'She ... didn't come back': A woman went into hospital for a routine procedure - she died soon after

A woman who arrived at hospital for a routine outpatient procedure became ill soon after and died. Her son, Gareth Lowndes, who waited four-and-a-half years for a report on what happened said it resolved little. Lowndes is calling for an overhaul of the health watchdog that investigated, believing the office of the Health & Disability Commissioner was no longer fit for purpose. Tracy Neal reports 

Gareth Lowndes still grieves his mother, who died at Auckland’s Middlemore Hospital following complications after the routine procedure in December 2021. 

She had undergone an endoscopic retrograde cholangiopancreatography (ERCP), used to diagnose and treat problems with the biliary system, such as bile ducts, gallbladder and pancreas. 

She was discharged the same day but developed pain and was readmitted, where she was diagnosed with pancreatitis. 

She then suffered “significant complications” and died. 

“She went in for an ERCP and didn’t come back,” Lowndes said. 

He raised concerns with the Health & Disability Commissioner about care provided by the gastroenterologist who carried out the procedure and by Health NZ. 

Lowndes was especially concerned that the procedure was done without prior imaging. 

By January, four years after he lodged his complaint, Lowndes was still waiting to hear. 

The HDC report arrived in June, and left Lowndes “pretty angry” for several reasons, including his belief that the doctor involved had not been held to account. 

“There’s nothing in the report that couldn’t have been decided upon four years ago,” he told NZME. 

Lowndes said the failures led the hospital not to pick up on the need for fresh imaging before scheduling patients for the type of procedure his mother had. 

Commissioner Morag McDowell said in the report the failure belonged to the health provider and not the individual specialist, who did not breach any care standard. 

However, she did issue an “adverse comment” over his failure to document an aspect of the procedure. 

Health and Disability Commissioner Morag McDowell. Photo / HDC 

McDowell found Health New Zealand|Te Whatu Ora – Counties Manukau in breach of the Code of Health and Disability Services Consumers’ Rights for a series of systemic failures in triage. 

She also found referral processes had not properly considered the need for recent imaging before scheduling patients for ERCP procedures and did not stipulate this as a requirement. 

The gastroenterologist said in response he was surprised that recent cross-sectional imaging had not been done and that it was not his usual practice to perform ERCP without it. 

He said this made the situation difficult, but the patient had been reviewed and referred for the ERCP by the general surgeon and grading gastroenterologist. 

He told HDC that the decision to proceed to the ERCP was a joint one between himself and the patient after a “long and fulsome discussion”. 

Adverse event  

As a thin tube was inserted into the woman’s bile duct, the guidewire initially entered her pancreatic duct and a small amount of contrast was injected. 

Health NZ’s Adverse Event Report noted this happened inadvertently in at least 10% of ERCP procedures. 

The doctor did not document it in the woman’s clinical records, nor did he administer prophylactic treatment in the form of non-steroidal anti-inflammatory drugs (NSAIDs) to guard against pancreatitis, the HDC said. 

Health NZ confirmed that at the time of her care there was no process mandating prophylactic treatment in the event of what occurred. 

Regrettably, she developed post-ERCP pancreatitis, the HDC said. 

Lowndes believed if his mother had received anti-inflammatories after the procedure, it might have reduced the risk of her getting pancreatitis. 

Health New Zealand/Counties Manukau, which oversees Middlemore Hospital, told NZME it had extended its condolences and sincere apology to the family. 

“We accept that the systems and processes supporting the assessment and referral pathway for this procedure did not meet the standard expected at the time,” said group director of operations, Dr Vanessa Thornton. 

The HDC apologised for delays in investigating Lowndes’ complaint and acknowledged his feedback about its report, but did not accept the notion the HDC was not fit for purpose. 

“We are confident that people who make a complaint to HDC today will not encounter the same delays Mr Lowndes experienced,” acting commissioner Rose Wall said. 

HDC ‘still needed’ 

The HDC is an independent Crown entity that protects the rights of people who use health and disability services. 

Its remit is to assess, investigate and resolve complaints about care quality, then make recommendations to health organisations and monitor their implementation. 

Wall said the HDC completed around 190 investigations each year and findings were taken “extremely seriously” by health and disability providers and played a key role in affecting systemic change. 

Around 90% of HDC’s recommendations were complied with by providers, Wall said. 

“Many complainants report that HDC’s process of independent inquiry has helped them to understand what occurred and brought them a sense of accountability and closure. 

“Complainants also express a strong desire to prevent their experience from happening to other consumers,” Wall told NZME. 

Lowndes believed the HDC was still needed to look after vulnerable members of society who might not have capacity or know-how to complain about the health system. 

But systemic change was needed to make it a worthwhile agency. 

He believed the problem was linked to under-resourcing which, had led to “far-reaching consequences” for families, healthcare professionals, and the integrity of New Zealand’s healthcare system. 

The Government provided additional funding of $1 million in 2025/2026 to help reduce the backlog of cases. 

However, the total operating budget for that year fell from $20m to $18m because of the expiration of time-limited funding originally introduced for assisted-dying services, RNZ reported in May last year. 

For the current financial year, the HDC shared a combined allocation of $36.7m with the Health Quality & Safety Commission and the Mental Health and Wellbeing Commission. 

Lowndes petitioned Parliament last year for “urgent resourcing” to address the HDC’s backlog of complaints and make its processes more efficient. 

A select health committee decision last December was non-committal about further steps, other than saying future resourcing might be needed to address some concerns. 

‘Significant and successful’ effort 

The HDC said it had made “significant and successful efforts” to reduce delays in its process caused by an “unprecedented and sustained increase in complaints” since the Covid-19 pandemic. 

In 2025-26 it received 3770 complaints and closed 4304 complaints (including 197 investigations). 

In the same year it reduced the number of open complaints by a further 28% on top of a 33% reduction the year before. 

There had been a 42% decrease in the number of complaints older than two years. Over the past 18 months, the HDC had reduced the number of open investigations by 54%. 

Acting Health and Disability Commissioner Rose Wall was confident that people making a complaint today would not encounter the same delays experienced by Gareth Lowndes. 

Lowndes believed the HDC was hamstrung by politics when it needed neutral oversight. 

“There needs to be a serious cross-party look at the HDC and ask, ‘how can we make sure that this agency is fit for its purpose?’” he said. 

The Government didn’t say whether broad change was needed. 

Health Minister Simeon Brown told NZME that the HDC played an important role in New Zealand’s health system and was focused on reducing the backlog of complaints. 

He said progress was being made but there was more work to do on behalf of patients and their families. 

“I expect Health NZ to work closely with the Health and Disability Commissioner to respond to findings and ensure patients receive the timely, quality care they deserve.” 

Labour’s health spokeswoman, Dr Ayesha Verrall, said there was no review mechanism, for which concerns had been longstanding. 

“It is disappointing that the minister has not acted on the Ministry of Health’s recommendation that the law is changed to require a review mechanism.” 

She said there has been some improvement in the timeliness of handling complaints to the HDC, but more was needed. 

“Overall the process is cumbersome and overly legalistic. Inexplicably, preliminary assessments and investigations use largely the same information but both are lengthy processes.” 

Middlemore Hospital said it was committed to applying what it had learned from the case (involving Lowndes’ mother) and would update the HDC on progress in the coming months. 

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.