The Hawke's Bay District Health Board has made a number of changes following the death of Wairoa woman Arohaina Gilbert last year.
As a patient of Hawke's Bay DHB, Arohaina's life was placed in danger after a combination of eight key delays which failed to address the health problems she desperately needed fixed.
The series of errors by the DHB meant the 25-year-old missed out on the urgent surgery she desperately needed to treat an enlarged goitre in her neck. A goitre is a relatively common and harmless condition where the thyroid gland that is located in the neck is abnormally swollen.
"This whole situation could have been avoided, it's not good enough," says Arohaina's close friend Melissa.
A CT scan in March 2018 confirmed the enlarged thyroid, with significant tracheal compression, which was affecting Arohaina's breathing. When a goitre is so large, it can cause swallowing or breathing difficulties.
Her case was prioritised as urgent, meaning she'd be seen again within six weeks. But that didn't happen - her appointment in early May was cancelled because the surgeon she was supposed to see was needed for a cancer operation at another hospital.
This would be the first of a series of missed opportunities to get the treatment she desperately needed.
"If she had an appointment, even the routine appointment after six weeks, the surgeon would have recognised the urgency at the clinic and would have gone and done the operation within the week. An earlier appointment might have made all the difference," says consultant physician at Hawke's Bay Hospital, John Gommans.
Dr Gommans was the hospital's Chief Medical and Dental Officer at the time Arohaina was being treated.
"Thyroid goitres are very common - up to one in 10 women can develop them and the vast majority have no symptoms. It's about 1 in 200 that get the narrowing of the airways that sufficient to be at risk. Lots of people have some narrowing of the airway which they just live with, it's fine, so she drew a very short straw to have such severe narrowing," Gommans adds.
Arohaina was working on fishing vessels in the Southern Ocean. She took sick leave from her job in order to attend to her health problems but was getting frustrated by delays from the hospital.
She was rescheduled to see the surgeon at the end of May 2018 - that's nine weeks after she first went to see the doctor.
This new appointment was outside of the recommended wait time for someone with her condition and was another crucial oversight in her treatment.
"She never complained, that wasn't her. She just didn't moan that much, she just knew what the doctor said to her, that she'll probably go back to normal. That it would be better after your surgery," says Arohaina's older brother, Te Rangi Gilbert.
"I could see it was affecting her - the first time they postponed the surgery. She was just mad."
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Just three days before her death in May 2018, Arohaina saw a GP in Wairoa for an unrelated matter. The GP, in consultation with Arohaina's surgeon, noted that her chest was clear and she didn't appear unwell. There was no indication to either doctor that her situation had become critical and that she needed immediate hospitalisation.
Instead, they brought her appointment forward by two weeks, with a view to operate soon after.
"She was a little bit worried about the surgery but when I asked her how bad it was, she was like, 'Oh no, I'll be all better once I get the operation.' That's all she wanted, was to get that done so she could be healthy again," Melissa says.
But Arohaina Gilbert never got the operation.
In the early hours of May 14 last year, just days after her last visit to the doctor, she was rushed to Wairoa Hospital - struggling to breathe. Arohaina was later pronounced dead a short time after, having suffocated to death due to her closed airways.
Her passing has been a huge blow to not only her parents, but also her brother, who she was so close to.
"They were like the best of friends, it was like she was the older sister, always looking out for her brother, and then just to not have that around, I guess for him it'll always feel like there's something missing. It does feel like something's missing all the time," says Melissa.
The Hawke's Bay District Health Board have offered their condolences to the Gilbert whanau and admit that Arohaina's death was preventable.
Whanau living out of Wairoa face delays in an emergency because of how far away they are to the main hospital, which is a two-hour drive away in Hastings. That makes urgent healthcare, particularly for Māori, that much more difficult to access.
"I think that equity for Māori in the Hawke's Bay is really challenging for a number of reasons. So we've got a lot of hugely deprived Māori whanau here and that presents the initial challenge," says Hawke's Bay District Health Board executive director of health improvement and equity, Bernard Te Paa.
Te Paa's role was established following Arohaina's death to help address the issues faced by the area's large Māori population.
"I think that as an organisation and as a system we're always challenged by making sure that we deliver services equity, and look, sometimes we don't get that right, but we're striving to be as good as we can be. There are in the health system some biases that we have to deal with, that's why we're doing things like trying to encourage more Māori to work in the health system," he adds.
And he doesn't rule out an element of personal and institutional bias in Arohaina's case.
"I think what we are definitely seeing is that there is some inherent bias that occurs, and that bias is something that we in health we feel actually we have a responsibility to eliminate."
The fatal errors that occurred in Arohaina Gilbert's case are some of the worst consultant physician Dr John Gommans has seen in his 30 years at the Hawke's Bay DHB.
A review by Hawke's Bay DHB into what went wrong found numerous critical delays in the two-and-a-half months Arohaina was being treated for her goitre, and what ultimately contributed to her death.
Following the damning report, the DHB wasted no time tightening up their systems just months after Arohaina's death.
"Each of the delays was understandable on their own, but it wasn't until you sit back and look at the totality of them that you realise that opportunities were missed. While we can't undo what happened for poor Arohaina, it's unforgivable if we let that happen to someone else," Dr Gommans says.
The Hawke's Bay DHB undertook a full review of their failings and changed a number of their procedures, including:
- amending the category of urgency given to thyroid cases
- prioritising conditions that aren't cancer, but potentially life-threatening
- and ensuring that administration staff or nurse specialists chase up delays with surgeons.
It's a small consolation for Te Rangi and his family that some good might come from their loss.
"That's what we want, a change in their way of dealing sort of consultation process for that type of sickness, so good on them."