Patient’s death no Seals ‘remarkably resilient’ in coping with quake accident - coroner
The death of Auckland woman Heather Bills was no accident, the chief coroner has confirmed – but her death largely remains a mystery.
Chief Coroner Judge Deborah Marshall released her findings into the death yesterday following an inquest in September.
Bills, 64, died in 2013 while in the care of Middlemore Hospital in South Auckland, having survived a huge fire at her O¯ ra¯ kei home six weeks earlier.
It was later discovered she had suffered an irreversible brain injury after being given a massive dose of insulin on the evening of December 26, 2012.
It is still not known who administered the fatal dose.
She had been rescued from the explosive blaze by neighbours and admitted to hospital with serious burns.
Bills refused visitors, often expressed suicidal thoughts, and offered to pay hospital staff to end her life.
But her condition began to improve and staff expected she would recover from her injuries.
On the evening of December 26, Bills became extremely unwell while still in hospital.
A house surgeon was called to her bedside, and she was admitted to the intensive care unit.
Tests revealed her blood sugar levels were ‘‘extremely low’’, which in turn was injuring her brain. It became clear the hypoglycaemic event was caused by an overdose of insulin.
Earlier coronial inquiries had tried to establish how Bills, who was not diabetic, had been given the dose. Nurses who were witnesses at the inquest gave conflicting accounts of what happened that night.
Judge Marshall’s findings were that the fatal dose of insulin was either handed to Bills or administered to her. Bills could not get out of bed to source insulin herself, and opening a vial and preparing an injection would have been beyond her abilities, Marshall found.
But she may have been able to inject insulin if it was given to her.
Judge Marshall said she was satisfied Bills was administered an overdose of insulin, and that the overdose must have been administered by someone who had access to insulin and the secure National Burn Centre.
Detective Senior Sergeant Ross Ellwood told the coronial inquest that police were called to investigate Bills’ death as there ‘‘was a clear suspicion she had been injected with insulin’’.
‘‘We are looking at someone working in a hospital potentially causing the death of patients,’’ Ellwood said at the time of the inquest.
It was the only case in New Zealand of its kind, he said.
While the police had not charged anyone for administering the fatal dose, police had three suspects who worked at the hospital. Three nurses who were suspects in the police inquiry were still employed by Counties Manukau District Health Board as of September.
A spokesperson from the Counties Manukau DHB, which runs the hospital where Bills’ was given the overdose, had earlier, said it was ‘‘never advised that police had any particular concerns about the acts or omissions of any particular individual’’.
‘‘In the absence of any proof of wrongdoing, the DHB could not take action against an employee,’’ she added.
Yesterday, having received the coroner’s report, the spokesperson issued a statement: ‘‘The DHB is considering the coroner’s findings and what, if any, action it may need to take.’’
The criminal open. case remains It was once one of the most popular attractions on the Kaiko¯ ura coastline – an idyllic river pool beneath a waterfall, filled with seal pups at play. That changed on November 14, last year.
When the earthquake struck, the cliff above the pool came crashing down, while tonnes of rock and earth fell from O¯ hau Point onto the coast which a large seal colony called home.
It seemed the colony was gone, but one year on, the seals have proved ‘‘remarkably resilient’’ – though dozens have been killed in the efforts to rebuild the crucial road and rail which hugs the coastline.
About 180 bull seals have settled along the coast around O¯ hau Point, boding well for the breeding season about to begin. Formerly about 2000 seal pups were born at the site each year.
Department of Conservation (DOC) ranger Mike Morrissey, who has worked with the seals over 30 years, was one of the first at the waterfall pool after the quake. He said it was ‘‘no longer a pool, it’s just a mound of rock’’.
Northern South Island operations manager Roy Grose said further rock falls from the cliff beside the waterfall pool were possible. The area would remain closed to public access.
The waterfall pool and track leading to it are on privatelyowned land. Grose says DOC had been in discussion with the land owners but no decision on the pool’s future had been made yet.
He said seals were still being seen in large numbers around the O¯ hau Point area, though many had moved to a new territory slightly to the north.
The Kaiko¯ ura seal population seemed ‘‘remarkably resilient to the impacts of the earthquake’’ and subsequent work on the road and railway line that butted up against their habitat, said Grose.
Dozens of seals have died because of the highway rebuild following last November’s earthquake, despite the best efforts of the workers.
In the last three months, the North Canterbury Transport Infrastructure Recovery alliance (NCTIR), who are rebuilding the battered transport corridor, have recorded 41 seal deaths caused by earthworks or road rebuild activities.
A total of 294 dead seals have been found by rebuild workers over the same time period, but the cause of the remaining 253 deaths is unknown – but not thought to be related to the works. It is common for young seals to die in the late winter and spring.
NCTIR environmental manager Manea Sweeney said they were doing ‘‘everything they can’’ to minimise seal deaths throughout the project.
More than 11,000 seals (many repeat offenders) have been moved by seal handlers who are constantly monitoring the coastline outside the ongoing roadworks. In places, a row of 5-tonne seawall blocks have been temporarily laid on the edge of access roads to keep the rare mammals outside the work zone.
She said moving seals involved ‘‘a huge amount of work’’. Teams of seal handlers were working 24 hours a day to match the schedule of the road works.
Sweeney said NCTIR had a ‘‘robust’’ environmental management framework which helped the construction crews with how they should go about their work. The environmental team was made up of about 40 people.
‘‘With the sheer scale of it, this could be the largest environmental team on a construction project ever in New Zealand.’’
Grose said DOC was very pleased with the ‘‘care and considerable effort’’ those rebuilding the road had shown in keeping the seals safe.
The New Zealand fur seal, or kekeno, is fully protected by the Marine Mammals Protection Act. Those rebuilding the road were given permission to kill or injure seals as part of their work until March 2018, as legal protection for any incidents which saw seals accidentally killed during the works.
In May, 30-40 seal pups were found dead in one area just south of O¯ hau Point. Autopsies done at the time suggested their deaths were because of pneumonia. There have been no reports of similar group deaths since.
Not all marine life has proved as resilient as the seals, with paua struggling to recover from huge losses post-quake.
Ministry of Primary Industries (MPI) manager inshore fisheries Allen Frazer said because of quake-related uplift of the seabed, juvenile paua and seaweed suffered ‘‘significant mortality’’.
An emergency closure of the affected fisheries was announced following the quake, due to expire on November 20, 2017.
However, once the scale of the losses was known, a further closure was put in place, and would apply indefinitely. The closure banned recreational and commercial fishing of all shellfish and seaweed in the impacted areas.