Procedures and protocols’
breaking his ribs and confused as to why she was bringing it up now.
“I was worried that she made Dad scared,” Megan says, so she asked the registrar to leave.
At around 1am, Jim had still not been transferred to the respiratory ward, so Viv and Megan went home to sleep.
“If we knew what was about to happen, there’s no way we would’ve left him overnight,” Megan says.
THE NEXT morning — Monday, January 23 — there was still no inpatient bed.
A nurse noticed Jim’s heart rate had increased and that he was working harder to breathe. The respiratory team advised giving Jim more oxygen and said someone would review him soon.
Viv arrived around 8am and Nathan not long after. Jim refused breakfast but drank water.
Blood tests showed that Jim’s lactate level, although still severely elevated, had fallen to 4.2 mmol/L, which the doctors took as encouraging.
Megan arrived around 9am. She says Jim was awake but struck her as less responsive than the previous night. She chatted to him about a rugby sevens tournament being played in Hamilton, but Jim didn’t say much.
For long periods, the Weteres waited for something to happen.
“Still awaiting bed on ward,” a nurse scribbled on an assessment form at 11.30am.
By then, Jim had been in the ED for 24 hours. Then it was 25. Then 26.
Still mistakenly believing that Jim was merely fighting pneumonia, the Weteres fixated on the chest drain as the crucial intervention. “Get that fluid off his chest and he’ll be sweet,” Megan thought.
At 2.55pm, Jim was given a blood transfusion. He had to give written consent to receive blood but was so weak he could barely hold a pen.
Then a senior nurse confronted Viv, Megan and Nathan. Why were there three visitors in the cubicle? It was against ED rules. They would have to leave.
Megan pushed back. Jim had now been waiting nearly 29 hours. They weren’t leaving him again until he moved to the respiratory ward.
Nathan, trying to keep the peace, said he would come back later when the chest drain was done.
Then the atmosphere changed, Megan says.
Perhaps the senior nurse went away and examined Jim’s chart for the first time, Megan figured, because she returned with a new sense of urgency.
Orderlies arrived and adjusted the bed to make Jim more comfortable. Then a pair of doctors came to examine Jim.
Jim was moved to a resuscitation room.
One of the doctors recorded that Jim’s blood pressure, oxygen level, and responsiveness to stimulation had gotten worse.
“Deterioration, likely terminal,” the registrar wrote.
The young doctor took Viv and Megan aside in the hallway and told them Jim probably wouldn’t survive.
It was the first time in 30 hours they were told Jim had sepsis, let alone that it was likely to be fatal.
“You might as well have hit us with a truck,” Megan says.
Megan phoned Nathan and told him to come back to the ED right away. He arrived just in time. Megan called her daughters and Jim’s sister and told them to come too. They would have been there already if they’d known Jim’s life was at risk.
Jim was given more IV fluids, but his blood pressure kept falling. His lactate had shot up to 9.3 mmol/L.
His breathing became “extremely slow and erratic”, a nurse observed.
“Entering last moments of life,” a registrar noted at 4.15pm.
Monitors and IV pumps were switched off.
Jim’s breathing stopped. His heart stopped. With the family’s agreement, there was no attempt to resuscitate him.
“Rest in peace,” the registrar wrote. “Time of certification: 16:26.”
JIM WETERE’S death wasn’t just a shock to his family.
On Friday, January 27 — the same day that an unprecedented downpour devastated Auckland — a crowd of mourners filed into the Suburbs Rugby Club, where Jim had been a constant presence, for his funeral.
Draped in rugby shirts from the local Suburbs and Tainui Waka clubs, Jim’s coffin was carried past the bar where he’d spent many hours socialising over the years, and placed in front of the club’s honour board. Nathan read the eulogy and then others came forward to give tributes:
“You were the backbone of the wha¯nau,” said one of his granddaughters.
“Hell of a man,” said the Suburbs chairman.
“I’m honoured just to have walked in his life,” said a woman who worked with him in Enderley.
At the end of the ceremony, a montage of family photographs was played to the sound of the Rolling Stones’ You Can’t Always Get What You Want: Jim in his wedding suit. Jim with the grandkids. Jim with his dog Poppy. Jim wearing an All Blacks jersey. Jim holding a beer. Jim in the garden. Jim at Disneyland. Jim dressed as Santa Claus.
In the weeks that followed, the Weteres struggled to make sense of what happened.
It was hard enough to accept the loss of such a monumental figure in their lives, but the family’s grief was compounded by the disorienting circumstances.
Their shock was mingled with anger and guilt. They had spent so many hours waiting with Jim without realising he was dying; should they have pushed harder for something to be done?
For Megan, it was especially heartbreaking that her daughters had not been there to say goodbye. Jim had helped raise them as if he was their father.
Megan obtained copies of Jim’s medical records and began digging through the charts, test results, and clinical assessments. A friend who had been a senior nurse at the ED helped decipher the terminology and figure out what to ask.
At the end of June, Megan sent the hospital management a five-page email detailing numerous alleged flaws.
Her concerns fell under three main themes.
First, there was the medical care: the four hours it took for Jim to be seen by a doctor after he was triaged as code 2; that he wasn’t immediately moved to a resuscitation room or ICU where he would’ve got closer attention; the long periods when it seemed nobody had a handle on Jim’s condition.
“There was no urgency in his care,” she wrote.
Second, the lack of communication about how sick Jim was and the allegedly insensitive interactions with the respiratory registrar and senior nurse.
Finally, Megan also claimed there had been cultural failings.
The family wasn’t offered assistance from the hospital’s Kaitiaki Ma¯ori liaison service until after Jim died, and she alleged that tikanga (Ma¯ori death custom) wasn’t followed because THE HOSPITAL opened an internal review, treating Jim’s case as a “SAC 1” incident — an unexpected death that may not have happened naturally.
In July, an operations manager informed Megan that the hospital had “identified that there are abnormalities in your father’s care plan and acknowledge that these should have been picked up earlier”, although she did not identify the abnormalities. The manager said the hospital aimed to complete the investigation within four weeks.
Later that month, the Weteres met the staff conducting the review to discuss their complaint. Megan says they seemed sympathetic and promised to keep her in the loop and share their findings when they were ready.
Weeks went by. Megan pushed for updates. Finally, the document arrived in her inbox in November. Megan was crushed.
“It has been ascertained through completing this review that Mr W was provided with the appropriate level of care by the nurses and medical staff,” the review said.
It found that Jim had been given the appropriate triage code, diagnosis, and treatment plans and there was no clinical indication that he needed to be sent to a higher level of care until late on Monday afternoon. Staff followed the correct path for sepsis and Jim responded to treatment. Jim’s observations were “stable and managed” until he suddenly deteriorated; he didn’t need to be seen by a senior doctor; and another course of treatment was unlikely to have had a different outcome.
Near the end of the report were two paragraphs acknowledging “communication issues.
“It is clearly evident that communication between the nurses and medical staff did not meet the expectations of Mr W’s wha¯nau,” it stated. “They were absolutely shocked when Mr W deteriorated on 23 January 2023 and the wha¯nau were informed he was unlikely to survive. Because of this, the wha¯nau feel they were robbed of precious time with their husband, father, and loved one.”
The report said the miscommunication was a “learning opportunity” for the staff who were part of Jim’s “journey”.
After reading the document, Megan says she regretted participating in the process. She hadn’t expected it to substantiate all the family’s complaints, but as she saw it the 13-page document — written in passive, impersonal clinical and bureaucratic language — minimised their experience, left many of their questions unanswered, and was insufficiently critical of the service that had been provided.
It felt as if the hospital had strung them along for months and then deflected responsibility.
Megan sent back another long email with a point-by-point rebuttal.
“Waikato ED failed to provide Jim with the care he required,” she wrote.
In early December, a hospital representative wrote back apologising that the review was traumatic and didn’t “provide the peace and resolution that you are seeking.
“I acknowledge the report exposes gaps in Jim’s care that do not meet the standards we would expect,” the manager said, without elaborating on those gaps, and invited the Weteres to another meeting to discuss the findings.
Viv refused, her trust in the system exhausted. Megan was also sceptical, but having pushed it this far decided to see the process to the end. She and Nathan agreed to meet.
A WEEK before Christmas, they arrived at a hospital building across the road from the ED. It was unnerving to be back.
Entering the room where five hospital staff waited, including the clinical leaders of the emergency and respiratory departments, Megan says they were braced for an awkward, defensive conversation — but were surprised.
The staff struck her as empathetic and conciliatory, and they went beyond what had been said in the report.
Dr Harry Gallagher, head of the respiratory department, said it seemed from Jim’s clinical notes that he had been triaged correctly but “then there’s a real lack of apparent urgency around treatment being given.
“So then you naturally arrive at some uncomfortable conclusions,” Gallagher said. “And it may not have been the case, but with the lack of urgency comes the perceived lack of care.”
Dr Greg Stevens, head of the ED, said Jim waited too long to be seen by a doctor after being triaged. “There’s no way that a four-hour delay is acceptable. I’m not hiding that one. Unfortunately, that’s a common occurrence in our department because we have so many sick patients coming through.”
Stevens pointed out that nurses had begun treating Jim while he waited for a doctor, with IV fluids being the most important intervention. Someone in Jim’s condition would also usually be given IV antibiotics immediately, Stevens said, and he wasn’t sure why that hadn’t happened with Jim.
“Would that have made a difference? I don’t know.”
Stevens pointed out that Jim’s heart condition was severe, which complicated the sepsis treatment and diminished his body’s natural ability to fight the illness.
Stevens apologised for the long delays and said the ED is “working really hard” to cut waiting times. They discussed Jim’s lactate level. “As you’re aware, monitoring lactate is an important part of how we gauge our fluid resuscitation,” Gallagher said. “That wasn’t checked frequently overnight.”
Although Jim’s lactate had decreased slightly on Monday morning, which the internal review cited as evidence that he was responding to treatment, Gallagher now said: “You can reasonably say that that’s an inadequate response, and that it actually hadn’t come down enough. And that should’ve probably raised alarm bells to say that we’re possibly undertreating your dad with regard to sepsis management. So I think that’s a clear shortcoming.”
Gallagher apologised that Jim’s lactate hadn’t been checked more often and his treatment reviewed overnight.
Megan choked up.
It wasn’t a definitive answer to the question that haunted her most: Would Jim still be alive if things had been done differently? Megan knew that emergency medicine was too fraught with uncertainty for the doctors to go that far, but it was a relief to hear their apologies.
The staff also apologised for communication failures.
“Communication was a huge issue that we didn’t deliver on,” said Melody Mitchell, operations director for medicine.
“I could pick up from your feedback one insult after another when it came to lack of communication, lack of respect, and that’s something that weighs on us hugely because it’s a common trend. We get it right sometimes and sometimes when we get it wrong, we get it really wrong. And I think in your dad’s case, in your family’s case, we got it really wrong.”
Hemi Curtis, a cultural adviser, spoke up.
“You hit the nail on the head, Megan, with your first letter [in June], and it was around empathy, compassion, and communication,” Curtis said.
He said reading the internal review was “like getting slapped in the face by a cold fish.
“Where are you in that review? You’re not there,” Curtis said. “All you see are the processes, procedures, and protocols that are in place.”
Curtis thanked the doctors for fronting up. He thanked Megan for holding the hospital accountable. “Ever since I read your first letter, it’s been in the back of my mind.”
“I’m in quite a lot of these types of cases,” he said.
You naturally arrive at some uncomfortable conclusions. And it may not have been the case, but with the lack of urgency comes the perceived lack of care.
Dr Harry Gallagher Head of the respiratory department
Jim Wetere is presented with his QSM by Governor-General Anand Satyanand in 2009.
AFTER THE meeting, Megan didn’t feel that the family’s complaints had been resolved, exactly, but it was vindicating — and now they could start to move on.
Megan spent six months pursuing the complaint with unusual doggedness, out of love and respect for her father but also because she believed that is what Jim would have done. It had been exhausting, and it had also prevented her from properly grieving.
“It just feels like this unfillable hole,” she says of losing her father. “You’ll be fine for a while, for a day or two. Then you’ll be driving somewhere and pow, it just comes over you.”
She intends to keep pushing the hospital to make meaningful changes so that other families don’t endure a similar experience. A Te Whatu Ora spokesman says there are “a number of existing initiatives” under way that are relevant to Jim’s case — and Megan plans to complain to the Health and Disability Commissioner, which would conduct a fuller investigation of Jim’s care, although that is likely to take years.
For now, though, she is concentrating on celebrating Jim’s life as it deserves to be.
Next week, a year to the day after Jim was buried, the Weteres plan to unveil a headstone at his grave at Hamilton Park Cemetery. They have had a korowai, a Ma¯ori cloak, specially made to drape over the headstone. After the ceremony, they will go back to Jim’s home and throw the party he would’ve wanted as a send-off. They will put on the Rolling Stones and turn it up loud.