A coroner says the risk of catastrophic events happening at Taranaki Base Hospital's Emergency Department remains high. Photo: Google Maps
* This story has been updated to correct the staffing levels at the time of the fall in ED.
A coroner has warned that five years after the death of a "sociable" and "straight-talking" former publican at Taranaki Base Hospital's Emergency Department, the risk of catastrophic events happening there remains high.
Hāwera man Leonard Collett died following a fall at the ED in July 2020, aged 78, after being admitted with shortnesss of breath.
An inquest was held into his death in September.
Coroner Ian Telford found the primary cause of death was bleeding from injuries caused by the fall, which ultimately led to terminal cardiac arrest.
He said Collett's fall was both "foreseeable and preventable" and shortcomings in the nursing care provided in the ED.
Telford referenced a report which found the department was fully staffed but with two casual nurses, and at the time of Mr Collett's fall the department was five patients over capacity.
He was further concerned that in May 2025 the department was running short of 15 full-time staff.
There was evidence that significant changes had not been made and the risk of another 'catastrophic event' occurring remained high.
In a statement provided to the inquest and reproduced in full in the Coroner's finding, Collett's wife, Vicky, said "everyone knew Leonard as 'Lenny' or 'Len' and that she called him Len".
The couple, who were married 39 years and had a blended family with four children, got into the pub business in New Plymouth 1976.
"We started at the Breakwater Tavern and had a real mix of patrons including all the 'wharfies'. Len was well liked and respected by everyone. Len had a great sense of humour and a real way with words.
"He was sociable but a straight talker as well. He treated everyone the same regardless of their background. I remember that in our first week there Len had to jump the bar seven times to sort things out! It wasn't unusual to have the bar full by 11 each morning."
The couple took over the Ngāmotu Tavern in New Plymouth and Rahotu Tavern before retiring from the pub business about 20 years ago.
Collett was then employed at Works Infrastructure and the Manaia waste management centre, before retiring aged 67 due to health problems.
On the afternoon of 16 July 2020, Collett was referred to Hāwera Hospital by his GP Dr R Bruce, who arranged for an ambulance.
Collett had become increasingly short of breath over the preceding two weeks and had low haemoglobin.
Ambulance staff decided instead to take him to Taranaki Base Hospital ED and he arrived at about 5.30pm, was triaged and taken to a bed space.
At around 10.10pm, while waiting to be transferred to the ward, Collett was seen struggling to get back to bed after visiting the toilet (unassisted).
A nurse went to get him a wheelchair. However, he was then seen sitting on the end of the bed.
Around a minute later, a loud noise was heard, and Collett was found on the floor. It was immediately assessed that he was in a critical condition.
Emergency treatment, then resuscitation, was started immediately.
Unfortunately, despite extensive efforts, he could not be revived, and one of the attending doctors formally verified Collett's death.
An internal inquiry into Collett's death found that the fall was preventable, the falls assessment protocol was not followed, and a falls risk assessment was not completed.
At the time, the Emergency Department was five patients "over capacity".
A review recommended a falls risk assessment on all patients be undertaken within two hours in the ED and six hours in wards, as per the updated policy.
An audit was to be completed within six months - to show at least 90 percent compliance - while a "falls icon" was also to be used on the department's whiteboard to improve awareness of potential falls risk to patients.
In his findings, Coroner Telford noted that a falls risk assessment had not been implemented by February 2024 and there was no evidence of a further audit being done within the six month timeframe.
After considering the evidence of an expert witness on nursing practice and the prevention of falls, the coroner found the nursing assessment of falls risk was either inadequate or entirely absent, and there was a failure to implement appropriate interventions and monitoring to safeguard someone as vulnerable as Collett.
Coroner Telford said oral evidence given at the inquest provided some assurance that improvements to nursing processes were underway and continued to be developed.
"However, it was evident that such changes will have only limited impact unless and until the broader systemic issues are also addressed.
"Put simply, if this Emergency Department continues to operate without adequate staffing and an appropriate skill mix to safely care for and monitor patients, the risk of another catastrophic event occurring remains high.
"At the very least, it is hoped that Len's case puts a face to the consequences of consciously deciding to operate an ED with 15 fewer full-time staff than it has been assessed as requiring."
Coroner Telford said Collett's death, and the trauma surrounding it, continued to be deeply felt by his wife, family, and all who knew and loved him.
"HNZ Taranaki has advised me that those involved in this incident were significantly affected. I accept this without hesitation and recognise that, in the context of the ongoing under-resourcing described [in evidence], some staff members may be left questioning their role and future within a healthcare system that is in such urgent need of their dedication and expertise."
Coroner Telford said although resourcing issues were well known, a copy of his findings would be provided to the Ministry of Health and Health New Zealand and likewise to the Nursing Council and the New Zealand Nurses Organisation.
He made a raft of recommendations including:
- That ED's nursing admission documentation have its Falls Risk Assessment section revised to align with expert evidence and literature in a way that leads to the clear identification of risk status.
- Its Fall Prevention Actions Taken section be revised and simplified to reflect the recording of nursing actions should be individualised, clear, easily read, and identifiable. This section should also record that risks and actions have been communicated to the patient and family.
- Adapt the admissions documentation and departmental policy to require nurses to routinely assess falls risk at triage or at the same time as their primary assessment when patients are received into the treatment area.
- Revise current policy and provide educational opportunities for all staff to foster a culture in which falls risks are communicated to patients, family and amongst staff members using direct, focussed, and targeted language.
Heath NZ Taranaki has welcomed the recommendations and intends to incorporate them.
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