Fighting for Zac

A father determined to find out why his son died from meningitis had to battle an obdurate hospital bureaucracy and a closed shop of doctors.
By Donna Chisholm

I
O

ts the sound

of the zip on

the body bag that still haunts Jenny Gravatt. Why couldnt they have just wrapped her darling boy in a blanket when they took him to the morgue? They went down there with

him to say goodnight. Then the two cops opened the door, let them out on to a foggy Grafton Rd at midnight and shut it behind them on the life theyd had. A life with Zac in it. Lance Gravatt remembers looking around him as if hed never seen this street before and thinking, I dont know do I go up or do I go down? Jenny is beyond thinking. She wakes the next morning and every morning since to the sound of a zip.
n July 8 last year,

Auckland

City Hospital, like every other, was by its own admission run
Lance and Jenny Gravatt, at home in Herne Bay. When their son Zac fell ill, says Lance, he was rushed to hospital but staff left him alone and he was not even given a chance of life.

off its feet with swine flu. Front-page headlines in that mornings New Zealand Herald told how medical centres were
donna chisholm is metros editor-at-large. Photographs by adrian malloch.

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hen Zac s parents

asked

research it. Thats when I found out triage category 3 means he should be seen in a maximum 30 minutes and he wasnt seen for more than two hours. Then I find that low blood pressure is a sign of organ failure with sepsis. So you start laying out these concerns one after another after another and it just got worse and worse and your heart just sank more and more. In the end, you get this sense of, What did they do right? The Gravatts thought carefully about what to do next. Ive seen it so many times before on TV, of grieving, distraught parents with a kind of conspiracy theory, making fools of themselves or embarrassing themselves in front of the nation with their grief, when their concerns are not factually based, or a bit irrational and we said, We dont want to be one of them. So Lance documented his findings and sent them off to the Health and Disability Commissioner and the coroner and emailed Auckland District Health Board chief executive Garry Smith. Smith never replied or even acknowledged receipt of the email a discourtesy which so annoyed Lance that he called the Herald. The newspapers inquiries prompted a call from the boards chief medical officer, David Sage, who said hed been unaware of the familys concerns, and invited them in to go over the notes. I said I didnt buy that this was the first theyd heard of our concerns Id emailed Garry Smith and I thought, OK you guys, someone somewhere in your good ship lollipop has known about it. Sage told the Herald he was absolutely confident Zac had received the best possible care. I would like to reassure the public that when a patient comes into our care, they are in an expert centre with vast experience in the early diagnosis of [swine] flu and meningococcal disease. The comment further angered the Gravatts, who by this time had obtained a report for the coroner by a hospital intensivist who said that, in his opinion, Zac had overwhelming meningococcal sepsis at the time of presentation to hospital.

His death may have been inevitable even with earlier antibiotic therapy and early intensive care. For the Gravatts, there was only one problem with that the word may. The chance, the lost chance, that Zac might have been saved. Alerted to the possibility Zacs death could be classified as an ACC treatment

for his medical records in November last year, it wasnt

because they wanted answers to any questions surrounding his death. I just felt they were all part of Zac a little like his autopsy remains, which wed also wanted back and which we buried on our farm, says Lance. We just felt we wanted all of Zac together. They also needed to fill in the gaps for themselves because during his critical hours in the emergency department, Zac was alone. Lance, Jenny and daughter Maddy were in Wellington for a Supreme Court case that Lances company was involved with. They flew back as soon as Zac told them he was in hospital, but they arrived less than two hours before he died. Jenny, a resource management planner, read the notes first, and while her first thought was that the timing didnt gel, she found it difficult to piece the story together. Lance couldnt face the task straight away and it was not until
Zac Gravatt overcame dyslexia to achieve a childhood dream of studying medicine. His father believes he picked up the meningococcal C virus from a patient.

to put him in a room and just leave him there for a few hours he deserved better than that.

injury, Lance filled out an application form not to get the money, but for an independent report on his sons care from ACCs medical expert. He then discovered a doctor had to sign the form, but Zacs hospital consultant had died of a heart attack, their GP had retired and moved away and he knew of no other doctor whod known Zac. I asked if ACC could suggest any doctors and they said, No, youll have to find yourself one. Then I phoned the health commissioner and the coroner and I remember crying and crying. I said, Are you telling me Ive got to walk around Auckland, door-knocking with my dead sons medical records tucked under my arm to see if I can find someone who will read them and then, if theyre of a mind to, sign them? They said, Thats right. He finally found a GP who not only signed the form, but also endorsed his concerns about the shortcomings in Zacs care. Lance then asked for a copy of the hospitals own morbidity and mortality review of the case the record of a meeting held every two months in which medical staff review adverse events and discovered there hadnt been one. We were absolutely gobsmacked. He says the DHBs medico-legal counsel told him many people died every day at Auckland City Hospital and you cant investigate them all. I said, They wont all be young, fit, healthy men like Zac who were not expected to die and of whom your own notes set out that you got the diagnosis wrong. He said, Look, Zac had an awful disease and he would have died anyway. I said, How do you know that when you havent investigated? There was no response to that. That, too, was his concern with Sages public reassurances. He told the public Zac got the best of care. But he had no basis on which to say it and it was such a put-down to us.
Lance and Jenny Gravatt on their farm near Mangawhai in Northland. Zacs autopsy remains are buried here.

the Christmas holidays that he finally read the records. For Lance, the chief executive of an international pharmaceutical company and with a PhD in organic chemistry, the notes were deeply troubling. The first thing that struck me was the lab report of his blood tests. They said he had low platelets and low white cells which are present in the setting of sepsis consistent with infection. And I thought, Well, no one ever said that. Even the consultant who saw Zac at 5.30pm, when Zac had only 90 minutes left to live and was already coming out in the telltale meningococcal rash, told the Gravatts he still thought their son had an influenza-like virus. He was transferring him to critical care, he said, to help him with his breathing. But Lance says Ministry of Health guidelines say flu-like illness is defined as a history of fever, chills and sweating plus a cough or sore throat. Zac had no cough and no sore throat, so statistically, at the time he arrived at Auckland City Hospital, the likelihood of his having swine flu was less than five per cent. His symptoms high fever, fast heart rate, low blood pressure and rapid breathing were, Lance believes, screaming infection. I thought to myself, Right Lance, youve found something that concerns you, lets lay it all out systematically and anything I dont understand, Ill just Google it and

struggling to cope with a rising flood of cases, with patient numbers up 40 per cent. The number of swine-flu hospitalisations had peaked the day before, at 38. Fourth-year medical student Zac Gravatt, 22, probably didnt read the story when he woke at 4am feeling as grotty as hell. By the time he saw the local doctor around 11am, swine flu was the prime suspect. Just the week before, he told the GP, hed been in contact with swine-flu patients on the wards. The GP didnt hesitate, ordering his immediate transfer by ambulance to Auckland City Hospital. Mask-wearing paramedics found a constellation of worrying signs a racing pulse, high fever (nudging 40 degrees), rapid breathing, and lowish blood pressure. By 1.43pm, Zac was in triage at the emergency department, where a nurse assigned him category 3 a designation which under emergency department guidelines means treatment should begin within a maximum of 30 minutes. But treatment did not begin in 30 minutes, 60 minutes or 120 minutes. From 2.30pm to 4pm, when the unit was at 80

per cent capacity, staff didnt even record his vital signs, nor did they give pain relief or fluids to this critically ill young man. It was care that even the health boards own independent expert describes as unacceptable. By 4.30pm, when antibiotics were finally given, Zac had less than three hours to live. And even then, the countrys premier centre of medical excellence had failed to diagnose the meningococcal septicaemia that was rapidly killing him. The only window of opportunity he had, says Lance Gravatt, was when he first came in, and he was not even given a chance of life. No one can say with certainty what the outcome would have been but he should have been given the chance. You know, to put him in a room and just leave him there for a few hours he deserved better than that. New Zealand deserves better than that. The Gravatts returned to Auckland City Hospital the day after Zacs death, to thank those responsible for his care. They had no idea then how little they had to be thankful for.

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n April , the Gravatts

search for

ashamed of the treatment he was given and how the medical community had dealt with the family since. Zac had wanted to be a doctor from the time he was little hed even dress up as one and had to overcome dyslexia to achieve top grades at Auckland Grammar. But it was his fathers serious illness in 2004 when Lance was hospitalised nine times for seven bowel operations that ultimately decided him. He said he could remember standing at the end of my bed looking at me and feeling totally helpless and he decided he never wanted to feel like that again. But the irony is thats exactly what happened to Zac. We all just stood by helplessly and watched him die. He says when the family arrived back from Wellington just before 5pm the day Zac died, they saw him only briefly before he was rushed to critical care. He was in
David Sage defended the care Zac received.

answers took another painful turn when Lance became the subject of

a whistleblower complaint from one of his own staff, who went to his companys Singapore-based bosses with concerns that Lance had a conflict of interest in taking a complaint against the health board when the company was doing business with it, and that he might be using his position as CEO to influence the outcome. I felt at the time that I was under immense pressure to either drop my complaint and keep my job or press on with the complaint and run the risk of losing my job. He said he never put his job title on emails to the board and often signed correspondence Zacs dad. The companys phone interview over the complaint reduced him to tears. In the end, I thought, If Ive got to lose my job, Ill lose my job. Ive got to stand up for my son. Thats what I kept saying to them its every dads right to stand up for his son. He later received an email telling him the company would not take the matter further. When the DHB told the Gravatts it had commissioned an independent report from Middlemore consultant physician Roger Reynolds, they were initially unconvinced. Their lawyer said it would show Zac received the best of care, Lance said. At that point we really felt this was not independent at all how can he possibly know the outcome of a report thats not yet been written of a review thats not been done? His confidence eroded, Lance sought his own independent expert, but found instead a medical closed shop. Everyone I spoke to offered condolences but said they were either too busy or not the right people. He and his lawyer approached 15 to 20 specialists nationally before finding a doctor at a neighbouring Auckland hospital who agreed to review the notes. He phoned back and said, Lance, I was hoping when I opened this envelope Id go through Zacs records and be able to reassure you that the best that could have been done had been done and allayed your concerns. But I cant. All the concerns youve raised are spot on. He said as a doctor this is just the worst, worst-case scenario: that youve had a young person die is bad, that it
nz herald

severe pain and barely able to talk. The last thing he said to me was to ask who was here. I said, Were all here, Mum, Maddy and me. He said, I suppose Mums freaking out, and I said, No, shes not. So hes lying there dying and hes thinking of Mum. Lance says the family had no idea how critical Zacs condition had become, reassured by the consultants calm manner. But then I heard someone say, Well just have to bag him and run [a reference to the respiratory bag] and I thought, That doesnt sound good. Says Jenny: They said I might like to go up with Zac in the lift Well let you know. But they didnt. I just saw this vision of six people around his bed pushing him with someone on the bag just going hell for leather. They also thought it was odd that they were asked to wait in the critical-care departments whanau room, rather than being taken to see him. Lance recalls phoning a friend to get a priest. I still thought Zac was going to live but I had this intuition this wasnt going well. Those fears were heightened when a critical-care nurse arrived and told them staff were doing everything they can for him. Youve watched enough of those medical movies to know that isnt good. She was still talking to us when another nurse rushed in and said: If you want to see Zac before he dies, youd better run now. They put us in the room next to Zac. There was a big window with a blind and they just lifted the blind and it was the worst thing Ive ever seen.

again, they were a colleague But he, too, declined to write a formal report, saying that because he worked in Auckland, it was too close to home. I started to get this feeling of this huge machine were up against here. Fortress Medicine has raised the drawbridge and turned off the lights and you can try to batter it down if you like but youre most unlikely to succeed. The experts comments spurred the family to keep trying to find an independent opinion, this time in Australia. After six to eight rejections, they found a Sydney emergency specialist whod do the job at $A400 an hour, and he couldnt start for two months. During this period, however, the reports of Reynolds and ACC arrived both finding Zacs treatment was delayed by up to two hours, and that doctors should have considered sepsis earlier. Reynolds said there were grounds for activating a code red referral to critical care as early as 4pm, and regular blood pressure recording might have indicated this threshold had been reached even before 3pm. In such an event, the emergency medical team would have been called and it is highly likely that Zachary would have received more intensive care two or even three hours earlier than eventuated. For meningococcal patients, said ACCs expert, Andrew Munro, a specialist from Nelson Hospital, every untreated hour in the emergency department increases the risk of death by up to 13 per cent. Lance Gravatt says his son would be

may have been preventable is worse, that they have enormous potential in life, that makes it more than worse, and worse

Metro | november 2010 | 45

could be very difficult to recognise. We should be reviewing a lot more of our deaths in hospital because if you scratch below the surface you may find elements of the care that were not done at all as well as one might think. Lance Gravatt points out, however, that the board promised former health commissioner Ron Paterson after a similar case to Zacs two years earlier, in 2007, that an early-warning scoring system would be established then but it was not. How many innocent people have got to die before the DHBs actually make good the undertakings they make and who follows it up? What sort of system have we got when years go by and nothing is done? He says it shouldnt be up to ordinary Kiwis to have to police the system. The
A sculpture commemorating Zac, by Northland artist Kerry Strongman, sits on the deck of the Gravatts farmhouse.

Zac, grotesquely swollen and covered in the meningococcal rash, was already dead. Tests at post-mortem showed that Zac Gravatt died of meningococcal C a strain of the disease that Environmental Science and Research (ESR) told the Gravatts almost certainly came from someone who had recently arrived from overseas. Lance believes it was most likely carried by one of the swine-flu patients Zac had seen on the wards the previous week. Zac had been vaccinated against men ingococcal B at school, but hadnt been offered any further shots despite Australasian emergency medicine policy saying all health-care personnel should be offered vaccinations against any vaccinepreventable disease. A vaccine is available for meningococcal C and, in Lances view, thats just one more failing by the DHB. He says the boards new chief medical officer, Margaret Wilsher, who started the job in July, has picked up the issues and made things happen, so he is now more confident they will reach some reconciliation. The board has apologised to the Gravatt family for the shortcomings in Zacs care. Wilsher told Metro that while it doesnt know whether earlier treatment might have saved him, we missed an opportunity. The eight-week swine-flu epidemic had swamped the hospital. Almost all hospitals crumbled to some degree. Although a registrar had first logged into Zacs case just four minutes after he arrived in the adult planning unit (APU) from the emergency department, it was likely he was

doctors need to change their mindset. We just dont like criticising each other.

legislation has largely stripped us of any rights to sue. The system is meant to be quick, cheap and accessible. Its turned out very expensive for us, very inaccessible and it doesnt bloody work. While Wilsher had apologised ex officio, it still rankled that not one of the doctors or nurses involved in Zacs care that July day had done so. In New Zealand, all you ever get is an apology. I just

interrupted, possibly many times, before he completed his assessment more than 100 minutes later. Wilsher says the board totally accepts the findings of the Reynolds report, and also regrets failures in the hospitals communication after Zac died. Its apparent that once Zac had died, it was as though the care of the hospital stopped. New systems have been instituted to try to prevent a similar tragedy. The hospital has appointed three more senior doctors to support the general medical services in the emergency department and APU. Patients assessed at triage as in category 3 (as Zac was) or 4 (less serious) are now automatically reassessed immediately on arrival in the admitting ward. The board has also developed a scoring tool to allow patients who are physiologically unstable, as Zac was, to be recognised earlier. It was trialled on cardiac patients and is due to be introduced before the end of the year. The board is also re-examining criteria for which cases are investigated internally at formal morbidity and mortality reviews. While Zacs death at the time was certainly shocking, says Wilsher, it was not considered surprising in terms of presentation and the rapid progression of meningococcal disease, which itself

feel like not only have you got to batter Fortress Medicine down to get a review, having battered it down you cant even get the people involved to say, Im sorry. Wilsher told Metro that apologies for members of the medical team are a very personal matter. The apology must come from me. As the most senior member of the clinical team, I am accountable for the care. Auckland Medical School professor of general practice Bruce Arroll, with whom Zac worked as a summer student last year, says he is appalled at the closed shop the Gravatts encountered when they tried to get an independent opinion from the wider medical community. I think doctors probably need to change their mindset. We just dont like criticising each other, and thats unfortunate. We have to become more critical of each other. People didnt want to think something terrible had gone wrong they wanted to believe nothing had. There was self-delusion. Lance Gravatt says he told the DHB that simply re-educating people doesnt cut it. Thats like reminding people to do their job. Some really organic things have to change to make it better. This is the final legacy that Zac can leave medicine to make it better. 

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