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 pjharrisonnz@gmail.com

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

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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…

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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.

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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.

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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: pjharrisonnz@gmail.com 1590