Lowndes was especially concerned that the procedure was done without prior imaging. <\/p>\n
By January, four years after he lodged his complaint, Lowndes was still waiting to hear<\/a>.<\/p>\n The HDC report arrived in June, and left Lowndes \u201cpretty angry\u201d for several reasons, including his belief that the doctor involved had not been held to account.<\/p>\n \u201cThere\u2019s nothing in the report that couldn\u2019t have been decided upon four years ago,\u201d he told NZME.<\/p>\n Lowndes said the failures led the hospital not to pick up on the need for fresh imaging before scheduling patients for the type of procedure his mother had.<\/p>\n Commissioner Morag McDowell said in the report the failure belonged to the health provider and not the individual specialist, who did not breach any care standard.<\/p>\n However, she did issue an \u201cadverse comment\u201d over his failure to document an aspect of the procedure.<\/p>\n McDowell found Health New Zealand|Te Whatu Ora \u2013 Counties Manukau<\/a> in breach of the Code of Health and Disability Services Consumers\u2019 Rights for a series of systemic failures in triage.<\/p>\n She also found referral processes had not properly considered the need for recent imaging before scheduling patients for ERCP procedures and did not stipulate this as a requirement.<\/p>\n The gastroenterologist said in response he was surprised that recent cross-sectional imaging had not been done and that it was not his usual practice to perform ERCP without it.<\/p>\n He said this made the situation difficult, but the patient had been reviewed and referred for the ERCP by the general surgeon and grading gastroenterologist.<\/p>\n He told HDC that the decision to proceed to the ERCP was a joint one between himself and the patient after a \u201clong and fulsome discussion\u201d. <\/p>\n Adverse event <\/p>\n As a thin tube was inserted into the woman\u2019s bile duct, the guidewire initially entered her pancreatic duct and a small amount of contrast was injected.<\/p>\n Health NZ\u2019s Adverse Event Report noted this happened inadvertently in at least 10% of ERCP procedures. <\/p>\n The doctor did not document it in the woman\u2019s clinical records, nor did he administer prophylactic treatment in the form of non-steroidal anti-inflammatory drugs (NSAIDs) to guard against pancreatitis, the HDC said.<\/p>\n Health NZ<\/a> confirmed that at the time of her care there was no process mandating prophylactic treatment in the event of what occurred.<\/p>\n Regrettably, she developed post-ERCP pancreatitis, the HDC said.<\/p>\n Lowndes believed if his mother had received anti-inflammatories after the procedure, it might have reduced the risk of her getting pancreatitis.<\/p>\n Health New Zealand\/Counties Manukau, which oversees Middlemore Hospital, told NZME it had extended its condolences and sincere apology to the family.<\/p>\n \u201cWe accept that the systems and processes supporting the assessment and referral pathway for this procedure did not meet the standard expected at the time,\u201d said group director of operations, Dr Vanessa Thornton.<\/p>\n The HDC apologised for delays in investigating Lowndes\u2019 complaint and acknowledged his feedback about its report, but did not accept the notion the HDC was not fit for purpose. <\/p>\n \u201cWe are confident that people who make a complaint to HDC today will not encounter the same delays Mr Lowndes experienced,\u201d acting commissioner Rose Wall said.<\/p>\n HDC findings taken \u2018extremely seriously\u2019<\/p>\n The HDC is an independent Crown entity that protects the rights of people who use health and disability services.<\/p>\n Its remit is to assess, investigate and resolve complaints about care quality, then make recommendations to health organisations and monitor their implementation.<\/p>\n Wall said the HDC completed around 190 investigations each year and findings were taken \u201cextremely seriously\u201d by health and disability providers and played a key role in affecting systemic change.<\/p>\n Around 90% of HDC\u2019s recommendations were complied with by providers, Wall said.<\/p>\n \u201cMany complainants report that HDC\u2019s process of independent inquiry has helped them to understand what occurred and brought them a sense of accountability and closure. <\/p>\n \u201cComplainants also express a strong desire to prevent their experience from happening to other consumers,\u201d Wall told NZME.<\/p>\n HDC \u2018still needed\u2019<\/p>\n Lowndes believed the HDC was still needed to look after vulnerable members of society who might not have capacity or know-how to complain about the health system.<\/p>\n But systemic change was needed to make it a worthwhile agency.<\/p>\n He believed the problem was linked to under-resourcing which, had led to \u201cfar-reaching consequences\u201d for families, healthcare professionals, and the integrity of New Zealand\u2019s healthcare system<\/a>.<\/p>\n The Government provided additional funding of $1 million in 2025\/2026 to help reduce the backlog of cases.<\/p>\n However, the total operating budget for that year<\/a> fell from $20m to $18m because of the expiration of time-limited funding originally introduced for assisted-dying services, RNZ reported in May last year.<\/p>\n For the current financial year, the HDC shared a combined allocation of $36.7m with the Health Quality & Safety Commission and the Mental Health and Wellbeing Commission.<\/p>\n Lowndes petitioned Parliament last year for \u201curgent resourcing\u201d to address the HDC\u2019s backlog of complaints and make its processes more efficient.<\/p>\n A select health committee decision last December was non-committal about further steps, other than saying future resourcing might be needed to address some concerns.<\/p>\n \u2018Significant and successful\u2019 effort <\/p>\n The HDC said it had made \u201csignificant and successful efforts\u201d to reduce delays in its process caused by an \u201cunprecedented and sustained increase in complaints\u201d since the Covid-19 pandemic. <\/p>\n In 2025-26 it received 3770 complaints and closed 4304 complaints (including 197 investigations). <\/p>\n In the same year it reduced the number of open complaints by a further 28% on top of a 33% reduction the year before.<\/p>\n There had been a 42% decrease in the number of complaints older than two years. Over the past 18 months, the HDC had reduced the number of open investigations by 54%. <\/p>\n Lowndes believed the HDC was hamstrung by politics when it needed neutral oversight.<\/p>\n \u201cThere needs to be a serious cross-party look at the HDC and ask, \u2018how can we make sure that this agency is fit for its purpose?\u2019\u201d he said.<\/p>\n The Government<\/a> didn\u2019t say whether broad change was needed.<\/p>\n Health Minister Simeon Brown told NZME that the HDC played an important role in New Zealand\u2019s health system and was focused on reducing the backlog of complaints.<\/p>\n He said progress was being made but there was more work to do on behalf of patients and their families.<\/p>\n \u201cI expect Health NZ to work closely with the Health and Disability Commissioner to respond to findings and ensure patients receive the timely, quality care they deserve.\u201d<\/p>\n Labour\u2019s health spokeswoman, Dr Ayesha Verrall, said there was no review mechanism, for which concerns had been longstanding.<\/p>\nHealth and Disability Commissioner Morag McDowell. Photo \/ HDC<\/p>\n
Acting Health and Disability Commissioner Rose Wall was confident that people making a complaint today would not encounter the same delays experienced by Gareth Lowndes.<\/p>\n