29 Oct 2018

Gravatt inquest: Treatment should have been escalated earlier

5:18 pm on 29 October 2018

An inquest has heard doctors should have recognised much sooner how seriously ill a young man was, before he died from meningococcal disease.

Zachary Gravatt

Zachary Gravatt Photo: Supplied

Medical student Zachary Gravatt, 22, had been healthy and active before he died suddenly at Auckland Hospital in 2009.

In 2011, a coroner found Mr Gravatt was not treated in a timely fashion and the District Health Board paid the family compensation.

The inquest was re-opened after the family received an anonymous letter that questioned aspects of the DHB's investigation.

In his evidence, Canterbury DHB intensive care specialist David Knight said even if meningococcal disease had not yet been diagnosed, medical staff should have recognised the severity of Mr Gravatt's illness and escalated his level of care and treatment.

Dr Knight also said that if a more experienced doctor had seen Mr Gravatt earlier, he could have received more intensive treatments sooner.

Those could have included earlier administration of the appropriate antibiotic, earlier admission to intensive care, and earlier intubation and ventilation.

However, Dr Knight didn't want to comment on the likelihood of an improved outcome if Mr Gravatt had been treated differently.

Since Mr Gravatt's death, Dr Knight said a national patient deterioration program has been introduced for adult hospital inpatients.

It encompasses an "early warning score", which is calculated from routinely obtained bedside vital signs.

Dr Knight said the score prompts a nurse to escalate treatment.

If that score system had been in place at Auckland Hospital in 2009, and it was properly implemented and resourced, there would have been alerts for Mr Gravatt hours earlier.

The inquest continues.

  • Anonymous letter alleges doctor delayed treatment of critical patient
  • Anonymous letter reopens inquest into medical student's death nine years later