Soldier died after lacklustre care
Lacklustre monitoring after surgery at Christchurch Hospital meant opportunities were "lost"' to prevent the death of a decorated soldier in 2009.
Coroner Richard McElrea concluded Clinton-John Botha, who was nominated for a bravery award while serving with the New Zealand Army in East Timor, had suffered a respiratory dysfunction that was undetected following brain surgery.
Investigations into the 21-year-old's death were carried out by Christchurch Hospital and the Health and Disability Commissioner, and recommendations were issued by the Commissioner in 2012.
Taking these and their implementation into account, McElrea did not make any separate recommendations.
The coronial inquest found Botha had been treated for Chiari malformation, a malformation at the crainiocervical junction, which had caused severe headaches.
At 7.30am on the day after receiving elective surgery, he was found unconscious. He could not be resuscitated.
McElrea concluded respiratory dysfunction was a known potential complication for patients with Chiari malformations.
A ''Root Cause Analysis'' report by Canterbury District Health Board found a lack of awareness of this by staff resulted in lacklustre monitoring following the operation.
''This contributed to Mr Botha's progressive ventilatory failure not being detected and resulted in a lost opportunity to prevent his death.''
The inquest revealed Botha had been anxious about the surgery, but following a discussion with consultant neurosurgeon Ronald Boet, he signed the consent form.
Botha's mother Charlotte Botha asked the coroner to investigate her son's death in September 2009.
She told the inquest research undertaken in Chiari type 2 points to respiratory arrest as the most common cause of mortality - 47 per cent.''
In a statement to police, she pointed to her son's history of respiratory infection and asthma.
She said if respiratory failure had been stated as a risk, ''we would not have gone through with the operation''.
In 2012, the CDHB carried out a review that led to improvements.
Chief medical officer Nigel Millar said staff now conducted more detailed pre-operative assessments which check for any respiratory or sleep disorders.
"The consent process for Chiari malformation also includes respiratory failure and death as potential risks."
Charlotte Botha told Fairfax she could not understand why there were no consequences for the staff who made the mistakes.
''There were at least three to five people that compromised his care, " she said.
"There was a nurse stationed next to his bed. A nurse was sitting next to my son while he was dying. There are no consequences. It's almost like his life was meaningless. That's my frustration.
"There should be something. I'm not saying they should lose their jobs; perhaps some retraining or a fine."
Botha believed that if she had not made the complaint and investigated, nothing would have happened.