Death of Koro Mullins: Authorities ‘obfuscated the search for the truth’

A coroner says a health authority investigation into a surgical mistake that caused the death of prominent shearing identity Koro Mullins “obfuscated the search for the truth” and “added to the trauma” of his whānau.

Mullins, from Dannevirke, died in Wellington Hospital on September 16, 2019, after a fatal injection of air into one of his arteries at the start of what was supposed to have been a routine stent procedure.

Over the past two decades or more, Mullins became well-known as a shearing competitions commentator with a unique and sometimes irreverent style which revved the crowd to fever-pitch, even those who had never seen shearing and hadn’t heard of those they were cheering for.

He was an integral part of the commentating and presentations team at the Golden Shears event in Masterton, and in recent years has presented, commentated and interviewed on the Golden Shears TV live-streaming around the World.

His daughter Korina, in the hours after her father’s death, questioned staff and received an admission that there had been a mistake and that a full investigation would follow.

But an inquest into the death in November and December last year heard that there wasn’t a “full investigation”, which annoyed deputy chief coroner Brigitte Windley.

In findings made public at the weekend, Windley says the manner in which the Capital & Coast DHB conducted itself throughout the investigation was “largely unhelpful, obfuscated the search for the truth and served only to add to the trauma they [the Mullins family] had already suffered”.

Korina said the report made her fear that her father’s death was not a unique event in New Zealand and that there was the potential for medical procedure mistakes to be kept quiet to protect the interests of hospitals, health service providers and staff.

She said the whānau had consistent concerns about why there was cleaning or disposal of medical equipment after the fatal surgery, and why a foreign national among the surgical team was able to leave the country shortly afterwards without being interviewed. Capital, Coast and Hutt Valley, now a division of Te Whatu Ora, acknowledged it “failed” Mullins and his whānau and that there were shortcomings in the review process into his death.

It said it had implemented several changes to ensure such an incident did not happen again.

In her 71-page report, Windley says what happened before and after Mullins’ death was “not an outcome that should ever sit easily with the medical professionals involved” and that, in addition to the family, it would continue to affect the theatre clinicians.

Windley noted her jurisdiction did not encompass “an examination of the manner in which the Capital & Coast DHB, its review panel and its clinicians engaged with the Mullins whānau following Koro’s death, in particular relation to the hospital’s systems analysis review process”.

Korina Mullins, a nurse who has recently moved into a new job involving privacy and legal issues in health, sparked in part by her experiences of the past four years, said she wondered what would have happened if she had not asked questions on that tragic afternoon in Wellington.

“We wouldn’t be here,” she said as she again pored over her folders of documents at her home in Hastings.

Expert evidence at the inquest said it was the first time such an event had occurred in the New Zealand health system.

Korina had a simple question for those experts: “How would we know?”

How did this happen?
The events that led to Koro Mullins’ death began after he went to the Palmerston North Hospital emergency department on August 20, 2019, concerned about chest and back pains.

After a brief examination, he was sent home with relief for musculoskeletal back pain and referred to an accelerated diagnostic chest pain pathway [ADCPP]. Given his profile as a male Māori aged over 65, he should have been given a more comprehensive analysis, including a follow-up with a cardiologist within 72 hours.

But that never happened and, in evidence at the inquest, expert witness and Christchurch clinician Dr David Smyth said that, in the MidCentral DHB, this analysis was “mythical”.

There was no follow-up and in the meantime, Mullins travelled to Fiji with his wife Mavis for a presentation she was making at a conference.

He returned to the hospital on September 11, reporting intensified pain and a fall while working on the family dairy farm just east of Dannevirke.

He was diagnosed as having had a heart attack with damage to the heart muscle and was admitted to hospital. A stent procedure was scheduled in Wellington five days later.

Smyth noted at the inquest that many others presenting in similar circumstances in the scope of MidCentral Health had died without even that opportunity.

An audit he recommended found that, while the pathway was supposed to include the follow-up within 72 hours, the average patient wait for those presenting at Palmerston North Hospital was 129.6 days, and that 38 people had died while waiting for follow-ups that never happened.

He said the death or severe adverse event rate for those referred to the ADCPP at Palmerston North was 6.77 per cent, compared with just 0.5 per cent at Christchurch, and that such a difference “should not occur”.

Windley’s report says there was “inadequate” assessment at Palmerston North Hospital’s emergency department, there was “inadequate” resourcing of Mid Central DHB’s outpatient cardiac investigations, and “iatrogenic/human error” in the theatre in Wellington. “Iatrogenic” refers to any illness caused by medical examination or treatment.

The names of clinicians involved are subject to interim non-publication orders.

A man with a global reputation
The Mullins family had developed a global reputation in the shearing industry, as employers in the shearing contracting enterprise Paewai Mullins in the Tararua district, as well as in shearing sports.

Koro Mullins, originally from Rotorua, was described as a strong, physical man. In a lengthy shearing career was 6th in the 1993 Golden Shears Open final, won by shearing legend Sir David Fagan, and went on to become an internationally recognised competitions arena commentator.

Mavis Mullins won the Golden Shears Open woolhandling final in 1987 and 1993 and became a woolhandling competitions judge, the first female president of the Golden Shears International Shearing Championships Society, a top businesswoman at the board table with induction to the New Zealand Business Hall of fame, and the first woman on the board of the Hawke’s Bay Rugby Union, of which she is now president.

While Korina Mullins veered away from a career in the shearing industry, her sister Aria and brothers Tuma and Punga all had winning careers in shearing or woolhandling competition, with Tuma now in a senior arena commentating role and Aria running the shearing contracting.

Korina said she had wondered whether “people will be thinking we’re all psychos” for raising so much concern about her father’s death.

She did not want “heads on sticks” or compensation. Instead, the whānau wanted accountability and, most of all, effective change that would mean “this does not happen to anyone else”.

Coroner Windley said that, at the inquest, the whānau “expressly recognised the effort of the clinicians to be present ‘kanohi ki te kanohi’ at the inquest opening, where Mavis Mullins spoke of the symbolism of the kawakawa and olive branches that were brought to the inquest as representations of strength and fortitude and coming to the inquiry in peace, with respect, and in looking for solutions to make our community a better place”.

“I am hopeful that those who had a role in the review process, and more importantly Te Whatu Ora, in an organisational sense, have reflected on the approach taken in this case, and have identified measures to engage early, honestly and constructively with whanau who lose a loved one in circumstances where iatrogenic error is at least implicated.”

– NZME