'Acute unexpected incident': Review released into Waikato ED death

An investigation after a man died at Waikato Hospital’s Emergency Department has found his death was the result of an “acute unexpected incident” where extra monitoring would not have saved his life.

Health New Zealand (HNZ) released details of its “rapid clinical review” before a more thorough “serious adverse event” investigation expected to be completed within two months.

“The review did not identify that additional monitoring would have changed the outcome in this case,” HNZ’s clinical national director Dr Richard Sullivan said.

He described the man’s death as an “acute unexpected incident”.

He said the waiting room was being monitored when the patient died, but national guidelines are now being drawn up to ensure anyone who deteriorates while waiting is “escalated appropriately”.

The new guidelines will standardise the frequency of checks. Signage in EDs is also being reviewed so patients know what to do if their condition changes while they wait.

The Herald revealed last Tuesday the patient was found unresponsive in the waiting room toilet and could not be revived.

A hospital worker told the Herald that before his death early that morning, the patient spent “nine hours waiting” to be seen in the overcrowded waiting room.

HNZ’s initial review did not say how long he waited, what he died from, or whether the ED was understaffed as nurses and witnesses have told the Herald.

However, Sullivan said some doctors and nurses were sick and off work at the time, and two wards were closed to new patients because of a contagious bug.

“Recently, wait times have been affected by the closure of two wards within the hospital to new patients due to vancomycin-resistant enterococci [VRE] impacting on patient flow and unplanned leave of frontline nurses and doctors due to sickness,” he said.

Health New Zealand has completed a “rapid clinical review” into the death of man at Waikato Hospital’s Emergency Department. Photo / Alan Gibson

A witness, Zanae Kahu King, said the man was in pain and complaining of the long wait before collapsing.

She told the Herald she heard a “big bang” in the toilet cubicle next to her before she found the man on the floor and notified security.

Another patient at the ED that night, Grace Minardo, heard staff come running to help.

“We heard a whole lot of commotion: ‘Pass me the adrenaline. Check the pulse; there is no pulse’.

“There were a lot of people and everybody was very upset.”

The hospital source said children were in the waiting room when staff scrambled to try to save the patient.

“He [the patient] was wheeled through the patient waiting room with a nurse on top doing CPR.”

Another patient, Earl Stevens, also in the ED that night, spoke of waiting for more than 10 hours before he was seen.

He said staff told him on the night they didn’t have enough staff to cope with the workload.

“They said they had doctors away that were sick and they hadn’t filled them with anyone else, and so they were operating under extreme conditions.”

The day before the man’s death, Waikato ED nurse Tracy Chisholm told the Herald about staff being under pressure amid a wave of presentations.

At the time, Chisholm, who’s a New Zealand Nurses Organisation delegate, said she’d recently experienced her busiest day ever when more than 300 patients arrived over the course of a single day on June 8.

“That was the worst day I’ve seen in 18 years. It was standing room only. We brought out extra chairs ... and there were still people standing. It was at capacity,” she told the Herald.

Health Minister Simeon Brown said last month data showed wait times in EDs were improving, with a national average of 74.4% for all ED patients being admitted, discharged, or transferred within the six-hour target.

Michael Morrah is a senior investigative reporter/team leader at the Herald. He won News Journalist of the Year at the 2025 Voyager Media Awards and has twice been named reporter of the year at the NZ Television Awards. He has been a broadcast journalist for 20 years and joined the Herald’s video team in July 2024.