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Transcript of New Zealand Notice of Opposition: Medical Malpractice cover up continued
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In the High Court of New Zealand Number CA723/2012
[CIV 2011-404-006634]
Auckland Registry
UNDER THE High Court Rules Part 5, Rule 30.3
New Zealand Bill of Rights Act 1990sections 8, 9, 19, 27
Crimes Act 1961
sections 150A, 151, 155, 156, 157, 160, 165
Crimes Act 1961
Sections 71, 107, 116, 405, 408
Health and Disability Commissioner Act 1994
Sections 5, 6, 34 , 39, 74
Health and Disability Commissioner (Code of Health
and Disability Services Consumers Rights)
Regulations 1996
Medicines Act 1981
Sections 3, 3A, 37
Misuse of Drugs Regulations 1977
Schedule 1 andregulations 44, 45, 52
/
TO CHIEF JUSTICE
NOTICE OF OPPOSITION BY APPELLANTS FOR REVIEW OF DECISION MINUTE
BY JOHN RICHARD WILD J DATED 31 JANUARY 2013
ON THE GROUNDS:
ERROR OF LAW AND FACTS
PROFOUND BIAS AGAINST SELF-REPRESENTED LITIGANTS
Dated 11th
day of February 2013
This document is filed by the plaintiffs in person. The address for service of the plaintiffs is38 Damien Place, Bromley, Christchurch 8062, email [email protected]
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Protection of Personal and Property Rights Act 1988
section 18(1)(c)
Health Practitioners Competence Assurance Act 2003
section 3
Human Rights Act 1993
sections 3, 21 (1)(h)(i), 65
Births, Deaths, Marriages and Relationships
Registration Act 1995 sections 3, 84(2), 85(A)
Coroners Act 2006
sections 3, 12, 13(1)(c)(iii)(v), 17, 57
IN THE MATTERS OF Culpable homicide
sections 160, 408 Crimes Act 1961Causing death that might have been prevented sections
165, 408 Crimes Act 1961
Major departures from the standard of care required of
persons under legal duties:
sections 150A, 151, 155, 156, 157, 408 Crimes Act1961; Health and Disability Commissioner (Code ofHealth and Disability services Consumers Rights)Regulations 1996; sections 8, 9, 19 Bill of Rights Act1990; sections 6, 39, 40, 105A, 105B Medicines Act1981; sections 3, 21(1)(h)(i), 65 Human Rights Act1993; section 18(1)(c) Protection of Personal andProperty Rights Act 1988; section 3 HealthPractitioners Competence Assurance Act 2003
Contravention of statute
section 107, 408 Crimes Act 1961
Accessories after the factsections 71, 408 Crimes Act 1961
Conspiring to defeat justicesections 116, 408 Crimes Act 1961;section 27 Bill of Rights Act 1990
Breach of coronial, health and disability commissioner
and police officer legal duties:
sections 3, 12, 13(1)(c)(iii)(v), 17, 57 Coroners Act2006; sections 5, 6, 34, 39, 74 Health and DisabilityCommissioner Act 1994; Health and DisabilityCommissioner (Code of Health and Disability ServicesConsumers Rights) Regulations 1996
Erroneous death certification
sections 3, 84(2), 85(A) Births, Deaths, Marriages and
Relationships Registration Act 1995
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BETWEEN
first plaintiff PAULINE JANICE HARRISON of 38 DamienPlace, Bromley, Christchurch, sister and inquestrepresentative forMALCOLM ARMSTRONG
HARRISON (Victim)
second plaintiff ANGELA JANICE HARRISON of 38 DamienPlace, Bromley, Christchurch, niece and inquestrepresentative forMALCOLM ARMSTRONG
HARRISON (Victim)
AND
first defendant AUCKLAND DISTRICT HEALTH BOARD for
AUCKLAND CITY HOSPITAL, Grafton,Auckland
second defendant ANNE OCALLAGHANC/o Auckland City Hospital, Grafton,Auckland, doctor
third defendant KATHERINE JANE RIX-TROTT
C/o Auckland City Hospital, Grafton, Auckland,junior doctor
fourth defendant AROHA WAAKA
C/o Auckland City Hospital, Grafton, Auckland,nurse
fifth defendant HEALTH AND DISABILITY COMMISSIONER
Level 10, Tower Centre, 45 Queen Street, Auckland
sixth defendant CORONIAL SERVICES UNIT,
Level 7, 3 Kingston Street, Auckland
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To the Chief Justice, Supreme Court, and the Court of Appeal
Copy to represented defendants
The decision of Wild J is Opposed on the Grounds it is a travesty of fundamental
justice and entirely erroneous in law and fact.
1 The prima facie substantive evidence stands solid and no money shall
be extorted with dishonest intention in a tactic to barricade victim, self-
represented litigants and the public the Right to Justice.
2 The defendants have no defence and have not even filed a statement of
defence and are not in the position to extort security for costs from
genuine Appellants which will not be paid when the substantive
evidence of malpractice is so strong and justice must be served for theVictims legal Rights and for Public Interest Importance for the Right
to safety of the public at large. No person of integrity would be coerced
to pay security for costs in these circumstances.
3 The entire decision of Wild J is erroneous against Facts and Law and
bigoted against self-represented litigants.
4 Clause 3(2) of the Health and Disability Services Consumers Rights
Code requires that The onus is on the provider to prove that it took
reasonable actions.
5 The defendants deceitfully refuse to answer to the lethal combination of
drugs with no monitoring and their long half-lifes and synergistic
effects, or to Metoprolol overdose, or to not complying with aseptic
hygiene and infecting Mr. Harrison with nosocomial (hospital-
acquired) pathogenic bacteria, or to refusing Mr Harrison necessary
tests and life saving specialist expertise, Intensivist care and effective
pain management, et cetera, so breaching the legislated HDC Code of
Consumers Rights.
6 Rule 1.2 of the High Court Rules and section 27 of the New Zealand
Bill of Rights Act have been breached.
7 The chain of malpractice against Mr Malcolm Armstrong Harrison is
not up to the standards of good medical practice. With good medical
practice Mr Harrison had no reason not to pull through as Senior
Medical Officer Emergency Consultant Dr Robin Mitchell vouched for
on Oath.
8 Anyone who comes at clich-ing the word frivolous to the seriousmalpractice in this case compounds malpractice and puts others at risk.
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9 The Health and Disability Commission was established for the Public
with a legislated Code. When it doesnt carry out the purpose for
which it was established then that is serious Public Interest.
10 Investigation has established that Auckland District Health Board at
Auckland Hospital has no audit of similar wrongful deaths resultingfrom lethal combinations of controlled drugs and hid the circumstances
of wrongful death of Mr Malcolm Armstrong Harrison at a defective
inquest. Nor does Auckland District Health Board have a protocol for
Methadone dispensing, prescribing and administration and this is
equally unacceptable.
11 Auckland District Health Board employed a pathologist (LLOYD
DENMARK) concurrently contracted by the Coronial Services Unit
knowing that this pathologist immigrated to New Zealand because ofdisciplinary action against him in Alberta, Canada, and prior to that for
erroneous post mortem reporting in the murder of LINDA GRIMM
which only came to light afterwards when the same killer murdered
another victim LINDA WARDELL because he walked free through
incorrect post mortem reporting by this same pathologist who made a
substandard post mortem report on Mr Harrison.
12 Other patients continue to be at risk from the malpractice that caused
MrHarrisons anguished death where they left him to scream inunattended agony day after day when the expertise was available to
relieve him. The courts cannot look the other way from this tortured
death which is not frivolous at all but deadly serious and of major
significance of major departures from the defendants duty of
standard of care.
13 This Judge is already holding up the decision of the High Court when
the judgment was ultra vires.
14 On this Ground of appeal against Ultra Vires the decisions of Wild J
and Abbott A J are exposed by the stark contrast of Law and
commonsense in the Oral Judgment of Associate Judge Bell re.
application for stay of security for costs judgment in CIV-2011-404-
4768 [2012] NZHC 22 wherein Bell AJ complies with what the High
Court Rules say as follows: If I had given a direction that the matter
was not to be heard in chambers but was to be heard in court , then
the matter would have had to be heard before a Justice, not before an
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Associate Judge because a court hearing of an interlocutory
application is not within the jurisdiction of an Associate Judge.
15 So, what is Wild J coming at against self-represented litigants, in effect
making a deception against self-represented litigants by holding up an
Ultra Vires ruling of an Associate Judge who outreached himself by
exceeding the jurisdiction of an Associate Judge and presiding in open
court despite protest from the plaintiffs? Either the Judicature Act
1908s High Court Rules are wrong or the Associate Judge is, but as
shown by Associate Judge Bell, the limited jurisdiction bestowed on
Associate Judges must be kept within its boundaries, which have been
broken, hence Ultra Vires.
16 It follows that any judgment or decision made under Ultra Vires is
illegitimate in law and the Court of Appeal cannot be seen to uphold an
illegitimate judgment. Any forcing of Ultra Vires onto self-represented
plaintiffs is lawless, unfair, unjust, and duress. This is fundamental.
Under r 2.1 an Associate Judge has the jurisdiction and powers of a
Judge in chambers conferred by the Judicature Act. That rule has been
made pursuant to s 26J of the Judicature Act 1908. It is erroneous
therefore for Wild J to piggy back on an Ultra Vires Associate Judge.
17 In addition to piggy backing on what he knows to be Ultra Vires, Wild
J does not engender confidence when he was involved with another
Judge in this case, namely Brewer J who also glossed over the Ultra
Vires breach of the High Court Rules. Shockingly both Wild J and
Brewer J reportedly were involved in another cover up, which has
really shattered the trust of the appellants who have learned:
18 It is reported that JUDGE WILD was the first judge who ordered the
'Butcher Report'(an investigative report that showed the NZ Army
was negligent in a King Country bridge collapse that killed a man in
1994)to bekept out of evidence. This judicial impediment allowed
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the Army to submit its own report that whitewashed this important
evidence (a sanitised report which Wild J happily allowed).
19 Also reported, as a Crown lawyer, JUDGE BREWERwas behind the
unlawful cover-up of NZ Army culpability in the 1994 Te Rata(Berryman) bridge collapse which resulted in the wrongful death of
beekeeper Kenneth Richards. Brewer had the engineer's investigative
report (the Butcher Report) into the collapse materially altered to
expunge reference to the poor construction by the NZ Army just
eight years earlier.
20 Past performance is an indicator of future performance. Both of thesejudges have been involved in a serious cover up previously and have
come at it again. Combined with an Associate Judge (Abbott) and a
coroner who worked for the first defendants lawyer Meredith Connell
and who worked for the fifth defendant before she worked for the sixth
defendant, this is one huge cover up.
21 Pharmac, MIMS, FDA and other authorities agree that the combinationof controlled and other potent drugs which was pumped into Mr
Malcolm Armstrong Harrison, without monitoring and refusing
specialist intervention was a deadly drug cocktail, and so too they agree
that overdosing Metoprolol succinate and crushing the controlled
release beta blocker causes cardiogenic shock with ventricular
fibrillation and asystole. On top of this there are no Oxygen
prescriptions, Extra Controlled Drug Methadone was not written on the
Drug Chart, the Hospitals Pain Specialist from the Department ofAnaesthesia was refused, so to was Specialist expertise from
Respiratory, Neurological, Intensivist and Pharmacology. On top of
this vital monitoring and tests were refused such as Arterial Blood Gas,
Blood Culture, Sputum Culture, CT chest scan, non-invasive Optic
Nerve Ultrasound for intracranial pressure monitoring,
Echocardiogram, etc. On top of this malnourishment, dehydration,
under-Oxygenation, no weight taken, inadequate supervision. On top
of this infecting with nosocomial pathogenic bacterial infection through
dirty nursing practices after a clear screen on admission. On top of this
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causing Glasgow Coma Scale Score to fall through over-fatigue and no
protocol for Acute stage head injury. On top of this no Methadone
Protocol for opioid nave patients, no auditing of deaths after drug
administration.
22 The defendants via their lawyers have abused the interlocutory processto hinder and obstruct the appellant plaintiffs to the Right to Justice in
section 27 New Zealand Bill of Rights Act 1990 which is unacceptable.
The appellant plaintiffs stand by this Right in the victims and publics
interest without threat of security for costs and when the defendants
havent so much as made a statement of defence!
23 Appeal is made as of Right in the prescribed time and not by Leave.There is no payment for security for costs for public interest
importance.
24 This now brings into focus the Facts and Law which underpin the case.The respondent defendants have no defence and no statement of
defence. A summary judgment should be made against them on the
weight of substantive evidence and law.
25 On what basis does the Registrar presume to decry pharmacologicaland medical facts which are recognised internationally as malpractice
events?
26 Who in good conscience can say that violating a patients safety isfrivolous? Violation of patient safety causing wrongful death is not
frivolous. It is the domain of the courts to get to the truth when
bureaucrats derelict their legal duty. If in turn the courts derelict their
legal duty towards violations of citizens safety then where does that
leave the public? It is therefore elementary that such issues are not
frivolous and demand to be brought to justice which is the courts social
duty, responsibility and obligation to get to the truth and not hand out
favours to perpetrators of acts of illegality.
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27 Wild J is offensive against the Rights of the Victims Family and heagain deceives by erroneously putting a non-family executor foremost
overthe legal Rights of the Victims Family. Section 4 of the Victims
Rights Act 2002 protects the Appellants standing under Victims in
addition to the significant public interest of this prima facie case of
malpractice.
28 Comprehensive Facts and Law follow in the Addendums.
Reflection
If the Supreme Court is seen to uphold Ultra Vires of an Associate Judge
acting outside jurisdiction and abolishes the Victim and Publics legal and
moral Right not to be deprived of life, the Right to safety, and the Right to
Justice which has been fought for legislation by the New Zealand Public, then
Victims have no recourse left to them which equates to anarchy. The public
are not stupid and resent being treated as stupid. All the speeches in the world
eminating from New Zealand about the Rule of Law are an empty vessel of
rhetoric unless their substance is seen to be meaningfully carried out in
practice. Treating represented defendants with favours is in itself unlawful
over the Right to Justice of unrepresented plaintiffs whose documents go
unread. Anyone who aids and abets malpractice makes themself a partaker of
malpractice and carries the innocent blood on their hands along with
perpetrators.
Inquiry to Auckland High Court and the Ministry of Justice and disclosure by
Associate Professor Duncan Webb at the Confidence in the Courts
Conference held by the National Judicial College of Australia and the
Australian National University 9-11 February 2007 in Canberra elucidates that
self-represented plaintiffs do not get treated fairly or impartially in the courts,
which is definitely against what the Rule of Law and the New Zealand Bill of
Rights 1990 require.
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In particular, Page 1 of the conference paper by New Zealands Duncan Webb,
(one who knows), states: My thesis is that the rule that a citizen is entitled to
represent themselves is in substance hollow and he continues in page 17
Thus suggestions are made as to how questions might be phrased to ensure
that it is clear to all litigants that the judicial r ole is to get to the truth rather
than to protect or promote the interests of one party. I am advocating that
the li tigant should not be disadvantaged by a systemic bias in favour of
representationbecause they have chosen, or have been forced, to represent
themselves. No prima facie self-represented cases in the civil jurisdiction see
the light of day of justice in substance because of the bias against self-
represented litigants which definitely exists in the Auckland High Court and
evidently the Court of Appeal.
Wild Js decision is entirely nude ofreliance on legislation. The only claim he
has is to piggy-back on the Associate Judge and Registrar before him whose
judgment is appealed against on the Grounds it was made Ultra Vires outside
Associate Judge Jurisdiction and he is in error of law holding up the decision
appealed before the appeal is heard.
Victims Rights Act 2002 section 4
victim(a) means
(i) a person against whom an offence is committed by
another person; and
(ii) a person who, through, or by means of, an offence
committed by another person, suffers physical injury,or loss of, or damage to, property; and
(iii) a parent or legal guardian of a child, or of a
young person, who falls within subparagraph (i) or
subparagraph (ii), unless that parent or guardian is
charged with the commission of, or convicted or
found guilty of, or pleads guilty to, the offence
concerned; and
(iv) a member of the immediate family
of a person who, as a result of an
offence committed by another person,dies or is incapable, unless that member ischarged with the commission of, or convicted or
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found guilty of, or pleads guilty to, the offence
concerned;
The intention of the represented defendants is to make a serious miscarriage of
justice. When the defendants departed from their legal duty they became
accountable under the law and they have abused interlocutory processes to
hold back substantive trial.
All three of the Government entities are insured for litigation, as are the other
three defendants who all have medical liability insurance. The defendants
opposition to dispense with security for costs is another barricade to the Right
to Justice and they havent so much as filed a statement of defence to these
prima facie court proceedings when Mr Harrisons medical record and other
substantive evidence exposes them in malpractice failing a safe standard of
care, the defendants also refusing to answer to the elements, lying about
Discovery provisions and setting out to deceive the appellant plaintiffs on the
Right to take proceedings and insulting Family Rights falsely and callously
saying that Family have no greater right than the public generally.
The defendants argument is with the Law and the Fact which say otherwise.
The appellant plaintiffs are backed by the Legislation, legal rights and human
decency, and with the proper social conscience determinedly stand firm for the
Victim, the Public at Large Right to Safety, and for the Principles of the Rule
of Law and Fundamental Justice.
Incorrect post mortem reporting and cover up of malpractice is also very much
in the public interest.
Security for costs should be quashed in these circumstances where the onus is
on the respondent defendants to answer to the elements of the case of
malpractice (HDC Code of Consumers Rights) which they are evading
answering to. The Legislation safeguards the Right to Justice and the Rule of
Law decrees that perpetrators of acts of illegality should not be favoured or be
allowed to walk free or use money to barricade substantive trial.
Dated this 11th day of February 2013
Appellant Plaintiffs
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ADDENDUM 1 of 5
AETIOLOGY
[1] Every action has a reaction in physics.
[2] This High Court Proceeding is the outcome of lethal drug cocktails and othermajor safety breaches causing morbidity and death and refusal to carry out legal
duty, responsibility and obligation to the law, to the victim and to the public.
[3] When the Acts were breached by the defendants refusing Mr. Harrisonreasonable care in breach of best practice standards and global warnings which
caused dangerous morbidity and iatrogenic death then this is seen in law (under the
provisions of the Acts) to have breached that legal duty. Once it gets to that point
then the foundation is laid for charges to follow. This has resulted in the legal
basis for the claim and the court proceedings against the defendants.
CIVIL LIABILITY - LEGAL BASIS FOR CLAIM
Matters of Fact
Duty of Care
[4] The first, second, third and fourth defendants had a legal and ethical duty ofcare under the Acts to Mr. Malcolm Armstrong Harrison as health providers and
are required to comply with best practice standards and heed universal safety
warnings which they defied.
[5] Mr. Harrisons case has elements of the Michael Jackson case, described bythe prosecutor, Deputy District Attorney David Walgren:
Murrays actions represented a criminal breach of the Hippocratic
oatha doctors pledge to do no harm.1
1Rhys Blakely reported in The Press Christchurch, World News Section B3, 9 November 2011
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2
[6] The first, fifth and sixth defendants have a legal duty, responsibility andobligation under the Acts as government officers to protect, preserve and enforce
the victims rights which they defied.
Breach of DutyFirst Defendant
[7] Mr. Harrison, a patient, died under the first defendants roof through acontinual chain of malpractice. The defendant has a fiduciary duty to uphold and
did nothing.
[8] District Health Boards are required to review adverse events and report themto the Health Quality & Safety Commission New Zealand and the first defendant
did not.
[9] The defendant was required to diligently safeguard Mr. Harrison and did not.
Breach of Duty - First, Second and Third Defendants
[10] It is a doctors responsibility to know that a potent drug cocktail ofMethadone on Amiodarone, Haloperidol, high dose Co-Trimoxazole,
Benzodiazepines Lorazepam and Midazolam, Fentanyl and Morphine is a deadly
formula, or they are not skilled and should therefore not be working as a doctor.2
(Appendix B)
[11] START LOW, GO SLOW in prescribing potent drugs is the goldenrule and all doctors know it. The defendants prescribed contraindicated potent
drugs irresponsibly and indiscriminately.
2See letter from Professor Iain Martin, Dean, Faculty of Medical and Health Sciences, and
Warwick Bagg, Associate Professor of Medicine, Associate Dean (Medical Programme) The
University of Auckland, Medical Programme Directorate, dated 11 July 2011
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3
Methadone Overdose
[12] The Controlled Drug Register on the Ward shows that an additional 10 mg ofMethadone was dispensed to Mr. Harrison on 2 November 2007 on the day
Mr. Harrison died. This potent dose was not written on Mr. Harrisons Drug Chart.
The Watch Report confirms it was administered to Mr. Harrison at 0800 hrs. A
total of 35 mg of Methadone to the opioid nave patient. In addition Mr. Harrison
still had the previous days Methadone potent dose live in his system, taking him
up to 50 mg. In addition Mr. Harrison also had a combination of interacting
Methadone potentiating drugs in his system, taking the total Methadone serum
concentration well in excess of the amount to cause death to an opioid nave
person.
[13] The last dose of Methadone (concomitantly administered with Haloperidol)was administered at or about 1420 hrs. Mr. Harrison died at or about 1930 hrs
which was within the six hour time frame declared by Medsafe New Zealand
(New Zealand Medicines and Medical Devices Safety Authority) which states for
non-tolerant adults, doses of 50 mg or less have been known to be fatal, includingdoses taken orally. Potentially lethal overdoses of methadone can occur within 30
minutes to six hours after ingestion by non-tolerant or partially tolerant
individuals.3
[14] The second and third defendants breached good prescribing practice whichrequires to never prescribe indiscriminately, excessively or recklessly.4
[15] Against Best Practice and Safety Warnings, the second defendant increasedMr. Harrisons dose of Methadone from 2.5 mg on 1 November 2007 to 20 mg of
Methadone on 2 November 2007, flagrantly against all drug safety warnings.
She also dangerously increased Haloperidol, knowing that in combination these
potent drugs both increase the QTc interval and increase sedation, absolutely
3
Medsafe New Zealand Medicines and Medical Devices Safety Authority, Information forHealth Professionals Data Sheet,
www.medsafe.govt.nz/Profs/datasheet/b/Biodoneoralsoln.htm, page 7 on Overdosage4
Medical Council of New Zealand Good prescribing practice
http://www.medsafe.govt.nz/Profs/datasheet/b/Biodoneoralsoln.htmhttp://www.medsafe.govt.nz/Profs/datasheet/b/Biodoneoralsoln.htmhttp://www.medsafe.govt.nz/Profs/datasheet/b/Biodoneoralsoln.htm -
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4
contraindicated for the patient, as is Benzodiazepines Midazolam and Lorazapam
with Methadone. In addition there was no monitoring.
[16] The World Health Organisation recommends 2.5 mg once daily inMr. Harrisons age group. For frail elderly people an even smaller starting dose
can be used, e.g. 1 mg once daily, and warns that dose changes should not occur
faster than once weekly in this group.5
[17] On November 27, 2006, the FDA issued a public health advisory formethadone, entitled Methadone Use for Pain Control May Result in Death and
Life-Threatening Changes in Breathing and Heart Beat. Also an Alert onHaloperidol in 2007.6
[18] Waitemata District Health Boardwarns:There are a number of medications that, when taken with methadone, can
cause a variety of unexpected, unwanted or potentially dangerous outcomes.
For example, using methadone with any other drug that depresses the central
nervous system i.e. those which cause sedation such as alcohol, benzos,
other opioids, GHB, and medications with sedative side effects like some
antidepressants, antipsychotics and antihistamines can potentially be very
dangerous, and sometimes fatal.7
[19] Lethal doses of methadone can be around 25 mg for intolerant adults.8
[20] Benzodiazepines are Controlled drugs9 which when administered incombination with Methadone are renowned for causing lethal effects.
[21] The net effect of the deadly cocktail of drugs administered to Mr. Harrisonssystem is the sum of the substances individual harmful effects causing supra-
5
Best Practice Journal Issue 18, page 286http://www/fda.gov/medwatch/safety/2006/safety06.htm#Methadone. And FDA Alert
[9/2007] Haloperidol7
Waitemata District Health Board Information Sheet 18. Methadone8http://wiki.answers.com/Q/Lethal_dose_of_methadone
9Medsafe New Zealand Medicines and Medical Devices Safety Authority, Regulatory Issues,
Benzodiazepines to be Controlled Drugs
http://www/fda.gov/medwatch/safety/2006/safety06.htm#Methadonehttp://www/fda.gov/medwatch/safety/2006/safety06.htm#Methadonehttp://www/fda.gov/medwatch/safety/2006/safety06.htm#Methadonehttp://www/fda.gov/medwatch/safety/2006/safety06.htm#Methadone -
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5
additive (synergistic/potentiating) effect which is greater than additive. This is
explained in the statement of claim.
[22] In cases of methadone-associated death, alcohol, benzodiazepines, and/orother opioids are frequently implicated.10
[23] The third defendant inappropriately prescribed Mr. Harrison Amiodaronewithout a permanent defibrillator in situ. Amiodarone was administered
concomitantly with Metoprolol which competes against the Amiodarone.
In addition, as can be seen in the Drug-Drug Interaction Checker List
(Appendix A) multiple other interactive potent cardiotoxic drugs were
administered to Mr. Harrison from 30 October 2007 to 2 November 2007 in deadly
drug combinations which cause potentiating effects, dangerous QTc interval
prolongation and over-sedative effects causing respiratory depression,
cardiotoxicity. Not surprisingly Mr. Harrison died in the presence of
approximately 40 serious and significant drug interactions 11 harmful to the
human system which the first, second and third defendants were responsible for.
This evidence was concealed from an inquest.
[24] Amiodarone has an extremely long drug elimination half-life average of 58days (ranging from 25-100 days)12meaning it takes in the order of 58 days before
the drug reduces to half of its potency and 36 days for its active metabolite
desethylamiodarone. Amiodarone is extensively metabolized in the liver by
cytochrome P450 3A4 and affects the metabolism of numerous other drugs with
resultant potentiating cardiotoxic effects. Amiodarone was commenced at 1400 hrs
on 30 October 2007 at 400 mg, followed by a dose of 800 mg on 31 October 2007.
Amiodarone potentiates Methadone, adding to the Methadone serum concentration
in Mr. Harrisons system on the day he died.
[25] Under these defendants from 30 October 2007 to 2 November 2007 a regimeof potent drugs was prescribed for Mr. Harrison which has approximately
10Zador and Sunjic 2000
11 Medscape drug interaction checker, MIMs New Ethicals, FDA Drug Alert
12 Remington: The Science and Practice of Pharmacy 21st edition
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6
40 serious and significant cardiotoxic drug-drug interactions requiring close
monitoring.
[26] Cardiac monitoring was turned off. Necessaries of life were refused.Intensivist specialist expertise was refused.
[27] The defendants have no defence.
Breach of Duty - Fourth Defendant
[28] Mr. Harrison should never have been administered Metoprolol beta blocker, ablood pressure lowering drug when he had low blood pressure and was noticeably
dehydrated.
[29] This defendant knows that controlled release drugs should not be crushed andwhy they should not be crushed or she has no business to be administering drugs
putting patients at risk.
[30] At or around 0900 hrs on 29 October 2007 the fourth defendant crushed47.5 mg of Metoprolol succinate which released a 24 hour dose of the drug in a
surge which she administered to Mr. Harrison against pharmaceutical warning.
[31] Mr. Harrison was beta blocker nave.[32] Nine hours previously at or around 2400 hrs on 28 October 2007Mr. Harrison had been administered another 47.5 mg dose of Metoprolol succinate
also on low blood pressure and this dose was also still working in his system when
the defendant overdosed him at 0900 hrs the next morning.
[33] Metoprolol was started at 23.75 mg at 1115 hrs on 25/10/2007, stopped on26/10/2007, then started again (at double dose 47.5 mg) at 2400 hrs on 28/10/2007,
then overdosed nine hours later at 0900 hrs on 29.10.2007, which was an erratic
undisciplined regime of drug prescribing against the manufacturers and FDAinstructions.
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[34] Too much crushed Metoprolol succinate at or about 0900 hrs on 29 October2007 was given too soon after a preceding dose of Metoprolol which caused
chemically induced cardiac arrest with Asystole (no pulse, no heartbeat, no
respiration) at or about 1215 hrs on 29 October 2007, followed by CPR and
DC Shock. ECG rhythm strip held in evidence.
[35] No permanent defibrillator device was used which is a straight forwardprocedure.
[36] No Echocardiogram was performed which is important best practice afterinduced cardiac arrest.
[37] Documentation is poor and events leading up to chemically induced cardiacarrest were never investigated which were required to be investigated and the
fourth defendant never owned up.
[38] The defendant deprived the flow of Oxygen by causing Asystole fromMetoprolol overdose that she administered. The brain depends on the constantuninterrupted delivery of Oxygen and Glucose.
[39] The defendant never filed an Incident Report when she had overdosedMr. Harrison. She induced cardiac arrest then kept it secret when the underlying
cause is required to be investigated.
[40] It is a disgrace to the Auckland Nursing Organisation to apply for strike outwhen the Nursing Organisation knows full well that the fourth defendant broke the
rules by wrongful drug administration inducing cardiac arrest. The Food and Drug
Administration and other authorities have issued explicit warnings, and Mrs Shirley
Curtis13 died from the same dangerous practice overdosing Metoprolol beta blocker
into her system.
Breach of Duty - Fifth Defendant
13North Shore Hospital victim of Metoprolol poisoning
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[41] The fifth defendant has a conflict of interest with the sixth defendant(previously employed its coroner McDowell as its Director of Proceedings). That
coroner has a conflict of interest with the first defendant (previously employed by
Meredith Connell Lawyers who have the first defendant as its major client),
resulting in a domino effect against the complaint stonewalling the right to justice
which is totally against theNew Zealand Bill of Rights Act 1990.
[42] The fifth defendant has shown unjust disparity and selectiveness which isdiscrimination against Mr. Harrisons rights and the rules and principles of natural
justice. Some complainants receive a full investigation while other deserving
complainants do not. This inconsistency and disparity is not fair on the individual
and is not good enough where human life is concerned.
[43] For example the case of Mrs Anderson was investigated in depth by the fifthdefendant, yet the door is literally slammed shut on Mr. Harrison and other justified
complainants. More than lip service is necessary for the Code to be complied with
by the Health and Disability Commissioner. New Zealand has an increasing cohort
of dissatisfied people and this was not the intention of the Cartwright Report.
Progress Report Safety of Patients in New Zealand Hospitals by
Dr. Mary Seddon, MBChB, MPH, FAFPHM, FRACP those
that superficially used the language of safe and quality care but
their action plans did not give confidence .14
[44] The Health and Disability Commissioner discriminated against the legalrights of Mr. Harrison, against the purpose of the Health and Disability
Commissioner Act 1994 and against the Code of Health and Disability Services
Consumers Rights15 recommended by Judge Cartwright in her Report16 which is
14 Progress Report Safety of Patients in New Zealand Hospitals by Dr. Mary Seddon, MBChB,
MPH, FAFPHM, FRACP 6 October 2007. (the month and year that Mr. Harrison was an
inpatient at Auckland City Hospital)
15 Health and Disability Commissioner (Code of Health and Disability Services ConsumersRights) Regulations 1996
16 The Report of the Committee of Inquiry into Allegations Concerning the Treatment of Cervical
Cancer at National Womens Hospital and into Other Related Matters published in 1988
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enforceable in law to promote and protect the rights of health consumers and
disability services consumers.
[45] Right 10 (5) of the Code of Health and Disability Services ConsumersRights states that every provider must comply with all the other relevant rights in
this Code when dealing with complaints.17
CODE OF HEALTH AND DISABILITY SERVICES CONSUMER RIGHTS
[46] The Code must be enforced. Anything less is an effrontery to the CartwrightReport and to the Rights born out of suffering. The Cartwright Inquiry involved
Auckland Health Board, the first defendant in this case.
We must not forget that there were women who paid the ultimateprice forthese Rights. To them, and to the women who survived but had to enduremuch suffering as a result of Greens study, New Zealand owes a never-ending debt of gratitude.18
Breach of DutySixth Defendant
[47] The Coroners Act 2006 identifies deaths that must be reported to a coronerand the process for reporting and investigating those deaths. Section
13(1)(c)(iii)(v) of the Act stipulates there is a legal requirement to report to the
Police every death that appears to have been the result of medical, surgical, dental,
or similar treatment received by that person; or that appears to have been the result
of the administration to that person of an anaesthetic or a medicine (as defined in
section 3 of the Medicines Act 1981). Substantive evidence of medical malpractice
involving the first, second, third and fourth defendants was concealed at an inquest
which was defective.
[48] The sixth defendant hindered a full investigation into the circumstances ofMr. Harrisons death and concealed substantive evidence and by so doing breached
its legal duty under the Coroners Act.
17Code of Health and Disability Services Consumers Rights
18 Darise Ogden A never-ending story that must not be forgotten, NZLawyer online feature, 19
February 2010, Issue 130
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[49] The sixth defendant refused forensic investigation, blocked a properinvestigation and refused Mr. Harrisons Inquest Representatives proper
opportunity to study the medical record, while distributing it to others.
[50] The sixth defendant has been proven wrong by Dr Denis Wood, ForensicBiomechanic Engineer.
[51] If the sixth defendant had done its duty at Mr. Harrisons inquest it couldhave potentially safeguarded other victims like Ms Shirley Curtis from dying from
Metoprolol overdose cardiotoxic poisoning because a warning should have been
circulated. This shows how whitewash cover ups have a rebound effect oninnocent victims, which intensifies the importance of this proceeding to safeguard
the safety of other potential victims from the defendants dangerous practices.
[52] The sixth defendant contracted a pathologist to perform coronial postmortems who was also employed by the first defendant. Dr. Lloyd Denmark (the
pathologist) had a background of incorrect post mortem reporting which enabled a
killer to take another life in the United Kingdom and a background of disciplinary
action resulting in him being fired in Canada. He ignored evidence of brutal
bashing on Mrs. Linda Grimm the victim and wrote off her death to natural causes.
So too this pathologist knew that Toxicology should have been performed on
Mr. Harrison for a forensic post mortem and he deliberately never did it. The post
mortem did not comply with forensic post mortem standards and was not a forensic
post mortem at all. The post mortem report is defective and death certification is
erroneous in fact against the legislation requirements.
[53] No photographic documentation was made of Mr. Harrisons traumaticinjuries.
[54] The coroner refused to inquire into trace evidence on Mr. Harrisons clothingand footwear that he wore at the time of sustaining traumatic injuries.
[55] Mr. Harrisons wallet, bag and credit card and some other belongings weremissing from him when the ambulance arrived.
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[56] There was no neuropathologist or cardiopathologist involvement in a cursorypost mortem by Dr. Lloyd Denmark, a pathologist involved in incorrect post
mortem reporting previously, writing off wrongful death to natural causes.
[57] The contents of the Law Commission Issues Paper 23 is relevant. 19
19Final Words, Death and Cremation Certification in New Zealand, Issues Paper 23, May 2011
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Causation
[58] The application of res ipsa loquitur is relevant, but in addition substantiveevidence is in the medical record and elsewhere.
[59] On the preponderance of evidence there were multiple safety breachessuffered by Mr. Harrison in Auckland City Hospital during his admission which
would not have occurred had the defendants complied with best practice standards
and global safety warnings.
[60] The defendants refused Mr. Harrison specialist Intensivist expertise when heneeded it. Senior medical staff abandoned Mr. Harrison to junior doctors who
presumed beyond their scope of expertise. Mr. Harrison was over-sedated on
contraindicated potent cocktails of drugs and was treated like a guinea pig with no
specialist management.
[61] The Food and Drug Administration (FDA) is heeded by New Zealand.The FDA makes clear warnings with other authorities which the defendants
ignored.
[62] Misuse of drugs and not analysing and treating the root cause is not bestpractice. This dangerous practice is known to cause cardiac arrhythmias and other
adverse effects. Also, inadequate oxygen therapy causing hypoxia which is known
to adversely affect the brain and heart20, and unhygienic non-aseptic
contraindicated invasive practices which caused nosocomial pathogenic bacterial
infection and sepsis which thrives on dehydration. Also iatrogenic dehydrationcaused by regular administration of laxatives coupled with under-hydration and
inadequate nourishment. Inadequate nourishment caused malnutrition. These and
other breaches of the required standard of care formed a chain of malpractice, and
details are particularised in the statement of claim.
20Hypoxia and Hypotension are disastrous in traumatic brain injury patients and must be
prevented, as should secondary injury
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[63] None of these safety breaches should have happened and none would havehappened had there had been a proper standard of care and treatment exercised
which was Mr. Harrisons legal right.
[64] No reasonable fair minded person would wish to receive the samemaltreatment. When challenged, none of the defendants or their counsel have
shown the courage of conviction to volunteer to demonstrate taking the same
deadly drug cocktail which was administered to Mr. Harrison before he died.
Nor would they come forward to be infected with nosocomial pathogenic
Gram positive bacteria through staff unhygienic practices not washing hands as
Mr. Harrison was. Every defendant and their counsel would expect to have
nourishment and fluids to maintain organ functions.
[65] Hypoxia, Dehydration, Malnutrition, Sepsis, manifest as serious effects,including cardiac arrhythmias. Instead of treating these nosocomial conditions
properly the defendants kept indiscriminately throwing more potent drugs into
Mr. Harrisons system with side effects that worsened his condition and are also
known to cause arrythmias.
[66] Malpractice is not only against the law, it is a breach of patients trust.
[67] The expectation of the Emergency Consultant Specialist21 at admission on16 October 2007 was that Mr. Harrison would go on to survive to discharge. The
date for discharge was documented for 1 November 2007. Mr. Harrison died after
a deadly drug cocktail on 2 November 2007.
[68] This was aggravated by refusing important monitoring devices and refusingIntensivist specialist expertise when the signs and symptoms indicated.
[69] The substantive evidence in the medical record showing poisonous drugcocktails, overdose, times, dosage, signs and symptoms, and lack of discipline,
technique and decision making, and other safety breaches cannot be ignored.
Mr. Harrison was administered a deadly cocktail of drugs and died in agony and
the defendants have no defence.
21Dr Robin Mitchell, Emergency Specialist Consultant, Auckland City Hospital
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[70] The Courts have a responsibility to New Zealanders to enforce the provisionsin the Acts when governmental officers refuse to carry out their legal duty.
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CIVIL RIGHTS
[71] The purpose of theBill of Rights Actis to affirm, protect, and promote humanrights and fundamental freedoms in New Zealand and to affirm New Zealands
commitment to the International Covenant on Civil and Political Rights and the
Act protects and preserves the right to justice. 22
[72] Lord Denning:What then does it all come to. If one Attorney General after another doesthis if each in his turn declines to take action against those who break
the lawthen the law becomes a dead letter. That cannot be.23
HIGH COURT RULES
[73] HCR15.1.7(a) Dismissal or strike out: principles and approach general:Caution in disposing of such cases on a summary basis is necessary both to preventinjustice to claimants and to avoid skewing the law with confident propositions oflegal principle or assumptions about policy considerations, undisciplined by facts.
It is inappropriate to strike out a claim summarily unless the court can be certainthat it cannot succeed. The case must be so certainly or clearly bad that it shouldbe precluded from going forward: Couch v Attorney-General [2008] NZSC 45;[2008] 3 NZLR 725 (Elias CJ and Anderson J at paras [32] and [33]).
[74] HCR15.1.7(c) Cause of action: The power to strike out is to be exercisedsparingly and only in exceptional cases. The court must be able to say withconfidence that on the facts alleged by the plaintiff he has no case; the court must
be satisfied that it has all the requisite material to reach a definite and certainconclusion. If the court is left in doubt whether a claim might lie, or if disputedquestions of fact arise, the case must go to trial. [with emphasis] 24
[75] TheRules Committee addresses concern about interlocutory steps being usedto wear down the other side before trial.25
[76] To date counsels shopping list comprises:
22 Refer to long title of the New Zealand Bill of Rights Act 1990
23 Alfred Denning, The Discipline of Law, ISBN13: 978-0-406-17605-9 ISBN10: 0-406-17605-1, at
page 14024
Sims Court Practice (NZ)/High Court Rules/HIGH COURT RULES/Part 15 Disposal other than bytrial/Subpart 1 Dismissal or stay without trial
25 The Rules Committee Circular No. 26 of 2010, item 4 page 7, minutes of meeting held on 31
May 2010
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lawyers bullying the litigants-in-person fundamental right to justice balking at making a statement of defence within the prescribed time set
in the High Court Rules when counsel has already shown it fully
understands the statement of claim balking at Discovery unjustly not wanting the plaintiffs to file interlocutory steps yet filing
interlocutory steps themselves (do as I say but not as I do).26
wanting secrecy with interim name suppression, against open justiceand transparency and denying other patients the right to make informed
decisions
application to strike out a prima facie proceeding with substantiveevidence
unjustly wanting indemnity costs or increased costs when thedefendants know they have breached their legal duty and kept quietwhich has given rise to the proceedings.
[77] The defendants are taking advantage of self-represented litigants and this isagainst the Rules. Lord Woolfsaid:
Only too often the litigant in person is regarded as a problem for judgesand for the court system rather than the person for whom the system ofcivil justice exists.27
[78] It is fundamental to justice that matters of substantive fact and matters ofsubstantive law require a full trial for justice and justice has to be seen to be done,
especially involving matters of importance concerning harm to human life and
public interest involving safety issues.
RULE OF BIAS
[79] In domino effect the first, fifth and sixth defendants banded together with acoroner named Morag McDowell who is employed by the sixth defendant.
[80] The conflict of interest here is that Ms McDowell is the commondenominator which through her networking has had the effect of blocking
Mr. Harrisons right to justice because others have refused to use applied logic and
26First Case Management Conference Minute of Associate Judge Abbott, 26 January 2012 at
paragraph [5]
27 Access to Justice, Interim Report p119
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think for themselves. A domino effect of stonewalling has resulted and this is
illustrated in the correspondence.
[81] Mr. Harrison died iatrogenically in an Auckland District Health Boardhospital and his death was referred to the Coroner. Auckland District Health Board
was and is a major client of Meredith Connell Lawyers. The coroner sitting on the
coronial bench was previously employed by Meredith Connell, and she refused to
allow Mr. Harrisons Inquest Representatives a proper opportunity to research the
medical record.
[82]
The first, second, third and fourth defendants were required to report theirbreaches of patient safety28 and kept silent, including the first defendants in-house
lawyer Mr Peter Le Cren, at an inquest which was predetermined to outcome.
[83] The fifth and sixth defendants acted against the rule of bias.[84] When the first, fifth and sixth defendants stonewalled the serious complaintand acted with disparity and bias they breached their legal duty and became
accountable under the law.29
During the Inquiry, Rodney Harrison, says Matheson, toiled for seven months
and beyond, much of that time endeavouring to batter down the wall of silence
and denial (A Never-ending Story, p 53).
FUNCTION OF THE COURTS
[85] Upholding the rights of the individual and ensuring that government agenciesstay within the law is the function of the Courts.30
28major breaches to patient safety were omitted from the Serious and Sentinel Events
Report29
Sections 8, 9, 19, 27 New Zealand Bill of Rights Act 1990; Sections 5, 6, 34, 39, 74 Health
and Disability Commissioner Act 1994; Health and Disability Commissioner (Code of
Health and Disability Services Consumers Rights) Regulations 1996; sections 3, 84(2),
85(A) Births, Deaths, Marriages and Relationships Registration Act 1995; regulations 44,45, 52, Schedule 1 Misuse of Drugs Regulations 1977; sections 71, 107, 116, 405, 408
Crimes Act 196130
The Role of the Courts www.courtsofnz.govt.nz/about/system/role/overview
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[86] It falls on everyone, including the defendants, and including the Courts, forsocial responsibility to prevent continued non-compliance.
[87] Prima facie evidence shows that the defendants have a legal duty, that theybreached their legal duty and that they caused morbidity and mortal harm, which
are not grounds for strike out which would be unjust.
[88] The negative effect of strike out involving a prima facie case would send anerroneous message and make a dangerous precedent for future defendants in
medical malpractice cases to misuse by indicating that the Courts allow offenders
to fiddle and skew the law to defeat accountability under the law and empowermalpractice offenders to avoid the law with impunity for which they are liable
under the Acts, which would further oppress victims rights, which is not
fundamental justice.
[89] The defendants should have reported their breaches to safety and kept silent.Dishonesty by silence is an aggravating factor.
[90] Everyone knows that the Courts must uphold the sanctity of life and giveconsideration to the safety of others.
[91] In addition, a strike out of this case of importance couldnt help but beconstrued as advocating an undesirable governmental culture of secrecy,
protectionism, systemic indifference, complacency and disparity, which is in total
conflict with the Dr Harold Shipman Reviews which castigate such practices and
which have established that people in New Zealand are at risk from defective
attitudes and processes. Strike out is inappropriate for a case of this importance
before the Court, and would be profoundly against the Purpose of the law and the
Principles of Natural Justice.
[92] These are issues of probity as well as facts and law. Litigants in personshould not be impeded from genuine pursuit of justice which is brought before the
Court for good cause after other avenues have been exhausted where officers have
refused to comply with their legal duty. Matters of importance cannot be recklessly
brushed off as frivolous or abuse of process, which are words used unwisely
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too often in legal parlance by some legal practitioners to ruthlessly cut down
another party (tactic). These words, like anything else, have to be used
appropriately and not for the defendants own convenience. The defendants
erroneous application of these words does not apply to this particular case on the
preponderance of evidence.
[93] There is nothing frivolous whatsoever about the grave matters of fact inMr. Harrisons medical record which record him screaming in pain while the
defendants refused him specialist intensivist expertise, and indiscriminately dosed
him up with deadly drug cocktails instead of giving him therapeutic treatment
which he needed. It is a cold hearted person indeed lacking in humanity whowould find the words to call this human suffering frivolous. Counsel need to be
ashamed of themselves.
[94] The Courts cannot forsake the Purpose of the law which protects andpreserves the right of the victim to justice.31
[95] Oppression is felt by a significant New Zealand public and this is relayed byHelen Cull QC32 in her Review of processes concerning adverse medical events:
Failure to report practitioners believed to be practising below an
acceptable standard: As identified under the previous section in thisreport, patients have expressed their concerns as to the way in whichtheir complaints are treated, often feeling patronised, disbelieved or
belittled. With Health professionals rarely working in isolation,
professional bodies consulted during the course of this Review havehighlighted the problem that colleagues often know of incompetent or
bad practice, but do not report it. The courage which patients
describe as being needed to take on the medical profession as theysee it, has clearly led to the perception that the consumer has not been
believed or belittled when complaints against senior practitioners aremade. The reaction to the complainants against Dr Fahey, is anexample of this.
RULE OF LAW
31 Section 27 New Zealand Bill of Rights Act 1990
32 Review of Processes Concerning Adverse Medical Events by Helen Cull QC, March 2001, at
page 75
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[96] The law is explicit. Under the rule of law, Government and citizens (andother individuals) are bound by the law and all are accountable under the law
without favouritism and irrespective of rank or title. An aspect of the rule of law is
access to courts that are independent and impartial.
[97] In a lecture given at Cambridge University on 16 November 2006,Lord Bingham of Cornhill, formerly senior Law Lord, spoke about the rule of law.
Lord Bingham emphasised that the core of the principle of the rule of law is that
all persons and authorities within the state, whether public or private, should be
bound by and entitled to the benefit of laws publicly and prospectively promulgated
and publicly administered in the courts.33 His lordship analysed the rule of law in
eight sub-rules, a style reminiscent of Dicey and Morris Conflict of Laws.
sub-rule 1 The law must be accessible and so far as possible intelligible, clear and
predictable;
sub-rule 2 Questions of legal right and liability should ordinarily be resolved by
application of the law and not the exercise of discretion;
sub-rule 3 The laws of the land should apply equally to all, save to the extent that
objective differences justify differentiation;
sub-rule 4 The law must afford adequate protection of fundamental human
rights;
sub-rule 5 Means must be provided for resolving, without prohibitive cost or
inordinate delay, bona fide civil disputes which the parties themselves are
unable to solve;
sub-rule 6 Is that ministers and public officers at all levels must exercise the powers
conferred on them reasonably, in good faith, for the purpose for which
the powers were conferred and without exceeding the limits of such
powers;
sub-rule 7 Adjudicative procedures provided by the state should be fair;
sub-rule 8 The existing principle of the rule of law requires compliance by the state
with its obligations in international law, the law which, whether deriving
from treaty or international custom and practice, governs the conduct of
nations.
33
Lord Bingham, The Rule of Law, (2007) 66 CLJ, 67-69 and cited by Attorney-General onbeehive.govt.nz official website of the New Zealand Government in his article entitled
Access to Justice, Legal Representation and the Rule of Law Speech to Legal Research
Foundation dated 23 October, 2009
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ACCOUNTABILITY
COLES MEDICAL PRACTICE IN NEW ZEALAND
STANDARDS AND GUIDELINES
PUBLISHED BY THE NEW ZEALAND MEDICAL COUNCIL
How medical practice standards are set by legislation:
Section 155 of the Crimes Act imposes a legal dutyon those who
undertake to administer surgical or medical treatment TO HAVE
AND TO USE reasonable knowledge, skill and care in doing those
acts., and Causing death by or as a resul t of medical or
surgical treatment may result in a conviction for murder
(if deli berate) or manslaughter.34
(with emphasis)
[98] The Acts bind the Crown.
THE DEFENDANTS
[99] The defendants have demonstrated indifference to the legal rights ofMr. Harrison and to the legal right to safety of others which is compromised by the
defendants breaching their legal duty.
[100] The defendants have attempted to skew the focus of the case toprejudice a fair trial and belittle the importance of the proceedings by resorting to
bullying, misleading, misinformed and irrelevant information which is immaterial
to this case. For example:
We also understand you made a complaint to the Cancer Society
alleging its inadequate management of Malcolm Harrisons cancer.This complaint was not accepted. N. Fisher - counsel for thesecond and third defendants
Fact: The plaintiffs have nevercomplained to the Cancer Society and want to
know how counsel has arrived at this fiction which is unjust and targeted at
discrediting the plaintiffs. The Lawyers and Conveyancers Act (Lawyers: Conduct
and Client Care) Rules 2008 requires:
34 Coles Medical Practice in New Zealand Standards and Guidelines, published by the New
Zealand Medical Council, at section 4, page 36
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[101]A lawyer has an absolute duty of honesty to the court and must not mislead ordeceive the court.
A lawyer must not act in a way that undermines the processes of the
court or the dignity of the judiciary.
A lawyer must treat others involved in court processes with respect. 35
[102] The defendants are not concerned about the quest for truth or naturaljustice, nor the wider issues at stake of risk to public safety, but seek to avoid
accountability for themselves and are materialistically putting their own interests
ahead of the rights of Mr. Harrison and public safety.
[103] As proven, some of the nicest people and pillars of society are thebiggest offenders. It is wrong and nave to assume that because the defendants are
qualified that they did not breach their legal duty. The focus of this case is not
about opinions. It is about evidence and Acts breached.
Department of Political Science and Criminal Justice, Edinboro
University of Pennsylvania
by A. James Fisher: [re. Donald Harvey]
While suspicions were aroused, it was hard to imagine that this
friendly, helpful little man who was so charming and popular withmembers of his victims families, could be a stone-cold serial killer. Serial poisoning is a crime that can be detected through forensic
science. The technology is there, but until these cases are moreaggressively pursued within the health-care community, and by the
police, patients will be murdered and their deaths will be registered asnatural.
THE VICTIM
[104] The victim at the focus of this court proceeding is Mr. MalcolmArmstrong Harrison whose legal rights have been breached by the defendants who
have conspired together in a domino effect prior to and during the proceedings to
35Lawyers and Conveyancers Act (Lawyers: Conduct and Client Care) Rules 2008
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defeat the course of justice against section 27(1-3) of the New Zealand Bill of
Rights Act 1990.
THE PLAINTIFFS
[105] The case in the North Shore District Court36 which was heard beforethe Head Judge Buckton is not a matter for Mr Waalkens sarcastic scepticism.
Mr Waalkens is required to conduct himself towards the plaintiffs in accordance
with the Lawyers Regulations. It is a matter of fact that this case was won on its
own merit by Mr. Harrisons mother and the second plaintiff, with research
assistance by the first plaintiff in this proceeding. Various authorities who belittled
the plaintiffs like counsel are doing in this case were proven wrong.
[106] From the early 1990s to 1999 the plaintiffs engaged in a longstandingbattle with Transit New Zealand, with carefully researched facts. Because Transit
NZ Management were not being fair this climaxed with screening on Fair Go and
received widespread public support, so much so that Fair Go repeated the screening
in their Christmas highlights which received further support. This battle resulted in
a retraction from Transit NZ in 1999.
[107] In 1999 the second plaintiff took legal action against Mr Graeme RossHarrison (uncle) for his assault against a woman causing injury with photographic
evidence (kept). This resulted in a guilty plea and Police Diversion with Orders not
to re-offend, apologise to the second plaintiff, and pay a sum of $300.00 to the
Liam Williams-Holloway fund. Mr. Graeme Ross Harrison retaliated with an
unsubstantiated charge against the second defendant out of malice and without
evidence, which Judge S McAuslan at the North Shore District Court dismissed,
citing Mr Graeme Ross Harrisons appalling behaviour towards his motherwhich
the second plaintiff had taken him to task about.
[108] Theplaintiffs are not cranks or busybodies as caustically referredto by Mr Waalkens. This is arrogant disrespectful language coming from a lawyer
towards self-represented litigants. The plaintiffs will not dignify Mr Waalkens
name-calling. This proceeding is too serious forMr. Waalkens insults.
36Harrison v Ken Stout Motors Limited NP1159/95 Judgment by Judge B E Buckton
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[109] The plaintiffs are principled quiet-living and law abiding citizens whohave selflessly put the rights of Mr. Harrison before their own interests and this has
been with significant self-sacrifice, and seek nothing for themselves. All of the
second plaintiffs annual leave for several years has been totally devoted to
researching this case, including travelling overseas to consult with experts.
[110] Counsel needs to remember that the plaintiffs are not on trial in thisproceeding.
[111] A lawyer must, when acting in a professional capacity, conductdealings with others, including self-represented persons, with integrity, respect, and
courtesy.37
[112] The plaintiffs live by their conscience and not by counsels opinion andthis Right is enshrined in sections 13 and 14 of the New Zealand Bill of Rights Act
1990.38
[113] The plaintiffs have done nothing to be ashamed of and should not beoppressed by counsel for bringing this case before the Court which concerns
significant matters.
[114] A particular phenomenon always occurs if certain conditions bepresent.39 Actions cause reactions. The defendants need to look hard at
themselves.
President John F. Kennedy took time from his other responsibilities to
compose an answer to criticism directed against him.
40
He did notsubmit in silence and nor do the plaintiffs towards wrongdoing. Theprinciple conveyed in President Kennedys words is clear.
37Lawyers and Conveyancers Act (Lawyers: Conduct and Client Care) Rules 2008
38Section 13 Everyone has the right to freedom of thought, conscience, religion, and
belief, including the right to adopt and to hold opinions without interference. Section
14 Everyone has the right to freedom of expression, including the freedom to seek,
receive, and impart information and opinions of any kind in any form.39Wikipedia on Physical Law (law of physics)
40Page 89 Macmillan, Kennedy and the Cuban Missile Crisis, Political, Military and
Intelligence Aspects by L. V. Scott
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I think your attention might well be directed to the burglar
rather than to those who caught the burglar. President JohnF. Kennedy (emphasis added)
[115] Silence is not an option where Acts are breached.
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PUBLIC INTEREST
[116] Unsafe clinical practices in Auckland City Hospital and inadequateauditing justify public interest. Contrary to what Mr. Waalkens says,
Public hospital patients and private hospital patients have equivalent right to safety.
Counsel is wrong to imply that public hospital patients have a lesser right.
COLES MEDICAL PRACTICE IN NEW ZEALAND
PUBLISHED BY THE MEDICAL COUNCIL OF NEW
ZEALAND
Preface
In the wake of the Shipman enquiry in Britain, questions have been
raised about the perceived inadequacies of self regulation. LordHaskins (GMC News February 2005) wrote that for doctors, state andself regulation must run side by side. He listed tests of good
professionally led regulation; they are: publ ic in terest must alwaystake precedence over vested interest; competence is maintained;ethical standards are upheld; the regulatory process is carried out by
competent people; the processes must be transparent and fair (nocover ups and no scapegoating); the processes should seek to beeffective, flexible and responsive.
In New Zealand, society permits self regulation by doctors butdemands accountability in return, an accountabili ty that doctors
acknowledge by good medical practice in terms of demonstrable
performance, and main tain ing good health and proper conduct.41
(with emphasis)
[117] In addition, the Ministry of Health National Health Boardin its emailto the plaintiffs dated 12 September 2011 corroborated risk factors referred to in
the Law Commissions Issues Paper and admitted that there is no credible auditing
of hospital acquired deaths. In particular bullet No. 5 of that email states:
Nosocomial conditions are not reported in the Mortality Database,therefore each post-mortem report would need to be scrutinised by aclinical coder to ascertain if a nosocomial condition was documented
41 Preface, Coles Medical Practice in New Zealand, published by the Medical Council of New
Zealand
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on it, and bullet No. 1 states It is not mandatory for hospitals toprovide post-mortem reports to the Ministry.42
[118] Without proper controls and auditing there is no knowing how manypatients have potentially been adversely affected by these defendants dangerous
practices, particularly when the first defendants LabPlus pathologists frequently
neglect to perform Toxicology testing for coronial post mortems on patients who
die in Auckland City Hospital. In Mr. Harrisons case, the defendants malpractice
was only found out by the plaintiffs careful scrutiny of the medical record.
Dr . Harold Shipman
[119] The substantive matters of fact in this case have profoundcharacteristics of the Dr. Harold Shipman case where opioids were indiscriminately
used to induce death in his victims.
[120] The methods used by Dr Harold Shipman are not remote toNew Zealand. The concern is real and acknowledged by the Law Commission and
must be treated seriously.
[121] The New Zealand Law Commission has produced a 73 page IssuesPaper entitled Final Words: Death and Cremation Certification in
New Zealand.4344(Appendix D) Much focus has been given to Dr Harold Shipman
in this document as it relates to the New Zealand context.
Harold Shipman was a respected and trusted English doctor who, in
January 2000, received a life sentence after being found guilty of 15
counts of murder. He went undetected for more than two decades. Thefirst person known to have died under Shipmans care was a woman
with terminal cancer who was killed by a lethal dose of opiates.Injecting lethal doses of opiates remained Shipmans modus operandithroughout his 24 year career In her first report, published in July
2002, Dame Janet suggested the esteem in which Shipman was held inthe community, and in particular by his elderly patients, provided partof the explanation as to why these murders went undetected for so long:
42 Email from Ministry of Health, National Health Board, Manager Classification &
Terminology, 12 September 201143 Law Commission, Issues Paper 23, May 2011
44 also see Dame Janet Smith, The Shipman Inquiry. First Report Death Disguised (2002)
at 14.2 [The Shipman Inquiry].
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It is deeply disturbing that Shipmans killing of his patients did not
arouse suspicion for so many years. The systems which should have
safeguarded his patients against his misconduct, or at least detectedmisconduct when it occurred, failed to operate satisfactorily. Theesteem in which Shipman was held ensured that very few relatives feltany real sense of disquiet about the circumstances of the victims
deaths. Those who did harbour private suspicions felt unable to reporttheir concerns.45
[122] Pausing on the sobering contents of this document, it is described howShipman was also held in esteem which ensured that most of his victims families
misguidedly trusted him whilst others felt unable to report their concerns. Ofparticular concern is that the systems which should have safeguarded patients
against his misconduct failed to operate satisfactorily. This holds a pertinent
message for the first defendant, fifth defendant and sixth defendant.
The Issues paper continues:
Most of the deceased were cremated, a process which at that timerequired three different medical signatures: the first, that of the attendingdoctor who completed the MCCD; the second, that of a (nominally)independent medical practitioner confirming the cause of death, andfinally, that of a third doctor, a medical referee, authorising the cremationafter checking the paper work provided by the other two.
Despite this onerous three-tiered system, Shipmans actions went undetected.
(emphasis added)
These procedures are intended to provide a safeguard for the publicagainst concealment of homicide. Yet, even with these procedures in
place, Shipman was able to kill 215 people without detection. It is clearthat the procedures provided no safeguard at all.46
Dame Janets far reaching inquiry called for a radical overhaul of the
English coronial and death certification systems. Many of herrecommendations for reform were echoed in the Home Offices own
parallel review of death certification, the Luce Report, which alsoconcluded that the system was fundamentally flawed. 47
45 Law Commission, Issues Paper 23, May 2011 at page 4
46 Ibid. at page 447 Tom Luce et al, Death Certification and Investigation in England, Wales and Northern
Ireland The Report of a Fundamental Review (United Kingdom, Home Office, CM3831,
2003) [The Luce Report].
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The conclusion reached by these two reviews was that the checks and
balances built into the death and cremation certification processes had
been systemically undermined and no longer provided a meaningful
safeguard. In particular, Dame Janet drew attention to the fact families
had no input into the certification process which had effectively becomea closed information circuit without any meaningful auditing.48 (withemphasis)
NEW ZEALAND MEDICAL JURISPRUDENCE
[123] The Issues Paper has identified that New Zealand does have a potentialfor Harold Shipman style wrongful deaths, and failing to acknowledge the
seriousness of this is like burying ones head in the sand . This is expressed in the
following excerpt from that document:
New Zealands death and cremation certification systemsshare many
of the features of the pre-reformed British systems, including areliance on a single certifying doctor and an absence of anynationalised system of monitoring or auditing. This lack of auditingmeans there is an absence of empirical data on the efficacy of thecurrent regime. This presents an immediate challenge whenattempting to assess its strengths and weaknesses. However it issignificant that the Chief Coroner, Judge Neil MacLean,
representatives of the funeral industry, and those within the Ministryof Health responsible for compiling national cause of death data, all
believe a review of the current system is overdue.49 (with emphasis)
In an interview with New Zealand Doctor in 2010 Judge MacLeandescribes the different laws affecting doctors, undertakers andcoroners as an unholy mishmash of overlapping and incompatible
legislation.50
[124] This concern is in stark contrast to the complacency shown by thedefendants who brush off the seriousness with caustic criticisms.
OPPRESSIVE INJUSTICE
[125] Dr Morgan Fahey was a pillar of the community, esteemed NewZealand doctor, deputy mayor. None of this gave Dr Fahey impunity for breaking
48 Law Commission, Issues Paper 23, May 2011 at page 5
49 Ibid. at page 5
50 Ibid. at page 6
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the law. A reproof is published in the NZ Herald Editorial entitled Doctor
exposed34 years too late, giving a pointed message that it took journalism to
expose the man: What were the authorities doing ????
Still, the Medical Council should reappraise its procedures in the
light of it. It should not have taken journalism to expose a man
with a history such as his.51
[126] More published disturbing and revealing facts are in the Health AffairsJournal, (article also published on Medscape News):
The culture of secrecy, professional protectionism, defensiveness,and deference to authority is central to such major failures, and
preventing future failures depends on cultural as much as structuralchange in health care systems and organizations.
Lack of management systems: Fourth, these failures often happen invery dysfunctional organizations. On the face of it, the problemsoften centre on an individual clinician or a small team and seem tocontradict the conventional belief that most threats to patient safetyresult from systems failure rather than from the individuals
behaviour. However, the organizations where these failures occur
usually lack fundamental management systems for quality review,incident reporting, and performance management, or those systemshave been bypassed with ease. They frequently show littlecollaboration between managers and clinicians and a lack ofcoherent clinical leadership. They are often isolated and inward-looking organizations, unwilling to learn from elsewhere. Their staffand patients are likely to be disempowered, vulnerable, and poorly
placed to raise concerns. 52 (with emphasis)
REMEDIES
[127] Section 405 Crimes Act 1961: No civil remedy for any act or omissionshall be suspended by reason that such act or omission amounts to an offence.53
51 NZ Herald Editorial [on Dr Morgan Fahey] Doctor exposed 34 years too late, 24 May
2000
52 Health Affairs Journal. 2004;23(3), pages 103-111 Kieran Walshe and Stephen M.Shortell When Things Go Wrong: How Health Care Organizations Deal With Major
Failures, also on Medscape News
53 Section 405 Crimes Act 1961
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[128] A standard of humility and respect should be shown by the defendantsfor the victim who suffered.
[129] The plaintiffs are acting for Mr. Harrison in this proceeding and forthe general public interest without any motive or desire for personal gain and do
not want the defendants money, indeed would not take it for it would represent
blood money to them, but Dr Wood should be paid and any award of exemplary
damages could and should go into a trust for charity such as Guide Dog
sponsorship with The Royal New Zealand Foundation of the Blind, which the
plaintiffs know in their hearts would have the approval of Mr. Harrison.
EXAMPLES OF CASES
[130] Although the Bill of Rights Act has no remedy provisions, the courtshave developed various remedies for infringement of the rights and freedoms
identified in the Act. In Simpson v Attorney-General (Baigents case)54 the Court
of Appeal held that effective and appropriate remedies are available for breach of
the Bill of Rights Act. The courts were seen as having a positive duty to provide
remedies. As Cooke P explained in Baigent.1
we would fail in our duty if we did not give an effective remedy
to a person whose legislatively affirmed rights have been
infringed.55
[131] Section 5.31, Schedule 2, High Court Rules provides:Specifying relief sought 56
(1) The relief claimed must be stated specifically, either by itself or inthe alternative.
(2) Despite subclause (1), it is not necessary to ask for general orother relief but the court may, if it thinks just, grant any otherrelief to which the plaintiff is entitled, even though that relief has
54 [1994] 3 NZLR 667
55 See http://www.justice.govt.nz/publications/global-publications/t/the-guidelines-on-the-new-zealand-bill-of-rights-act-1990-a-guide-to-the-rights-and-freedoms-in-the-bill-
of-rights-act-for-the-public-sector/part-iv-remedies-under-the-bill-of-rights-act
56 Section 5.31, Schedule 2, High Court Rules
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not been specifically claimed and there is no claim for general orother relief.
[132] In an appeal to the Supreme Court of New Zealand between SusanCouch Appellant and the Attorney-General Respondent Elias CJ states:
57
(Appendix C)
All members of this Court are in agreement that exemplary damages areavailable in negligence and are not confined to the intentional torts, rejectingthe high ground on which the Attorney-General sought to justify strike out ofthe proceedings. The majority imposes however the precondition of subjectiverecklessness proposed by the majority in the Court of Appeal in Bottrillbutrejected by the Privy Council. This species of negligence arises where the
defendant consciously appreciates the risk of causing harm and deliberatelyruns that risk. Such subjective recklessness was described by Tipping J in hisconcurring opinion in the Court of Appeal Bottrill as achieving a policysynthesis with the intentional tort approach, at least for personal injury cases.
In summary, I would decline to impose as a matter of law a precondition forthe award of exemplary damages that the defendant must consciously run therisk of harm to the plaintiff. Such precondition restricts the general exemplary
jurisdiction to mark societys condemnation of outrageous behaviour by thedefendant which is insufficiently addressed by other remedy, and is contrary tothe general application of the exemplary principle recognised in Taylor v
Beere. It treats the occasion for exemplary damages in negligence asdepending on conscious appreciation of the harm likely to be suffered by the
plaintiff rather than as arising more broadly out of the conduct of the tortfeasorand despite foreseeability of harm not being an element of the cause of actionin negligence. It saps the vitality of the exemplary principle in meeting theneeds of modern New Zealand society, and turns on the creation of asubcategory of the tort of negligence on no sound basis. These points areaddressed in what follows under headings which reflect this summary. I dealfirst however with suggestions thatBottrillrepresents a deviation and is out of step withother Commonwealth jurisdictions.
Floodgates concerns are not substantiated and seem inconsistent with legi slativeendorsement of the exemplary principle.
[133] McLaren Transport Ltd v Somerville.58 Exemplary damages awardedto a man injured when a tyre being filled with air exploded.
57 Couch v The Attorney-General SC 49/2006 [24 March 2010] NZSC 27
58McLaren Transport Ltd v Somerville [1996] 3 NZLR 424 (HC)
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[134] In F v Northland Health59 exemplary damages were claimed by ahospital employee who had been exposed to chemicals.
COSTS
[135] The plaintiffs oppose the defendants application for costs on thegrounds of section 14.7 (e)(f)(ii)(g) of Schedule 2 of the High Court Rules. Justice
and the evidence require that this proceeding to proceed to trial.
[136] The defendants have attempted to deflect from the focus of theproceeding with their opinions which are not evidence. The defendants know that
have breached best practice standards and ignored global safety warnings.
[137] The defendants have vexatiously inflated the paperwork of thisproceeding, wasting the Courts time and the plaintiffs time, when they know the
matters of fact and law are a prima facie case.
MEDICAL LIABILITY
[138] What is more, the defendants are covered by medical liability insurancewhich they have not disclosed. All doctors require medical practice indemnity