social origin, property, birth or other status.
UNIVERSAL DECLARATION OF HUMAN RIGHTS
On 24 October 1945 New Zealand became a Member State of the United Nations.
The Preamble of the Universal Declaration of Human Rights it reads: 395
…Whereas it is essential, if man is not to be compelled to have recourse, as a last
resort, to rebellion against tyranny and oppression, that human rights should be
protected by the rule of law.
400
… Whereas Member States have pledged themselves to achieve, in co-operation with
the United Nations, the promotion of universal respect for and observance of human
rights and fundamental freedoms. Whereas a common understanding of these rights
and freedoms is of the greatest importance for the full realization of this pledge. 405 Now, Therefore THE GENERAL ASSEMBLY proclaims THIS UNIVERSAL
DECLARATION OF HUMAN RIGHTS as a common standard of achievement for
all peoples and all nations, to the end that every individual and every organ of society,
keeping this Declaration constantly in mind, shall strive by teaching and education to
promote respect for these rights and freedoms and by progressive measures, national 410 and international, to secure their universal and effective recognition and observance,
both among the peoples of Member States themselves and among the peoples of
territories under their jurisdiction…
13
Article 3 Everyone has the right to life, liberty and security of person. Article 5 No 415 one shall be subjected to torture or to cruel, inhuman or degrading treatment or
punishment. Article 6 Everyone has the right to recognition everywhere as a person
before the law. Article 7 All are equal before the law and are entitled without any
discrimination to equal protection of the law. All are entitled to equal protection
against any discrimination in violation of this Declaration and against any incitement 420 to such discrimination. Article 8 Everyone has the right to an effective remedy by the
competent national tribunals for acts violating the fundamental rights granted him by
the constitution or by law. Article 10 Everyone is entitled in full equality to a fair and
public hearing by an independent and impartial tribunal, in the determination of his
rights and obligations and of any criminal charge against him. Article 25 (1) 425 Everyone has the right to a standard of living adequate for the health and well-being
of himself and of his family, including food, clothing, housing and medical care and
necessary social services, and the right to security in the event of unemployment,
sickness, disability, widowhood, old age or other lack of livelihood in circumstances
beyond his control. (3) Rights and freedoms may in no case be exercised contrary to 430 the purposes and principles of the United Nations.
Article 30
Nothing in this Declaration may be interpreted as implying for any State, group or
person any right to engage in any activity or to perform any act aimed at the
destruction of any of the rights and freedoms set forth herein. 435
THE LAW ALSO SAYS
EQUITY 440
Judicature Act 1908, Section 99
In cases of conflict rules of equity to prevail
Generally in all matters in which there is any conflict or variance between the rules of equity
and the rules of the common law with reference to the same matter the rules of equity shall
prevail. 445
RIGHT TO JUSTICE
New Zealand Bill of Rights Act 1990, Section 27
(1) Every person has the right to the observance of the principles of natural justice by
any tribunal or other public authority which has the power to make a determination in 450 respect of that person's rights, obligations, or interests protected or recognised by law.
(2) Every person whose rights, obligations, or interests protected or recognised by law
have been affected by a determination of any tribunal or other public authority has the
right to apply, in accordance with law, for judicial review of that determination.
(3) Every person has the right to bring civil proceedings against, and to defend civil 455 proceedings brought by, the Crown, and to have those proceedings heard, according to
law, in the same way as civil proceedings between individuals.
14
DUE PROCESS
The legal principle that the state must respect all of the legal rights that are owed to a person 460
under the law. Due process holds the state subservient to the law of the land and thus
protects individual persons from it. When a government harms a person without following
the exact course of the law, this constitutes a due-process violation, which offends against the
Rule of Law.
465
OBJECTIVE OF THE RULES
Judicature Act 1908 Schedule 2, Rule 1.2
The objective of these rules is to secure the just, speedy, and inexpensive determination of
any proceeding or interlocutory application.
470
JUSTICE, FAIRNESS AND EQUITY - Mr Harrison cannot speak for himself. His family
who care speak for his unalienable Rights which no-one is entitled to deny him after how
much he suffered with anguish and two terrible deaths. It defies human decency to mock
such heartfelt anguish by calling the victim’s unalienable Rights “vexatious” which the
respondents have tried along with other unprincipled tactics like ignoring the Victims’ Rights 475
Act 2002 which unequivocally recognises the victim’s family with standing and recognises
that the victim’s family are victims also. We have thoroughly researched Mr Harrison’s
medical records. We know what we’re talking about. We have researched the Law.
We know Mr. Harrison’s Rights, our Rights as his Family, and the Public’s Right to be
safeguarded from the same dangerous and lethal malpractices. No good family could turn 480
their back on the truth, knowing how much their loved one has suffered in anguish and
endured two terrible deaths, and do nothing. We fight for justice with good conscience and
on moral high ground for the serious and important issues of this case, because it is right, and
under the Rule of Law argument human and individual Rights must be upheld and protected.
The respondents are treating Mr Harrison’s tragic suffering and anguish of no consequence 485
and have no regard for the truth or justice of the case. Mr Harrison was a living human being
and his Rights shall not be cast out.
15
GOOD CONSCIENCE AND PRINCIPLE RECOGNISED BY THE RULE OF LAW 490
AND THE LAW AS IT PERTAINS TO EQUITY
THE SCRIPTURES WHICH ARE IN EVERY NEW ZEALAND COURTROOM
- King James Bible "Authorized Version", Cambridge Edition
495 Isaiah 59:14
And judgment is turned away backward, and justice standeth afar off: for truth is fallen in the
street, and equity cannot enter.
500
Dr Martin Luther King
In his words: “A just law is a man made code that squares with the moral law or the law of
God. An unjust law is a code that is out of harmony with the moral law.“
“One has not only a legal but a moral responsibility to obey just laws. Conversely one has a 505 moral responsibility to disobey unjust laws”
We know the victim’s and the public’s and our imperative Rights in the matter of serious
malpractice which caused anguish and tortured wrongful death, by definition culpable
homicide. 510
It is repugnant to the Law to ignore and diminish the victim Mr Malcolm Armstrong
Harrison’s Rights, the Rights of Mr Harrison’s family who care and who care for the safety
of others against ongoing repetition of lethal malpractice, and the seriousness and importance
of the general and public interest for the public at large in the grave matter of the Right to 515
life, the Right not to be deprived the necessaries of life, the Right to Safety and Dignity, the
Right not to be tortured, and the Right to Justice.
Other potential victims are at risk. This has already been proven with at least two more
unnecessary malpractice deaths in Auckland metropolitan hospitals. The courts can ignore 520
the fact no longer that there is a vacuum of gross injustice towards victims of malpractice in
New Zealand and public discontent at having Rights walked over. This is clearly articulated
in the Helen Cull Report which emphasises the public feeling.
With reference to paragraph [8] of the decision we cite the words of Lord Denning MR in 525
Re Vandervell’s Trusts (No 2), Lord Denning MR said – Every unjust decision is a reproach
16
to the law or to the judge who administers it. If the law should be in danger of doing
injustice, then equity should be called in to remedy it. This is backed up by section 99 of the
Judicature Act 1908 on Equity. Also, the existence of inherent jurisdiction means there is
never a vacuum in obtaining vindication of right according to law.7 McGrath, William 530
Young and Glazebrook JJ can not build a decision on an ultra vires decision stemming from
an Associate Judge in the Auckland High Court who has exceeded his conferred jurisdiction
outside of the law. The Supreme Court cannot lawfully perpetuate ultra vires decisions.
Associate Judge Abbott had no conferred jurisdiction to preside in open court. His decision
is ultra vires and therefore null under the law. Associate Judges cannot exceed their 535
jurisdiction and this is set out in r 2.1 the Judicature Act 1908. Under r 2.1 an Associate
Judge has the jurisdiction and powers of a Judge in chambers conferred by the Judicature Act
or these rules and other enactment. That rule has been made pursuant to 2 26J of the
Judicature Act 1908. That section allows rules to be made to confer on Associate Judges the
jurisdiction and powers of a Judge sitting in chambers. 540
The Decision places no value on inalienable human and individual Rights and fails to
safeguard the public.
The decision by McGrath William Young and Glazebrook JJ fails to acknowledge and 545
promote the Law in the Victims’ Rights Act 2002 and the New Zealand’s Bill of Rights Act
1990.
LETHAL MALPRACTICE PARTICULARISED
550
This or similar constellation of serious malpractice particularised below is capable of
repetition to other unsuspecting patients and their trusting families at Auckland City
Hospital. This metropolitan hospital is funded out of the Public’s purse. The second,
third and fourth defendants are covered with medical indemnity insurance.
Mr Malcolm Armstrong Harrison had a strong constitution. A patient of lesser 555
constitution would definitely have succumbed earlier under the battery of malpractice
assaulted on Mr Harrison’s system.
7 www.courtsofnz.govt.nz/about/high/role-structure
17
On 16 October 2007 at Waiheke Island Mr Harrison was walking on a footpath on his way
home when he sustained a great force of impact from behind that threw him forwards. 560
Biokinetics of how Mr Harrison sustained his traumatic injuries have been investigated using
forensic MADYMO simulation technology and reported by International Consulting Forensic
Engineer Dr Denis P. Wood, B.E., M.Eng.Sc.,Ph.D.,C.Eng,F.I.E.I.,Eur.Ing8 of Denis Wood
Associates, Consulting Forensic Engineers, Dublin, Ireland. Dr Wood’s forensic
biomechanic engineering report investigating various scenarios dated 15 July 2010 is 565
appended and states:
The injuries sustained by Mr. Harrison are only consistent with his being struck by
the rear of the Vogue Range Rover vehicle which was reversing at 10-15 mph or
being an impact from the front of a flat front vehicle with similar structure 570
characteristics to the rear of a Vogue Range Rover (in terms of height of bumper,
front roof rail, prominent front cross member etc.) which was travelling at 10-15
mph.
575 Measurements of the scene and vehicle which Coronial Services was not interested in are:
Width of footpath 114 cm
Width of grass verge 158 cm
Height from ground to bumper 62 cm 580
Height from ground to words ‘RANGE ROVER’ on the aluminium tailgate 106 cm
Height from ground to rain gutter dent 175 cm
Mr Harrison talked about stickers. The rear window of this vehicle had multiple stickers.
585
Dr Wood’s expert biokinetic report is corroborated in an expert report dated 26 August 2010
by world class Neuroradiologist Dr Philip Dubois MBBS, FRCR, FRANZCR9 who has
reviewed Mr Harrison’s medical record and radiology images and states:
On review of the images, I believe that the severity of the injuries is so great that they 590 cannot be attributed solely to a fall …The findings indicate severe trauma, far greater
8 Pedestrian and Cyclist Impact: A Biomechanical Perspective, by Ciaran Simms, Denis Wood, Springer – Publisher (Aug 14, 2009), The protection of pedestrians is the most important global road safety priority. This is the first book to provide a detailed treatment of the physical processes which occur when pedestrians and cyclists are struck by motorised vehicles. The principal focus is to show how pedestrian and cyclist pre-impact movements and vehicle design influence subsequent injury outcome. This involves recourse to several academic disciplines: epidemiology, mechanics, and anatomy/physiology. Therefore this book presents pedestrian and cyclist impact from a biomechanical perspective. It features a detailed treatment of the physics of pedestrian and cyclist impact, as well as a review of the accident databases and the relevant injury criteria used in the assessment of pedestrian and cyclist injuries. New data detailing the kinematics of the impact processes are presented, and the relationship between vehicle impact speed and projection distance and the relative importance of ground related injuries compared to vehicle related injuries is assessed in detail. The final focus is on the complex relationship between vehicle design and pedestrian and cyclist injury outcome in the event of a collision. This book is a "one stop" source for understanding the mechanics of pedestrian and cyclist impact and is therefore of significant value to both new and established researchers.
9 Dr Philip Dubois, Chairman, CEO and diagnostic radiologist Queensland X-Ray predominantly at the Mater Private Hospital
in Brisbane, Fellow of the Royal College of Radiologists, Fellow of the Royal Australian and New Zealand College of Radiology, and a senior member of the American Society of Neuroradiology with over 30 years experience in diagnostic imaging including CT, Ultrasound, MRI, Computed Radiography and Nuclear Medicine, and international speaker
18
than could be sustained in a fall to the ground from a standing position. Most
commonly such injuries are seen after a motor vehicle collision, following a fall from
a great height, or in combat or assault.
595
Forensic Toxicologist Dr Phillip Leveque PhD in Pharmacology, United States of America
said:
“In my opinion you do have a medical malpractice case. The first two errors at the
hospital were: (1) not having a senior physician in charge and (2) not using an ICP 600 device. As it was he was over medicated and under treated. Mr Malcolm Harrison
suffered moderately severe injuries by being hit in the back and back of the head and
from being knocked on the ground. He was initially quite alert and cognizant but
developed brain edema from his head injuries. The brain edema and faulty care
finally killed him.” 605
Traumatic injuries – coup contra-coup traumatic brain injuries including subdural
haemorrhage, subarachnoid haemorrhage, vasogenic oedema, right frontal and temporal lobe
haemorrhagic contusions, haemorrhage within the occipital horns of the cerebral lateral
ventricles and cisterna magna, haemorrhagic contusion in the left parietal lobe, undisplaced 610
full thickness basio-occipital skull fracture extending from occiput down the thick base of
skull to the edge of the foramen magnum, 1.5 cm laceration on back of head, extracranial
swelling, multiple 9/10/12 rib fractures possibly more, pneumothorax, full thickness
displaced L1-L4 vertebral lumbar transverse process fractures, large retroperitoneal
haematoma. 615
Emergency Department and transfer to the wards – Against St John Ambulance standards
the ambulance officer made Mr Harrison walk to the ambulance when he should have been
transported on the on-site hydraulic Stryker Mark II stretcher. Mr Harrison was flown to
Auckland City Hospital by Westpac Rescue Helicopter. At Auckland City Hospital the 620
Emergency Consultant Dr Robin Mitchell and his team stabilised Mr Harrison and found
there were no cardiac or cerebral causes for his traumatic injuries. At the inquest
Dr Robin Mitchell testified his expectation that Mr Harrison would have gone on to survive
his injuries and that there were no cardiac issues. He was surprised Mr Harrison had not been
transferred to the High Dependency Unit (HDU) which was his expectation also. 625
Mr Harrison’s serious condition demanded specialist monitoring, treatment and management
expertise. He was transferred from the Emergency Department to Ward 81 into the hands of
junior doctors and made to suffer unbearable anguish and two terrible deaths, first in ward 81
resulting from a battery of medical malpractice neglect and incompetence and Metoprolol
beta blocker overdose causing cardiogenic shock which they brought him back to life with 630
DC Shock and CPR, and then to be poisoned off with still more serious neglect and
malpractice with no specialist monitoring and a lethal combination of drugs which every
doctor knows is deadly. Mr Harrison’s medical record testifies to the inexcusable scandalous
constellation of serious malpractice which caused his anguished death twice over and which
is capable of repetition to other unsuspecting patients and their families and was repeated in 635
the delays and substandard care in meningococcal disease leading to the death of 22 year old
19
Zachary Gravatt also at Auckland City Hospital in 2009. Also the death of Shirley Curtis
after Metoprolol beta blocker overdose at North Shore Hospital which could have been
prevented if Coronial Services, the Health and Disability Commissioner and the Attorney-
General had listened and acted from Mr Harrison’s wrongful death instead of covering up his 640
substandard care and serious breaches of medical and pharmaceutical standards and
guidelines, because their tragic untimely deaths involved some of the same serious issues of
the malpractice against Mr Harrison that they refused to heed. It is inexcusable and criminal
neglect not even to have taken any Arterial Blood Gases after Mr Harrison left the
Emergency Department when these are fundamental and vital for traumatic brain injury and 645
respiratory monitoring which every doctor knows should be done and they never did it.
Flagrant disregard like that constitutes culpable homicide. By their acts they demonstrated
they didn’t care.
Normal physiology of Mr Harrison’s heart before it was ruined at Auckland City 650 Hospital - On admission to the Emergency Department Mr Harrison’s heart sounds were
normal (1 + II with no third sound), his ECG was unremarkable. No need for blood pressure
intervention. Troponin test normal at < 0.01 µg/L (normal range < 0.03) Mr Harrison’s
lipid10
levels taken on 25 August 2007 were excellent, Mr Harrison had excellent exercise
tolerance and was known for walking miles including up hills and steep steps. There are 655 multiple witnesses who have confirmed that Mr Harrison was feeling fine before he sustained
the traumatic injuries. A PA and lateral view chest x-ray taken on 21 August 2007 confirms
that Mr Harrison’s heart was not enlarged and his cardiac and mediastinal contour were
within normal limits. His lungs and pleural spaces were clear. In a letter to the Coronial
Services Unit received by them on 24 January 2008 Dr C Wasywich, Cardiologist, wrote 660 “cardiovascular system examination was unremarkable”. When Mr Harrison was
transferred out of the Emergency Department to Ward 81 and thereon to Ward 34 everything
turned bad and he was caused to suffer the torture of an incredible battery of one serious
malpractice after the other until in the end his system could take it no longer. This should
never have happened in a large metropolitan hospital but it did, and it has happened to others 665 since, which if Coronial Services and the Health and Disability Commission had taken notice
of, could have prevented the deaths of others. Mr Harrison was left in the hands of junior
staff who did not have the required level of expertise to manage Mr Harrison’s case. They
were still wet round the ears out of medical school and Mr Harrison should not have been left
in their hands when his signs and symptoms needed specialist Intensive Care Unit 670 monitoring, treatment and management expertise. The consultants distanced themselves from
Mr Harrison and should have taken charge when his signs and symptoms were clearly
worsening. The continual battery of malpractice assaults finally broke down Mr Harrison’s
system which anyone with a lesser constitution would have died much sooner. Mr Harrison
was not allowed to die peacefully. He suffered constant anguish from improper medical 675 management and he went through two terrible deaths, one where he was brought back to life
after Metoprolol overdose, and the other when he was refused emergency help and was
poisoned with contraindicated cardiotoxic and neurotoxic lethal drug combinations.
10 Lipid levels include Chol/HDLChol ratio 3.0 mmol/L (normal range <4.5 mmol/L) good; Cholesterol
serum 2.9 mmol/L (normal range <5.0 mmol/L) very good; HDL Cholesterol 0.9 mmol /L (Normal
range >1.0 mmol/L) slightly low; LDL Cholesterol 1.5 mmol/L (normal range <3.4 mmol/L) very good.
20
Incorrect post mortem report – Mr Harrison’s post mortem was supposed to be a forensic 680 autopsy. The standards of a forensic autopsy were not met. The post mortem report is
seriously flawed and is substandard by forensic pathology standards. The pathologist was
Dr Lloyd Denmark. Neglected to do Toxicology. No blood culture, no urine culture, no
aspiration culture, no sputum culture. Omitted to disclose profuse green secretions from
Mr Harrison’s lungs significant for bacterial infection associated with aspiration pneumonia 685 caused by respiratory depression arising from lack of precautions and suboptimal practices in
ward 34. Omitted weight of Mr Harrison’s brain significant for intracranial pressure which
was never monitored or treated by the Neurologists/Neurosurgeons in ward 81 and ignored in
ward 34, yet he reported the weight of Mr Harrison’s other organs. He took Mr Harrison’s
brain weight, which was heavy, but he left the information off his report. Omitted to disclose 690 the deep retroperitoneal haematoma. Provided no histopathology evidence under the
microscope. Provided no photograph of the traumatic blunt trauma on Mr Harrison’s head,
nor of the remarkable scratches on Mr Harrison’s hands or his injured toes and toenails which
never had time to heal. Unknown how many rib fractures, only that they were multiple. Got
the number of vertebral lumbar transverse process fractures wrong. Should have consulted a 695 Neuropathologist for Mr Harrison’s brain examination and never bothered. Should have
recalled Mr Harrison’s footwear and clothing that Mr Harrison was wearing on the day he
sustained traumatic injuries for forensic examination and never bothered. Stereotyped
Mr Harrison into a category instead of getting to the bottom of how he died. Dr Denmark did
not attend Mr Harrison’s inquest, just as he did not attend Mrs Folole Muliaga’s inquest 700 whom he also reported earlier the same year and his report was disagreed by another
pathologist, Dr Koelmeyer. Dr Sage from Christchurch appeared instead of Dr Denmark and
even though small tissue samples from Mr Harrison had been sent to him Dr Sage was unable
to produce any histopathology evidence to corroborate Dr Denmark. When asked for
histopathology reports Dr Sage refused. Dr Sage is not a qualified forensic 705 biomechanical/biokinetic engineer. Dr Lloyd Denmark, was employed by Auckland District
Health Board to work at LabPlus. He was also contracted by Coronial Services for coronial
autopsies. Prior to coming to New Zealand, Dr Denmark worked in the United Kingdom
where it is a matter of public record that he incorrectly reported the death of Mrs Linda
Grimm, a victim who was brutally struck to death in the abdomen with an electric guitar and 710 Dr Denmark reported that she died of natural causes. Mrs Grimm’s killer literally walked
free because of Denmark’s incorrect post mortem reporting and he later broke out again and
took the life of another victim named Linda Wardill. The Humberside Police became
suspicious and revealed that Denmark had incorrectly reported Mrs Grimm’s wrongful death.
Denmark leap-frogged to Alberta, Canada where he was employed as a deputy medical 715 examiner but got into trouble, faced disciplinary action and was fired. He then leap-frogged
to New Zealand and was contracted by Coronial Services to do coronial autopsies and was
employed by Auckland District Health Board at LabPlus. Whilst not attending inquests for
those he has made reports, Dr Denmark has crossed the Tasman for conferences and has
participated in a journal article. 720
Substandard care, incompetence and neglect caused Mr Harrison to be severely
dehydrated, hypoxic, hyperglycaemic, hypercapnic11
and poisoned through contraindicated
and overdosed chemical drug agents. Iatrogenic cardiogenic, hypovolemic and septic shock
causes cardiac remodelling with iatrogenic swelling and systemic infection and inflammation 725 manifesting as flared arteritis/vasculitis iatrogenic non-atherosclerotic cause of coronary
11 A condition marked by an unusually high concentration of carbon dioxide in the blood as a result of hypoventilation
21
artery narrowing. Systemic inflammation of the blood vessels is consistent with extreme
un-managed pain, nosocomial bacterial sepsis, inflammation, hyperglycaemia and shock.
The severe infection and inflammation and shock are relayed by the laboratory test results
such as CRP, Fibrinogen Assay Haemostasis Screen, Serum Ferritin level, Serum Albumin 730 and other tests and the omission of tests which medical standards require should have been
done, particularly Arterial Blood Gases, Serum Drug Concentrations and others.
Inquest – Fractured vertebral lumbar transverse processes, haemorrhagic blood in the
cerebral lateral ventricles and full thickness basio-occipital undisplaced skull fracture in 735
particular take a great force of impact to damage consistent with the large SUV 1985 Range
Rover registration plate AAH279 reversing into Mr Harrison. The rear protruding tailgate of
this large SUV with a dent at the level of Mr Harrison’s vertebral transverse processes
extended out beyond the rear bumper which no-one would listen to. After the ‘inquest’ the
vehicle was transferred into another name, deregistered and registration number plates 740
removed, then taken away from Waiheke Island and has been traced going to rack and ruin
with cobwebs over it and deteriorating at the back of a section in Te Aroha. When traced the
vehicle in this setting presented a picture of culpability. Whilst giving copies of
Mr Harrison’s medical record to others, Coronial Services coroner Ms McDowell refused to
give Mr Harrison’s inquest representatives (the appellants) a copy of Mr Harrison’s medical 745
record to study and only allowed a cursory view with someone overseeing the whole time
which was an impossible situation and never provided a fair opportunity in which to study
and research medical notes, drug charts, laboratory results and radiology reports.
The serious chain of malpractice was totally submerged at the ‘inquest’. Coroner McDowell
also refused to call essential witnesses and refused to allow the Police Serious Crash Unit to 750
examine the SUV with the corresponding dents or ESR to examine the evidence.
GROSS MALPRACTICE NEGLIGENCE
755 This lethal combination of synergistic contraindicated drugs was prescribed and
administered to Mr Harrison with the instruction to turn monitoring off causing him to
die a terrible death which is culpable homicide – METHADONE on
AMIODARONE, High Dose CO-TRIMOXAZOLE, HALOPERIDOL,
LORAZAPAM (Benzodiazepine), MIDAZOLAM (Benzodiazepine), 760
FENTANYL, MORPHINE.
Amiodarone potentiates the strength of Methadone
Methadone with Benzodiazepines is warned as a deadly combination
The above potent drug cocktail is lethal 765 Auckland Pharmacist S Fitt refused to answer when asked does she condone this
deadly drug combination
Restraints – Mr Harrison’s arms and hands were continually strapped down with restraints
for hours on end. 770
Controlled Drug – Administration on controlled drug and other drugs not documented in
drug chart. Proven by Ward Drug Book and medical record.
22
No Arterial Blood Gas (ABG) Monitoring - After Mr Harrison was transferred out of the 775
Emergency Department on 16 October 2007, from that time right through to when he
wrongfully died on 2 November 2007 ADHB never did any Arterial Blood Gas (ABGs)
monitoring which every doctor knows is imperative and fundamental for traumatic brain
injury, respiratory and cardiac monitoring to monitor Oxygen Saturations. The arterial blood
gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the 780
blood from an artery. This test is used to check how well the lungs are able to move oxygen
into the blood and remove carbon dioxide from the blood. It is standard procedure for
neurology/neurosurgery, respiratory and cardiac patients and was fundamental and imperative
to be done and was totally criminally neglected. ADHB Wards 81 and 34 only used pulse
oximetry for Oxygen readings. They never did any Arterial Blood Gas testing which was a 785
gross deviation from best medicine practice. Pulse oximetry measures solely haemoglobin
saturation, not ventilation and is not a complete measure of respiratory sufficiency. It is not a
substitute for blood gases checked in a laboratory, because it gives no indication of base
deficit, carbon dioxide levels, blood pH, or bicarbonate (HCO3-) concentration. The
metabolism of oxygen can be readily measured by monitoring expired CO2, but saturation 790
figures give no information about blood oxygen content. Most of the oxygen in the blood is
carried by haemoglobin; in severe anaemia, the blood will carry less total oxygen, despite the
haemoglobin being 100% saturated.
Erroneously low readings may be caused by hypoperfusion of the extremity being used for
monitoring (often due to a limb being cold, or from vasoconstriction secondary to the use of 795 vasopressor agents); incorrect sensor application; highly calloused skin; or movement (such
as shivering), especially during hypoperfusion. To ensure accuracy, the sensor should return a
steady pulse and/or pulse waveform. Pulse oximetry technologies differ in their abilities to
provide accurate data during conditions of motion and low perfusion.
Pulse oximetry also is not a complete measure of circulatory sufficiency. If there is 800 insufficient bloodflow or insufficient hemoglobin in the blood (anaemia), tissues can suffer
hypoxia despite high oxygen saturation in the blood that does arrive. Since pulse oximetry
only measures the percentage of bound haemoglobin, a falsely high or falsely low reading
will occur when hemoglobin binds to something other than oxygen.
805 Oxygen Prescriptions – ADHB never made any Oxygen prescriptions. Oxygen is a Drug
and the medical standards require that in order to ensure safe and effective treatment, Oxygen
prescriptions should cover the flow rate, concentration, delivery system, duration and
monitoring of treatment.
810 Pain Score – No pain score
Early Warning Score – Never adhered to an Early Warning Score
Pain – It is a human right to be spared pain which was breached. Inadequate and 815
inappropriate analgesia. Ward staff never got an Anaesthetic Pain Specialist to review.
23
Methadone totally inappropriate. Should have had a nerve block for pain and pain should
have been managed by an expert Pain Specialist who is based in the Anaesthesiology
Department at Auckland City Hospital. Mr Harrison was made to endure unbearable pain
causing him to scream out in suffering by the standards and guidelines for pain management 820
not being adhered to in Ward 81 and Ward 34. Mr Harrison’s human right to be spared pain
was violated. Every doctor knows that severe pain exacerbates inflammation and
physiological haemostasis and ADHB doctors derelicted their duty and responsibility to spare
extreme pain when the resources were available in Auckland City Hospital which were not
used. 825
Drug Chart – Controlled drugs and other medication were omitted from drug chart
Poor documentation – Most of the medical record has illegible signatures or no signatures
and no doctor registration numbers. Suboptimal vital sign monitoring. No Oxygen 830
prescriptions. No details of IDC devices.
No CT scan of whole chest – should have had a whole chest CT scan as part of Trauma
work up
835
Early Warning Score – ADHB staff never bothered
Weight for calculating drug dosages – ADHB staff never bothered
Fluids - Mr Harrison was caused to become seriously dehydrated on Ward 81 through 840 inadequate fluids. His fluid balance charts reveal he was kept seriously under-hydrated in
Ward 81 in Auckland City Hospital up till the day he iatrogenically suffered ventricular
fibrillation, cardiac arrest and asystole. The normal daily fluid requirement is 2,500 mls:
Fluid record 845
17 October 2007 1330 mls
18 October 2007 550 mls
19 October 2007 1050 mls
20 October 2007 750 mls 850 21 October 2007 640 mls
22-24 October 2007 No fluid charts in medical record for 3 x days
25 October 2007 200 mls
26 October 2007 1000 mls
27 October 2007 487 mls 855 28 October 2007 1,600 mls
29 October 2007 280 mls) 0700 hrs - 1230 hrs
“ ) cardiac arrest 1230 hrs
“ 3710 mls) 1245 hrs – 1700 hrs 860
30 October 2007 1232 mls
24
31 October 2007 2,568 mls
01 November 2007 2,310 mls
02 November 2007 2,250 mls 865
Dehydration and Low Blood Pressure
When dehydration is not given immediate and proper care, it may result in more complicated
conditions such as hypovolemic shock which results from having low blood pressure. When
the body is dehydrated, the blood volume decreases and its pressure against the artery walls is 870 reduced. This causes a sudden drop in blood pressure and reduces the amount of oxygen
reaching the body tissues, and when this condition is left untreated, hypovolemic shock can
result to fatality.
Suboptimal nourishment 875
A high level of nourishment is vital for traumatic injury patients. The food given to
Mr Harrison in Wards 81 and 34 is appalling:
Journal of Neurosurgery. 2008 Jul;109(1):50-6. doi: 10.3171/JNS/2008/109/7/0050. 880 Effect of early nutrition on deaths due to severe traumatic brain injury.
by Härtl R, Gerber LM, Ni Q, Ghajar J. Source: Department of Neurological Surgery,
Weill Cornell Medical College, New York, New York 10021, USA.
Patients who were not fed within 5 and 7 days after TBI had a 2- and 4-fold increased 885 likelihood of death, respectively. The amount of nutrition in the first 5 days was
related to death; every 10-kcal/kg decrease in caloric intake was associated with a
30-40% increase in mortality rates. This held up even after controlling for factors
known to affect mortality, including arterial hypotension, age, pupillary status, initial
GCS score, and CT scan findings. 890
Auckland City Hospital failed to provide Mr Harrison with adequate nutrition required to
help treat traumatic brain injury and failed to provide him with PEG feeding which he would
have had in the Intensive Care Unit. Adequate nutrition is a duty, responsibility and
obligation under the necessaries of life. A report by the Institute of Medicine in the United 895 States commissioned by the Department of Defense
12 for service members wounded on the
battlefield emphasises the importance nutrition has in a vital role to improve the outcome of
traumatic brain injury. Calories and proteins are important to reduce inflammation and aid
recovery.
900
breakfast lunch afternoon
snack
dinner
16/10/2007 No food record chart
17/10/2007 No food record chart
18/10/2007 1 pottle puree fruit
1 pottle yogurt
2 pieces bread/vegemite
150 mls tea
1 cup yoghurt
7 spoons scrambled
egg and vegetables
1 serving peaches
OBSERVATION
12 Defense and Veterans Brain Injury Center: “TBI Numbers”, Institute of Medicine: “Nutrition and
Traumatic Brain Injury.” John Erdman, PhD, professor emeritus, department of food science and nutrition, University of Illinois
25
MADE: contrary to
the entry above on
the food chart, a
nurse named Donna
Apetu wrote in the
medical record that
Mr Harrison quote:
“only consumed
yoghurt and small
amount of fruit
salad at evening
meal”
19/10/2007 No food record chart
Half a sandwich is
written in medical
record
20/10/2007
21/10/2007 corn flakes
2 slices bread
milk
2 tbsp scrambled egg
Discontinued
1 serve mashed potato
½ serve broccoli
1 serve beef
1 serve apple
1 serve ice cream
22/10/2007 No food record chart
23/10/2007 No food record chart
24/10/2007 No food record chart
yoghurt is written in the
medical record
25/10/2007 No breakfast Chocolate mousse
1 x puree fruit
26/10/2007 No food record chart
27/10/2007 1 x pottle puree fruit
1 x porridge
1 x milk
No lunch 4 tsps main serve
1 serve cream
½ serve apple custard
28/10/2007 No food record chart
29/10/2007 Day of iatrogenic cardiac arrest – nil food
30/10/2007 No food record chart
31/10/2007 2 spoons yoghurt Small bowl custard
01/11/2007 Nil, not able to swallow
02/11/2007 No food record chart
Mr Harrison died in anguish and terrible pain
Serum/Plasma Drug Concentration – No drug toxicity monitoring was done for cumulative
controlled and other drug toxicity building up in Mr Harrison’s system. Blood toxicology 905
screens determine the level of a drug accumulating in the system. Overt signs and symptoms
of drug toxicity in Mr Harrison’s system continued to be ignored. Mr Harrison was over-
medicated and under-treated.
Echocardiogram – Failed to get a bedside diagnostic echocardiogram which would have 910 revealed pericarditis (inflammation of the pericardium, the sac containing the heart and roots
of great vessels).
Holter monitor for cardiac rhythms – never completed the diary. 915
Nosocomial pathogenic bacterial infection
26
ADHB infected Mr Harrison with nosocomial pathogenic bacterial infection with sepsis signs
and symptoms which were seriously deleterious to Mr Harrison’s condition. Aseptic (strict 920 hygiene) standards were breached. ADHB staff put their own convenience first without
regard for Mr Harrison’s safety, knowing there was high risk of serious urinary tract infection
if they used indwelling catheters and they did not care. The indwelling urinary catheters were
not indicated and they caused serious morbidity. They were also not properly documented in
the medical record. 925
Clinical Guidelines for Urinary Indwelling Catheters – Details are required to be fully
documented in the medical record and were not. The documentation should be signed by the
person inserting the catheter and was not. Documentation should include:
Indication for catheterization 930
Time and date of procedure
Type of catheter.
Size of catheter
Expiry date of catheter
Amount of water in balloon 935
Any problems with insertion
Description of urine, colour and volume
Specimen collected
Review date
Signature of person inserting the catheter 940
Insertion of an indwelling urethral catheter is an invasive procedure that should only be
carried out by a qualified competent health care professional using aseptic technique.
Catheterization of the urinary tract should only be done when there is a specific and adequate
clinical indication, as it carries a high risk of infection, which was contraindicated for
Mr. Harrison’s condition. 945
Failure to provide specialist expertise
Mr Harrison was left in the hands of junior medical staff and the senior medical officers
distanced themselves from him. No Neurologist reviewed Mr Harrison’s drug chart and 950 junior doctors prescribed contraindicated drugs to him which were administered to
Mr Harrison with disastrous side effects. Failed to responsibly respond to overt emergency
signs and symptoms requiring specialist expertise.
955 Failed to identify entries in the medical record. Illegible signatures, no doctor registration
number. Poor documentation.
Failed to scan the whole chest with multiple rib fractures
960 Failed to notify family until about six days after admission
Failed to comply with Graseby™ pump warnings, cautions and correct usage guidelines
causing inaccurate delivery and bolus of controlled drug Methadone.
965
27
Failed to follow general principles for appropriate site selection of syringe
Administered a controlled drug irritant into right shoulder without good depth of
subcutaneous fat and near a joint.
Mixed incompatible drugs
Ignored significant signs of inaccurate controlled drug delivery including 970 ignoring a leap from 27 mm to 37 mm in four hours and other erratic delivery
which required to be immediately acted on
Intracranial Pressure Monitoring - Failed to do a bedside optic nerve ultrasound to monitor
intracranial pressure. Persistent sleepiness and other signs and symptoms are markers for 975 increasing intracranial pressure. Hypotension and Hyperglycaemia and Hypoxia are
extremely dangerous for traumatic brain injury. Requires close monitoring.
Hyperglycaemia - On Friday 19 October 2007 without testing for serum/plasma Glucose 980 levels staff in Ward 81 staff started Mr Harrison on Lactulose knowing that his blood
Glucose level was elevated at 8.5 mmol/L on admission to the Emergency Department on 16
October 2007 after sustaining severe trauma.13
One month prior to admission Mr Harrison’s
serum/plasma Glucose was in the normal range at 5.8 mmol/L. It is a doctors responsibility
to know the importance of putting emphasis on strictly monitoring and managing 985 hyperglycaemia particularly in a traumatic brain injured patient so as to avoid secondary
brain injury, and they know that hyperglycaemia14
and hypotension15
are dangerous on a
background of traumatic brain injury. It was incompetent, irresponsible and dangerous for
Auckland City Hospital staff to select an osmotic laxative, known to dehydrate and known to
exacerbate hyperglycaemia, and when it is clearly cautioned that Lactulose is contraindicated 990 with existing diabetic hyperglycaemia
16 and dehydration which was overtly evidenced by
concentrated urine17
and other signs. Auckland City Hospital was also aware that Mr
Harrison previously had steroid-induced diabetes and should have been extra-cautious with
this knowledge in addition to his hypermetabolic response to trauma. It was reckless for
Auckland City Hospital to administer drugs known to increase serum/plasma Glucose levels 995 and exacerbate hyperglycaemia which is a serious problem if not treated in time. It was
Auckland City Hospital’s responsibility, duty and obligation to Mr Harrison to heed his overt
signs and symptoms of hyperglycaemia and act to moderate them, not to increase them.
1000 Serum/Plasma Glucose Levels
16 October 2007 8.5 mmol/L
19 October 2007 Lactulose commenced
22 October 2007 7.8 mmol/L 1005 24 October 2007 9.1 mmol/L
25-28 October 2007 No monitoring done
13 Severe trauma raises serum/plasma Glucose levels 14 Hyperglycemia means high blood glucose 15 Hypotension means low blood pressure 16 Auckland City Hospital was aware that Mr Harrison previously had steroid-induced diabetes and
its staff should have been extra-cautious with this knowledge in addition to his hypermetabolic
response to trauma. 17 Plenty of fluids should be given with laxatives
28
29 October 2007 11.1 mmol/L
By ignoring overt signs and symptoms of hyperglycaemia and continuing Lactulose in spite 1010 of MOH caution and standard practice Auckland City Hospital
Failed to do a Erythrocyte Sedimentation Rate (ESR)18
for vasculitis19
.
1015
On the morning of Sunday 28 October 2007 being the day prior to iatrogenic cardiogenic
shock, cardiac arrest and asystole, a junior doctor reiterated an instruction from the day
before to stop Metoprolol and commence intravenous fluids. Glasgow Coma Score 13/15.
Senior medical officers (consultants) in Ward 81 continued to distance themselves from
Mr Harrison and showed no interest in him and never even saw him on a ward round. 1020 Mr Harrison was still in the hands of the most junior doctor on the ward a house officer.
Mr Harrison’s wrists were tied down with restraints so that he could not move. A CRP (C-
reactive protein)20
test significant for infection and stress (not tested prior) was abnormally
high at 141 mg/L (normal range 0-5 mg/L). Mr Harrison had developed severe confusion,
apnoea and arrhythmia with inadequately managed hyperglycaemia, hypotension, 1025 dehydration, hypoxia and septic nosocomial pathogenic bacterial infection which he acquired
in Ward 81 through staff failing to adhere to accepted medical standards and guidelines.
Dehydration had become severe which was evidenced by “dry mucous membranes”,
“increased skin turgor”, “looks dehydrated” and despite nursing staff having been instructed
to commence IV fluids the house officer noted that as at 10.30 pm they had still not been 1030 started and IV fluids were not commenced until 11.30 pm. No temperature or respiratory rate
recorded in medical record. Mr Harrison’s blood pressure had fallen to a hypotensive
80/50mm/Hg. Mr Harrison’s JVP (Jugular Venous Pressure) was 5 which is significant for
hypovolemic shock21
(a medical emergency when the amount of circulating blood in the body
drops when a patient loses too many other body fluids. 1035
At 1030 pm (2230 hrs) the house officer knowing that Mr Harrison’s blood pressure had
dropped to 80/50 mm/Hg failed to use commonsense and questioned why the Metoprolol had
been withheld. He arranged for it to be re-commenced through another junior doctor from
Cardiology who although Mr Harrison was hypotensive with traumatic brain injuries he 1040 restarted Metoprolol succinate and increased the dosage to 47.5 mg from 27.5 mg at 2400 hrs
even though he was overtly hypotensive and was also being administered Inhibace
(Cilazapril) which is another blood pressure lowering ACE Inhibitor. It is emphasised in
traumatic brain injury medical literature that hypotension and hyperglycaemia are dangerous
with traumatic brain injury and this contraindication was absolutely ignored by Auckland 1045 City Hospital. The authorities state it is more preferable out of the two for hypertension
rather than hypotension which is particular dangerous with this type of trauma.
18 The ESR test measures the distance red blood cells fall in a test tube in one hour. A test that
measures how much inflammation is in the body. The farther the red blood cells have descended, the greater the inflammatory response of your immune system. 19 Vasculitis means inflammation of the blood vessels 20 CRP is an inflammatory marker of bacterial and viral infections, stress, tissue injury, inflammatory
disorders and associated diseases. 21 Symptoms can include anxiety or agitation, cool clammy skin, confusion, decreased urine output, general weakness, pallor, rapid breathing, unconsciousness. Cool, clammy skin
29
On the morning of Thursday 29 October 2007 staff in Ward 81 had both of Mr Harrison’s
arms tied down restrained and he was left on his own without supervision. At or about 0900 1050 hours Aroha WAAKA (nurse) defied universal pharmaceutical instructions and crushed 47.5
mg of controlled release beta blocker Metoprolol succinate which released a 24 hours dose
straight away causing cardiogenic assault on Mr Harrison. She did this only nine hours after
the preceding 47.5 mg dose of Metoprolol succinate was administered at 2400 hrs on
28 October 2007. Metoprolol succinate is required to be administered once per 24 hours. 1055 Mr Harrison was beta-blocker naïve, hypotensive and hyperglycemic, a deadly combination
causing cardiogenic shock with ventricular fibrillation and asystole. At 1220 hrs
Mr Harrison, no respiration, no pulse, no heartbeat. Metoprolol is cardiotoxic in overdose.
At 1200 hrs Mr Harrison stopped breathing.
1060
THE MEDICAL RECORD
Tuesday 16 October 2007 - 1420 hrs - Admitted to Auckland City Hospital Emergency
Department to RESUS: On admission Mr Harrison’s GCS22
was 13/15 improved to GCS 1065 14/15. Breathing 88% Oxygen on room air, started on 5 litres Oxygen by Hudson mask,
increased to 96%. Multiple scratches and grazes on hands observed by nurses. The
pathologist, Dr Lloyd Denmark never mentioned this on his suboptimal post mortem report.
At 1720 hrs Dr C Rosie documented in the medical record:
1070
“Neurosurgery aware, will review at their leisure”
“At their leisure” does not meet the accepted standards for patients transferred from the
Emergency Department. At 1830 hrs the Neurosurgery Registrar was again contacted to ask
when. It is understood the words were said by on-call Neurosurgery Registrar, Dr Naider 1075 Pouratian, who, after Mr Harrison died, also told Mr Harrison’s sister (Appellant):
“I wouldn’t tell you what time he died if you were the Queen of England.”
At 2300 hrs (8 hours 20 minutes since admission) Mr Harrison was still in the Emergency 1080 Department and was still in a cervical spine collar even though a CT scan revealed no
fracture. He became severely disorientated, pulling out the Oxygen and trying to take off the
collar which was causing him discomfort. No-one removed the collar. The medical record
indicates that Mr Harrison did not leave the Emergency Department to Ward 81 until
approximately 0515 hrs (ie 5.15 am the next morning) approximately 15 hours after his 1085 admission to the Emergency Department which grossly exceeds the standard for patient
transfer. Specialist neurological monitoring, treatment and management of traumatic brain
injury is time critical to prevent secondary cerebral injury from setting in and Mr Harrison
should have been transferred to a specialist service quickly. The Neurosurgery/Neurology
Department were unacceptably complacent and tardy towards their duty, responsibility and 1090 obligation to the patient. Dr Mitchell, Emergency Department Consultant said he expected
Mr Harrison to be transferred to the Neurosurgery HDU (High Dependency Unit) but
Mr Harrison was transferred to a ward, Ward 81 and was refused the specialist expertise he
needed.
1095
22 Glasgow Coma Score - a neurological scale that aims to record the conscious state of a person
30
Wednesday 17 October 2007 Admitted to Ward 81 at approximately 0515 hrs: Grazes
on hands noted again. Elevated blood sugar level noted yet commenced drugs which increase
the blood glucose level. Signs of secondary injury setting in not acted on. GCS fell to 13/15.
With traumatic brain injury head of bed should have been consistently maintained at 30
angle and was not. Inconsistently gave Oxygen through nasal prongs without Oxygen 1100
prescription and without Arterial Blood Gas (ABG) monitoring. Suffering from post
traumatic amnesia. Nurse noted injured toes and toe nails. The pathologist, Dr Lloyd
Denmark never mentioned this on his suboptimal post mortem report. 1045 hrs calling out in
pain.
1105
Thursday 18 October 2007 – Ward 81 - It is accepted practice for patients with moderate
to severe traumatic brain injury to be admitted to the Intensive Care Unit for specialist
monitoring, treatment and management where there is the expertise and technology for the
best outcome. Drug-induced coma is used for moderate to severe traumatic injury to rest the
brain, relieve suffering and assist with healing and prevent secondary brain injury. The 1110
Intensive Care Unit is also equipped with effective ventilation equipment to relieve the lungs
which is appropriate with multiple TBI associated trauma including multiple fractured ribs,
pneumothorax and multiple vertebral transverse rib fractures. The Intensive Care Unit would
provide specialist effective pain management. Instead ADHB staff tortured Mr Harrison in a
state of acute moderate to serious traumatic brain injury and unsafely forced him to over-1115
exert himself with “throwing and catching” beyond his ability and seriously fatigued and
distressed him when the medical authorities on traumatic brain injury warn that the acute-
stage moderate to severely traumatic injured brain must have therapeutic rest to prevent onset
of secondary cerebral injury. This was demonstrated by the over-exertion forced on Mr
Harrison during acute stage traumatic brain injury which deleteriously caused Mr Harrison’s 1120
blood pressure to escalate to 180 systolic in response to the stress and strain and his Oxygen
fell to 87%, and his GCS fell to 12/15. It has been established that Auckland District Health
Board has no protocol for physiotherapists for patients with moderate to severe traumatic
brain injury and this is disgraceful. Systolic blood pressure is the first part of the fraction
which hyperreacts to stress. Mr Harrison was under constant strain and stress in Auckland 1125
City Hospital which manifested in his systolic blood pressure and other factors covered later
in these submissions such as hyperglycaemia and dehydration which were also mismanaged.
The Systolic BP fraction is the pressure the blood exerts on arteries and vessels when the
heart is beating and is reactive to stress. The Diastolic BP fraction is the lower part of the
fraction and is the pressure exerted on the walls of various arteries around the body in 1130
between heart beats when the heart is relaxed. This was the precursor to a chain of
inexcusable malpractice and neglect. Every doctor knows that the acute-stage moderate to
severe traumatically injured brain requires total rest to prevent the danger of inducing
secondary cerebral injury through over-exertion at this critical time. 1530 hrs Trying to get
out of bed but he was so in pain. 1135
Friday 19 October 2007 – Ward 81 - No Orthopaedic review yet for Mr Harrison’s
multiple fractured ribs and L1-L4 vertebral transverse process fractures which caused him
excruciating pain. No specialist Neurologist or Neurosurgeon review. Deteriorating
31
neurological signs not acted on. GCS 13/15. Unable to be roused for any length of time, 1140
apnoea, Cheyne-Stokes respiration, severe confusion, eyes opened and limited engagement,
restless, disorientated., . Signs of intracranial pressure ignored. No intracranial pressure
monitoring or bedside optic nerve ultrasound provided. Head of bed not elevated to the
required 30. Mr Harrison was dehydrated23
, and without re-checking Mr Harrison’s
serum/plasma Glucose Level since the date of his admission to the Emergency Department 1145
on 16 October 2007, ward 81 staff ignored Ministry of Health MEDSAFE24
Data Sheet and
the MIMS New Ethicals25
‘warnings and precautions’ and indiscriminately started
Mr Harrison on contraindicated osmotic26
Lactulose27
, administered concurrently with
another laxative, when they knew that Mr Harrison’s serum/plasma Glucose Level on the
day of admission to the Emergency Department on Tuesday 16 October 2007 was 1150
hyperglycaemic at a diabetic level of 8.5 mmol/L (which is consistent with serious traumatic
injuries28
) and that Lactulose is contraindicated. While on Lactulose the hyperglycaemia and
dehydration29
worsened and the signs and symptoms of hyperglycaemia and dehydration
manifested as cardiac arrhythmia and other overt manifestations which any competent doctor
would recognise and know to act on and they did not. Severe pain. 1155
Saturday 20 October 2007 – Ward 81 budget cutting, planned to transfer 66 year old
Mr Harrison to ‘Older People’s Health’ on the coming Tuesday while still denying him
Neurologist/Neurosurgical specialist monitoring, treatment and management. Staff were
curtly informed by Older Persons Health that Mr Harrison was not fit to be transferred. 1160
ADHB staff transferred Mr Harrison into ‘Room 9’ a side room where Mr Harrison was not
able to be continually monitored to make way for an acute patient. GCS 13/15. Signs and
symptoms worsened. No cough reflex any longer so in danger of aspiration pneumonia.
Laceration at back of head producing moderate exudate.
1165
23 Dehydration causes an increase in heart rate because in dehydration there is decrease in blood
volume, as a compensation it increases the heart rate to maintain adequate blood perfusion to other organs. 24 MEDSAFE is the New Zealand Medicines and Medical Devices Safety Authority, a business
unit of the Ministry of Health 25 MIMS New Ethicals is a pharmaceutical reference book readily accessible in every hospital ward 26 Osmotic laxatives are known to cause severe dehydration, so a physician should carefully monitor their use. 27 Lactulose is an osmotic laxative drug to be used with caution in diabetics because it elevates blood glucose levels. Osmotic laxatives are known to cause severe dehydration, so a physician should carefully monitor their use. Lactulose is also contraindicated in patients with hypersensitivity to the active substance or to any of the excipients. 28 Hyperglycaemia in trauma and other critically ill patients is caused by a hypermetabolic response
to stress. Instead of moderating Mr Harrison’s Glucose control to improve his outcome, Auckland City Hospital exacerbated his hyperglycaemic condition through indiscriminate drug usage contraindicated
with hyperglycaemia. The Ministry of Health and MIMs cautions should have been taken notice of and Lactulose should not have been used. 29 Dehydration People tend to notice the effects of dehydration on the cardiovascular system first,
but dehydration also impacts the central nervous system and metabolic system. The effects on these systems compound the effects on the cardiovascular system.
32
Sunday 21 October 2007 – Ward 81 – Increasing restlessness, minimal sleep, pulled out
indwelling catheter. No senior medical officer interest in worsening signs and symptoms.
Repeated references in the medical record about referring Mr Harrison out of Ward 81 the
coming week. Asleep most of the time.
1170
Monday 22 October 2007 – Ward 81/HDU – Clinical notes missing from 1900 hours on
21 October 2007 through to 0510 hrs on 22 October 2007. Appellants have asked for and
have not been given the clinical notes for this period. The first entry in the medical record on
this day written at 0510 hrs by a House Officer says:
1175
“at 5.00 am found by his bedside on the floor, bedrails still up”
Staff left Mr Harrison in Room 9 unsupervised through the night with the bedrails raised,
knowing that he had traumatic brain injury restlessness. The curtains were pulled around the
bed which concealed him. From bed over rails, which was unwitnessed. At 5.00 am in the 1180 morning ward staff still hadn’t returned to Room 9 to check on Mr Harrison and another
patient heard Mr Harrison groaning and alerted staff. The curtains were pulled back.
Mr Harrison was on the floor, groaning in pain, confused and disorientated. It was ADHB
staff’s responsibility to supervise Mr Harrison, particularly when they knew he was suffering
from TBI restlessness. We have asked for and have not been given the notes for the night 1185 that Mr Harrison was left unsupervised. Mr Harrison should have been safe in the Intensive
Care Unit where he could have been properly cared for by people who know what they’re
doing. Traumatic brain injury is required to be scrupulously monitored as is emphasised in
the literature and traumatic brain injury guidelines and standards. Mr Harrison’s signs and
symptoms deteriorated consistent with a secondary cerebral injury. The words “Torso old 1190 bruise left lateral” was written in Mr Harrison’s medical record by another junior doctor who
was called to the room, but no bruise on Mr Harrison’s torso had ever been mentioned before.
The senior medical officers continued to distance themselves. Mr Harrison’s rib fractures
were posterior rib fractures. No doctor ordered a follow-up radiological scan to review
cerebral damage from the fall. Mr Harrison’s Troponin (normal on admission at < 0.01 µg/L 1195 [ie less than 0.01]) elevated to 0.42 µg/L (normal range < 0.03). Raised Troponin is a
differential diagnosis for sepsis. At this point ward staff “phoned duty manager who advised
to move patient into HDU so patient can be watched.” the medical record says “Plan:
“Transfer to HDU” (High Dependency Unit), where Mr Harrison was supposed to have
been ever since being transferred from the Emergency Department, instead of being put in 1200 Ward 81 in Room 9 where he was left unsupervised. Blood Pressure. The medical record
says “Large bruise on patient’s back, not new”. Dr Denmark never mentioned this on his
suboptimal post mortem report. Mr Harrison was transferred to HDU at 0635 hours. The
medical record says “Unlikely MI (myocardial infarction) related to Troponin rise”.
At 1400 hrs Mr Harrison was reviewed by a Cardiology junior doctor who said “doesn’t 1205 require specific management” and “Troponin checked as part of confusion screen”.
1830 hrs Resting in bed. Talking about stickers on both side but couldn’t explain any more
on it. The Range Rover SUV had distinctive stickers on both sides of its rear window.
Tuesday 23 October 2007 – HDU – 0800 hrs Blood test done by doctor. Patient not well. 1210 Mr Harrison was infected with hospital-acquired urosepsis contracted from nosocomial
urinary tract infection by ADHB staff wrongly inserting indwelling urinary (IDC) catheters
into him and not adhering to cautions and aseptic standards. A urine culture from the
33
Emergency Department confirmed Mr Harrison was not infected with urinary tract infection
at his arrival to Auckland City Hospital on 16 October 2007. He acquired severe nosocomial 1215 urinary tract infection as an inpatient. On 23 October 2007 a subsequent urine culture showed
nosocomial urosepsis with a colony count of mixed pathogen bacterial growth > 100
million/L including Enterococcus and a predominant growth of Staphylococcus epidermidis
and other unidentified bacteria which were never followed up on and should have been. Nor
was a blood culture taken and should have been in the presence of urosepsis. The urine 1220 culture had 990 million/L White Cells which shows serious infection. A pH of 7 signifies
Lactic acidosis which is also significant for sepsis. Bacteria thrives on dehydration and
ADHB staff were providing Mr Harrison with inadequate fluids as shown by the fluid charts.
He was dehydrated as shown by his signs and symptoms. Dehydration also causes
hypertension, arrhythmia30
and hypovolemic shock. ADHB breached fundamental standards 1225 and guidelines of care. Urosepsis from bacterial infection can pass into the bloodstream and
be circulated systemically by the blood. ADHB failed to culture Mr Harrison’s blood for
infection. This hardy pathogen is also implicated in bacterial meningitis. ADHB exposed
Mr Harrison to this reckless risk on a background of brain trauma with damaged and
disrupted blood brain barrier31
. Staphylococcus epidermidis is very difficult to rid with 1230 antibiotics. The hardy bacteria has biofilms
32 which makes it particularly difficult for
antibiotics to effectively clear this type of infection once it is inside the human system. It is
common knowledge in hospitals that Staphylococcal epidermidis can be contracted through
non-adherence to aseptic (strict hygiene) practices and that it is often resistant to antibiotics
yet ADHB staff never took the precaution of following up the urine culture to monitor 1235 progression of the nosocomial
33 infection and they never took a blood culture. Staff hygiene
precautions and using invasive devices only when indicated are imperative for patient safety
which was seriously breached. Temperature pyrexic at 37C.
Wednesday 24 October 2007 – Ward 81 - House Office started Mr Harrison on wrong 1240 antibiotic. Amoxicillin (Amoxil) is unsuitable and ineffective for Staphylococcal
epidermidis. Temperature elevated further to 37.8C. Untreated hyperglycaemia and
dehydration. Decreased vision. First onset of occasional beats of spontaneous Ventricular
Tachycardia (VT) associated with persistent untreated hyperglycaemia. Myocardial
dysfunction in diabetes can be reversed by proper correction of metabolic changes. 1245 Hyperglycaemia causes tachycardia and increases cardiac output. Nothing was done about it.
No specialist review. Still under junior doctors. Untreated hyperglycaemia and associated
ventricular tachycardia can progress to ventricular fibrillation a lethal arrhythmia. ADHB
staff still continued to administer contraindicated Lactulose which is an osmotic dehydrating
drug cautioned in diabetics and traumatically debilitated patients due to the risk of elevating 1250 serum/plasma Glucose levels.
34 The normal range for serum/plasma Glucose is 3.0-5.6
mmol/L. No Endocrinology specialist review. On 24 October 2006 Mr Harrison’s blood
Glucose level was 9.1 mmol/L. At 1250 hrs extreme agitation (consistent with
hyperglycaemia and dehydration). Have still not done any Arterial Blood Gas testing (ABG).
30 Arrhythmias are disturbances in the normal rhythm of the heartbeat. 31 In simple terms the blood brain barrier prevents harmful materials from the blood from entering
the brain but when the blood brain barrier is damaged or disrupted by trauma or other causes the brain is unprotected and vulnerable. 32 Biofilms are a slime produced by the bacteria which allows other bacteria to bind to the already existing biofilm, making a multilayer biofilm. 33 Nosocomial means hospital acquired. 34 Serum/Plasma is blood. The Serum/Plasma Glucose Level is the level of Glucose in the blood
34
Junior Cardiology review – did nothing. Still no senior medical officer review of 1255 neurological signs and symptoms. Patient very confused. 1230 hrs Aggressive outrage
consistent with hyperglycaemic crisis. Code Orange called. Remains confused with
intermittent bursts of agitation and restlessness. 2130 hrs “Has been restless and trying to
get out of bed since 2130 hrs.” 2400 hrs episode of absence seizure “noticed patient very
pale, not responding as quickly as earlier – only opened eyes on applying quite severe pain – 1260 noticed heart rate at time 38 and blood pressure 134/70 (much lower than earlier). Patient
slowly back to his normal level of alertness.” No intracranial pressure monitoring.
No specialist Neurologist review. The medical record shows that staff started counting the
days Mr Harrison had been in the Ward, writing it as “Day 8” in the medical record “not
making much progress”. 1265
Thursday 25 October 2007 – Ward 81 - Staff continued to count the days Mr Harrison had
been in the Ward, writing it as “Day IX” in the medical record. On the ‘Admission to
Discharge Planner’ a date quota for discharge was 1 November 2007. Mr Harrison died on 2
November 2007. The calendar was being watched and cost-saving essential monitoring, 1270 treatment and management was being restricted from Mr Harrison. Pulse oximetry showed
Oxygen desaturating to 85% on air. An Arterial Blood Gas was never performed.
Temperature 37.5C. A nurse wrote “Urinary tract infection evident”. Periods of
restlessness, calmed well when reassured. ADHB still had Mr Harrison on the wrong
antibiotic for Staphylococcus epidermidis. The urine culture on 23 October 2007 stated 1275 antibiotic sensitivities. Mr Harrison should not have been given Amoxil for this bacteria.
Flexi-monitoring in situ for tachycardia/arrhythmia. Dizziness. 1430 hrs started a Holter
monitor35
with staff instructions to “document activity such as physio on Holter monitor
diary, also when medications administered, ie cardiac medications.” No documentation was
done. No Blood Pressure reading written in the medical record. Started on Betaloc 1280 (Metoprolol succinate)
36. Metoprolol was charted, started at 1115 hrs at 23.75 mg ignoring
the pharmaceutical authority caution concerning diabetes. Metoprolol succinate is associated
with hyperglycaemia. Mr Harrison was already having other hyperglycaemia potentiating
drugs including Lactulose. It is important that Hyperglycaemia requires proper management
to avoid hyperglycaemic crises and it was being ignored by ADHB junior doctors and the 1285 senior medical officers distanced themselves and did not supervise the junior staff with a
serious patient. Safer alternatives were available instead of using Metoprolol and Lactulose
which are both contraindicated with diabetes and hyperglycaemia. A non-osmotic laxative
should have been selected. Carvedilol is a premium beta blocker over Metoprolol, and
Carvedilol is not associated with development of hyperglycaemia and would have been a 1290 safer option than Metoprolol. New Zealand and international pharmaceutical authorities give
clear warnings which were not heeded. Another reminder to complete the Holter monitor
activity diary was written in the drug chart which was also not done. No Arterial Blood Gas
testing.
1295 Friday 26 October 2007 – Ward 81 - GCS 14/15. Changed antibiotic from Amoxil to
Co-trimoxazole. 1220 hrs House Officer Dr J Kao wrote in the medical record that
Creatinine and Urea were elevated “most likely secondary to dehydration/decreased oral
intake”. Discussed ECG rhythm strips again with junior Cardiology doctor “No concerns re.
frequent bigeminy + occasional 3 beat VT (Ventricular Tachycardia) x 2. The Cardiology 1300
35 Holter monitor is a portable ECG device 36 Metoprolol succinate is a beta blocker (β-blocker) which lowers blood pressure. Low blood pressure is ‘hypotension’
35
junior doctor still said “no concerns” and suggested continuing with Metoprolol and
increasing the dosage to 47.5 mg. 1430 hrs hyperglycaemic crisis with dehydration and
hypoxia manifested as agitated and aggressive, disorientated. No Neurologist review.
1305
36
Saturday 27 October 2007 – Ward 81 – Increased pain (headache + left flank area).
Increased pain of wound to back of skull. Blood Pressure 110/67 + Bradycardic 40 beats per
minute. 40 BPM is absolute bradycardia – very slow heart rate. Ward staff wanting to move
Mr Harrison out of ward to ‘Older People’s Health’. Plan: “awaiting Cardio management
and discharge”. 1400 hrs very agitated, restless, combative, unable to calm down situation. 1310 House Officer named Dr V Shaw made a comment on an incident report which ADHB
refuses to disclose. ADHB’s under-treatment caused Mr Harrison to suffer gross indignity.
Through no fault of his own he was reacting to the effects of untreated conditions known to
produce these effects without proper treatment. Mr Harrison was on chair swearing, angry,
loud – Code Orange – signs and symptoms reflecting untreated hyperglycaemia, dehydration, 1315 hypoxia, bradycardia and severe nosocomial (hospital-acquired) urinary tract infection.
Instead of treating the cause, ward staff placed restraints on him and continued not to treat the
causes. Pulse rate 42-51 beats per minute (seriously bradycardic). No senior medical officer
review. Still in hands of house officers. 0.5 mg of IM (intramuscular) Lorazepam
benzodiazepine administered with no result after 10 minutes, another 0.5 mg IM then 1.0 mg 1320 IM Lorazepam given, all of which was not written on the drug chart. Staff counting days on
ward written in medical record “Day 11 in Ward 81”. Still no Neurologist or Neurosurgeon
review. Left in hands of junior doctors and nurses. 2100 hrs very agitated and restless.
Taking monitoring secondary since patient is drowsy. Blood Pressure fluctuating. No
Arterial Blood Gas. CCS 12. Limbs moving. Very dehydrated. Blood Pressure down (no 1325 reading written in medical record). 2100 hrs “Nursing staff concerned about Blood
Pressure parameters and fluid intake”. Blood Pressure 106/70. Pulse 46.37
No knowing
how much Lorazepam was administered because at least one large dose was not written on
drug chart. Medical record says “No more Lorazepam today unless agitation. Tomorrow
can start with Lorazepam 0.5 mg tds.38
Subcutaneous fluids overnight. Intravenous fluids 1330 were not given. Severe dehydration. Drug chart says Metoprolol succinate withheld under
doctor’s instructions. 2300 hrs Pulse oximeter Oxygen saturation low. Drowsy or confused.
Sunday 28 October 2007 – Ward 81 – Breathing appears low at times and long periods
without taking a breath. Nurse put restraints on. The drug chart shows Metoprolol 1335 succinate withheld under doctor’s instructions in the morning. House Officer named Dr V
Shaw said “Stop Metoprolol. Intravenous Fluids”. GCS 13/15. Blood Pressure very low at
80/55 in the morning, 110/75 at lunch time – increased with oral intake. 1030 hrs Another
House Officer said “decreased Blood Pressure + looks dehydrated.” The House Officer then
said “Ward Round note to start Intravenous Fluids + withhold Beta Blocker – no 1340 documentation to why withhold”. Obviously no hand over but Blood Pressure reading and
bradycardia should have been self-evident to this House Officer. House Officer also said
“also NO I.V. line in situ” showing that nursing staff had disobeyed the other House
Officer’s instructions for IV Fluids. Mr Harrison was severely dehydrated with dry mucous
membranes, increased skin turgor, Pulse 100, Blood Pressure 80/50. High pulse rate or 1345 tachycardia is associated with low blood pressure. When the blood pressure is low and the
tissues of the body are not receiving adequate perfusion, the body raises heart rate in order to
compensate for the low perfusion. Therefore, almost all causes of low blood pressure will
result in low blood pressure with tachycardia. The staff on this ward and Cardiology ignored
the fundamentals. An Intensive Care Unit would have jumped into action with emergency 1350 management to stabilise metabolic and drug-induced effects of inappropriate drugs,
hyperglycaemia, dehydration, hypoxia, nosocomial urinary tract severe infection, and
37 Usually when the pulse becomes slow the patient will be restless. 38 tds means three times daily.
37
malnourishment which needed proper treatment with specialist expertise instead of house
officers fresh out of medical school blundering beyond their scope of expertise and training
while the specialists distanced themselves from Mr Harrison in need of expert monitoring, 1355 treatment and management. The heart was reacting to pharmaceutical, metabolic and
physiologic iatrogenic insults. Episodes of apnoea during sleep not noted previously,
JVP (Jugular Venous Pressure) raised to 5 cm significant for hypovolemia (severe loss of
body fluids which can lead to hypovolemic shock). Onset of LBBB (Left Bundle Branch
Block). Both wrists restrained by staff for hours on end with no detailed documentation. 1360 2300 hrs restless and agitated. Tried to get out of bed. Administered another 0.5 mg of
Lorazepam to chemically restrain on top of physical restraints. Pulse oximetry showed
Oxygen down to 84% on air. Did nothing. Hypoxia, hypotension, hyperglycaemia and
under-nutrition disastrous for traumatic brain injury. Never sought specialist expertise.
Restraints put on both hands. Two litres of Oxygen administered - no Oxygen Prescription, 1365 flow rate, duration or other important information. No temperature written in medical record.
Moving all limbs. No Arterial Blood Gas testing. Instruction written in medical record
“withhold blood pressure medications”. Mr Harrison was hypotensive, bradycardic,
hyperglycaemic, hypoxic and dehydrated – all suboptimally monitored and treated by staff in
Ward 81 and the Cardiology junior doctor. Not even any Arterial Blood Gases. Pulse 1370 oximetry is no substitute for Arterial Blood Gases in a critically ill patient. It was imperative
for ADHB staff to monitor hypoxia, hypercapnoea and blood pH acidosis with Arterial Blood
Gases. A junior Cardiology doctor then said “Give Metoprolol please. Ask for Cardiology
review mane (morning)”. 2333 hrs Troponin 5.07 µg/L (normal range < 0.03 µg/L.
Metoprolol succinate administered at 2400 hrs (12.00 am at night) in an increased dosage 1375 of 47.5 mg by nurse K Cassels-Brown with Blood Pressure 80/60. Why was Metoprolol
succinate administered at 2400 hrs when Mr Harrison was hypotensive? This is
contraindicated by the pharmaceutical authorities. Intravenous fluids stopped. Cardiology
junior doctor said start. Watch Report missing from medical record 1500 hrs 28/10/2007 to
1100 hrs 29/10/2007. 1380
Monday 29 October 2007 – Ward 81/Ward 34 (refused ICU) – Unsettled night. Apnoea.
Respiration 10-18 breaths per minute. Pulse Oximetry Oxygen low 88%. Temperature 37C.
Moaning during sleep. Calling out in sleep. Difficult to wake, needs loud voice close to ear
or pain for eyes to open. Left eye opens normally. Right eye slight ptosis. Disorientated 1385 always. Anxious. Lorazepam benzodiazepine. GCS consistently 11/15. Moving all limbs.
Blood Pressure very low 80/56 mm/Hg. Medicate for agitation. Extension of bruise on back
(not reported by Dr Denmark at post mortem). 0900 hrs nurse Aroha WAAKA (fourth
respondent) ignored best practice signs, symptoms, prescription and pharmaceutical cautions
and instructions and crushed and administered 47.5 mg of Metoprolol succinate in 180 mls 1390 of Resource Plus and liquid Panadol only nine hours after preceding 47.5 mg dose of
Metoprolol succinate to beta-blocker naïve Mr Malcolm Armstrong Harrison on background
of very low blood pressure and hyperglycaemia. Overdose caused Metoprolol cardiotoxicity
and cardiogenic shock - 95 mg of cardiotoxic Metoprolol cumulatively within nine hours.
Metoprolol potentiates hyperglycaemia. 0925 hrs Cross-covering House Officer wrote “No 1395 obvious documentation about Troponin check. No action taken about raised Troponin.
Patient’s Metoprolol withheld on 27/10/2007 and 28/10/2007 – unsure why ?decreased
Blood Pressure … To continue with Metoprolol (Betaloc) 47.5 mg once daily … Cardiology
Registrar will review patient today … NOT for re-check of Troponin … Consider Aspirin if
Neurosurgery happy.” 0938 hrs “Patient confused” “Beta-Blocker withheld over weekend. 1400 Was hypotensive over weekend. Plan: Re-start Beta-Blocker”. Discussed with
Neurosurgery Registrar (Dr Pouratian) “happy to start Aspirin”. 1200 Patient stopped
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breathing and he’s with doctor and registered nurses. Nurse kept quiet and never disclosed
her serious breach of patient safety when Mr Harrison went into Ventricular Fibrillation and
cardiac arrest with asystole. 1213:30 hrs Cardiac Arrest – Code Blue “patient arrested 1405 Code Blue called – patient was being flexied to CCU (Coronary Care Unit) at the time of
cardiac arrest“. The nurse grossly broke universal imperative cautions for Metoprolol
definitely in dangerous breach against medical standards and guidelines. Blood Pressure
68/40 mm/Hg. 1310 hrs Medical Registrar’s note (Dr Turnbull) Attended Code Blue Arrest
– VF (Ventricular Fibrillation) Arrest. DCCV (Direct Current Cardioversion) – Sinus 1410 Rhythm now. Cardiology and DCCM (Department of Critical Care Medicine) Registrar
involved. They are negotiating management plan. Still has oropharyngeal airway in place.
Blood Pressure borderline 80. Page in medical record not provided to Appellants. First time
too late a junior doctor has discussed with a senior medical officer Dr Jim Stewart. Messed
about too long. Left things too late. Dr Stewart said if DCCM (Department of Critical Care 1415 Medicine) can intubate the patient will take patient to Cath Lab for Angiogram. Otherwise
for transfer to CCU start on Amiodarone loading. “Unable to start Amiodarone due to
hypotension.”. However Mr Harrison was put on Amiodarone with a lethal combination of
other potent drugs. “spoke to CCU Coordinator – aware of patient now.” “Patient is able to
be anticoagulated, as per team Registrar”. Plan: As per Cardiology Registrar, for transfer to 1420 Ward 34 Cardiology team for cardiac management (Cath Lab DCCM or CCU). Mr
Harrison was not taken to the Cath Lab. Neurosurgical plan confirms to be awaiting
rehabilitation. Said: “If change in conscious status/neurological condition whilst in
Cardiology care, he should be investigated with CT Head.” There was a change in
neurological condition and no CT Head was done. Neurosurgery Registrar: Events noted. 1425 VF Arrest on background of uncertain cardiac irritability (?ACS/other cause). From
Neurosurgical perspective, patient requires no further acute input and is awaiting
rehabilitation – Older Persons Health. Discussed with Dr Stephen Streat – “Not for DCCM
admission.” They still denied Mr Harrison ICU care even after a cardiac arrest. Level 4
Anaesthetics/CVICU (Cardiothoracic and Vascular Intensive Care Unit and High 1430 Dependency Unit if need support for angiograph. Never did an angiograph. 1327 hrs
LabPlus received blood sample - High Serum/Plasma Glucose level 11.1 mmol/L (normal
range 3.0-5.6 mmol/L). 1430 hrs Transferred to Ward 34. At 1440 hrs after cardiac arrest
she wrote in the medical record: “Patient unsettled this mane (morning). Agitated +++ this
morning. Both arms restrained. No available watch from DM for this mane. Patient trying 1435 to jump out of bed at times. 1600 hrs Appears to be in a lot of pain. He is trying hard to pull
out the catheter. Cardiology review by Dr Jim Stewart “Patient is very agitated/confused.
Trying to pull indwelling catheter out himself. Urine output 80 mls in five hours. Blood
Pressure 78/58 mm/Hg. Pulse 111, JVP 0. Plan: not candidate for angiogram. Indwelling
catheter draining concentrated urine. Frusemide administered – not written on drug chart. 1440 Current plan is to manage medically. “He is for Code Red only”. Neglected to do an
echocardiogram ultrasound which would have shown pericarditis (inflammation of the sac
around the heart). ST segment elevation significant for pericarditis differential diagnosis.
Tuesday 30 October 2007 – Ward 34 – 0930 hrs Consultant’s ward round – Dr Wasywich. 1445 Sedated – quite drowsy. Blood Pressure 96/68 mm/Hg. Heart Rate 90/minute, Sinus
Rhythm. No ectopics. Not on intravenous fluids. Started on oral Amiodarone 400 mg b.d.
(twice daily) contraindicated with hypotension. Amiodarone has an exceedingly long drug
half-life and is exceedingly dangerous when administered with the wrong drug combinations,
which causes a deadly combination. 1000 hrs moving around and calling out. 1500 hrs 1450 Dr Glenie, junior doctor, discussed with Neurosurgical team – no further input from their
service therefore not keen to take patient back. Mr Harrison became a stranded patient.
39
No department wanted to care for him. Haemodynamically remains stable. No Arterial
Blood Gas tests taken. Continues with apnoeic episodes during sleep. Very drowsy +
difficult to rouse for most of the duty. Complete disorientation. Combative with 1455 interventions. Looks stressful and restless. Amiodarone commenced with low Blood
Pressure. Contraindicated. Intravenous fluid commenced at 1530 hrs. Still extensive
bruising left flank (not included in Dr Denmark’s post mortem report). Restraints taken
down. Blood Pressure 80/57.
1460 Wednesday 31 October 2007 – Ward 34 – 0430 hrs mouth dry. Poor oral fluid intake.
No oedema. JVP +2 cm. 0904 hrs slightly more agitated this morning. Blood Pressure
92/62. Heart Rate 70 bpm. Heart sounds dual, soft, no murmur. Chest clear. Impression:
severe head injury, Ventricular Arrest. Dietitian said “No food chart to review intake” –
food chart was missing. Dietitian queried fluid intake as poor. Observations within baseline. 1465 Still apnoeic. GCS 12/15. 1945 hrs Patient waking up frightened. 2200 hrs Yelling out
during sleep periods and sometimes gets up in a fright. 2300 hrs Coughing. Began coughing
and yells in pain.
Thursday 1 November 2007 – Ward 34 – 0100 hrs whenever coughs appears to be in pain. 1470 Condition still serious – unable to swallow last night. Pupils small 2+ (signs of opioid
toxicity). Appears to be in severe pain when rouses – fractured ribs and lumbar vertebrae
plus probably has headache – please get Pain Team to review. Anaesthesia Specialist Pain
Team was never contacted. Not swallowing for past 24 hours. GCS 11/15. Groaning.
Restless. Moving all four limbs. No obvious hand pressure. Need decisions re how to feed 1475 him. “I also wonder if his pain is adequately controlled.” 0300 Calling out in sleep.
Drowsy then agitated alternatively. 0400 Calling out on and off. Apnoeic periods of
breathing – Cheyne-Stokes. Impression: severe head injuries. Never called in a Neurologist.
Never did CT scan. Never took Arterial Blood Gases. Never did echocardiogram.
Too sedated to speak – eye opening only on rousing. Myoclonus. Apnoea. Methadone 1480 started. Partly sedated through Benzodiazepine administration. “It is difficult to be clear
about his prognosis and it seems reasonable to decrease the level of sedation so that we can
reassess his prognosis and talk to him if possible (he was apparently more awake and talking
yesterday)”. “I suggest keeping him hydrated but not feeding at present and again we can
review this once he is more alert” In breach of traumatic brain injury nutrition requirements. 1485 It is scientifically proven that traumatic brain injury must have a high level of nourishment.
Another nurse wrote in the medical record: “Patient very drowsy this morning. GCS 10/15.
When awakes from sedation is agitated and confused, coughing and appears to be in great
pain from ribs and chest wall. Not verbalising – occasionally saying “No” but nothing else.
Was in Sinus Rhythm till around 0915 hrs then went into atrial fibrillation with rate 120-130 1490 beats per minute with frequent PVCS” – “No need for monitoring”. Oxygen down to
70%. Dehydrated. Patient too sedated to assess today. Confused/combative at times still.
More Methadone administered. Life saving emergency treatment was refused. 0740 did not
sleep well. Coughing. Appears in pain. Restless. 0900 calling out in pain. 0940 Groaning –
appears sleeping on and off. 1010 hrs Nurse assess consciousness. No reaction. Looks 1495 restless and in pain. 1220 Doesn’t sleep well. Awake on and off. Seems like having bad
dream. 1300 groaning on and off. 1510 screaming out. Not breathing for some time and
then breathes again. 1545 agitated, restless, screaming. 2.5 mg of Methadone injected.
1630 hrs Unsettled. Restless. Holding his head and screaming. Drugs administered and not
written on drug chart. 1800 Of and on sleeping. Wakes up and holds his head and screams. 1500 1900 on and off sleeping. Gets agitated, restless, screaming, holds head, hands on chest
while screaming. 2.5 mg extra of Methadone given at 2108 hrs. 2200 hrs Now patient is
40
constantly off and on in sleeping. Very quiet breathing for 1-2 seconds and then regain
breathing again, then slow again in breathing. Eyes are closed. 2300 hrs Patient appears to
be crying out loud and sleeping. Patient sounds like he is in pain and returned to sleep. 1505 Patient groaning and back to sleep. 2330 hrs Nurse administered pain relief as patient
continues to grown. Methadone not written on drug chart. Patient heavy breathing heard for
a short time and breathing becomes very quiet.
Friday 2 November 2007 – Ward 34 – 0100 hrs groaning and falling in and out of sleep. 1510 0200 hrs groaning and heavy breathing observed, and then patient’s breathing is quiet and
now asleep. 0400 hrs pain relief – not written on drug chart. 0500 groaning while sleeping.
0600 hrs Patient’s breathing becomes heavy and suddenly quiet. Patient continues to groan
on and off during sleep periods. 0730 hrs Heavy breathing. Very restless. 0930 hrs very
restless in bed. 1030 hrs in pain. Drugs not written on the drug chart. 1200 hrs sleeps on 1515 and off. Breathes heavily. This is respiratory depression. 1300 hrs on and off breathes
heavily. IV site leaking. Left side of the chest bruise +++. Methadone. Blood Pressure
112/60. Reduced air entry at bases. No peripheral oedema. When he is breathing he wakes
and looks distressed and calls out. 1007 hrs Dr Anne O’Callaghan (second respondent)
wrote “I suggest increasing the background analgesia to Methadone 20 milligrams. 1520 He appears to be no more able to respond today, even when he rouses and has his eyes
open, than he was yesterday.”. This is a lethal dose for a debilitated opioid naïve patient in
combination with other contraindicated potent drugs. He has had 4 doses of 2.5 mg of
Midazolam (benzodiazepine) in the last 18 hours. Amiodarone and Lorazepam still in
system. She goes on to write in the medical record “It remains unclear to me why his 1525 conscious level has fallen – is this thought to be a result of added hypoxic insult in addition to
his traumatic brain injury) – would it be useful to have a Neurology opinion about this?” - It
is fundamental that Mr Harrison should have had a specialist Neurologist review
URGENTLY. Mr Harrison was never given any specialist treatment or management at all
throughout Ward 81 and Ward 34. His entire admission at Auckland City Hospital was 1530 botched. Dr O’Callaghan goes on to write: “it is not clear to me why his conscious level has
fallen if it is not related to sedation – which may be the case given that he has not yet
improved with stopping the Lorazepam”. Coarse breath sounds on respiration and decreased
air entry on left. 1500 hrs very restless. Sleeping. Sometimes takes breathes very fast. Did
not open his eyes. Is not responding to voice. 1600 hrs Patient is still sleeping and not 1535 responding. Sometimes he is placing one hand on forehead region and other hand on chest.
Breathing fast suddenly due to accumulation of saliva in throat. Respiratory depression set
in. No specialist monitoring provided. No precautions taken. Contraindicated and lethal
drug combinations administered. Too drowsy to assess. Restless at times. Physiotherapist
wrote: “?explore traumatic brain injury”. They left it too late. Mr Harrison was never 1540 given a specialist Neurologist/Neurosurgeon review. Mr Harrison was left in the hands of
house officers and registrars – very junior doctors, when all the time he desperately needed
intensivist specialist expertise. ADHB department cost saving was put first before life saving
essential services. Ward 81 was impatient to get Mr Harrison out of the ward and then
wouldn’t have him back. The Intensive Care Unit turned their back on him. Anne 1545 O’Callaghan and Katherine Jane Rix-Trott between them killed Mr Harrison off with a lethal
combination of drugs they knew was deadly, and turned off the monitoring, and deprived him
of necessaries of life. Mr Harrison should have been reviewed by a specialist Neurologist
and Anaesthetic Pain Specialist. Dr O’Callaghan is not a qualified Pain Specialist and she and
Dr Rix-Trott misused Methadone which is contraindicated and deadly with Amiodarone and 1550 benzodiazepines and other potent drugs which are lethal in combination. 1800 hrs the
41
medical record states: GCS 5/15. Patient is sleeping. Moving his both legs and placing one
hand on forehead and other on chest. Increased Methadone to 20 mg and Haloperidol to 2
mg for Graseby pump today, started 1424 hrs this afternoon. In other words doubled the
Methadone and doubled the Haloperidol. In a few hours Mr Harrison was dead. 1900 hrs 1555 Laboured breathing but sometimes normal. 1930 hrs Patient suddenly sitting up and
coughing lots of greenish secretion. He kept biting the suction tube. He suddenly stopped
breathing. No pulse. No response. Pupils fixed and dilated. No respirations. Time of death
1930 hours Never got a follow up CT scan. Never got an echocardiogram. Never did
Arterial Blood Gas testing. Turned off ECG monitoring. Never got a specialist Neurological 1560 review. Never got a Pain Specialist review. Never got a Respiratory review. Never got an
Endocrinology review for hyperglycaemia. Never acted on emergency signs and symptoms
requiring Intensive Care Unit specialist expertise. Broke best practice medical and
pharmaceutical guidelines. Mr Harrison had the signs and symptoms of Methadone overdose
toxicity: Miosis (constricted pupils), Hypoventilation (breathing that is too slow/shallow), 1565 Drowsiness, Skin that is cool, clammy, and pale, Limp muscles, Unconsciousness, and coma.
In 2006, the United States Food and Drug Administration issued a caution about methadone,
titled “Methadone Use for Pain Control May Result in Death.” In combination with
benzodiazepines and Amiodarone (and other potent drugs) it is particularly lethal which
every doctor knows not to do. Auckland District Health Board has done no audit of how 1570 many iatrogenic deaths have resulted from lethal combinations of drugs in Auckland City
Hospital.
There is much more preponderance of authority that can be put in these pages.
The fact is there is no justification for covering up lethal malpractice which has violated
human rights and caused anguish and tortured death and the Rule of Law does not 1575
abide perpetrators of acts of illegality to walk free and obstruct justice.
Dated 27 November 2013
1580
....................................................... .......................................................
Pauline Janice Harrison Angela Janice Harrison
Appellants with Standing Pursuant to the Victims' Rights Act 2002 which recognises the 1585 Family has Standing and in Defence of Individual and Human Rights Preserved in the
Rule of Law
Address for service: 38 Damien Place, Bromley, Christchurch 8062
email for appellants: [email protected] 1590