![\"Health](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/09\/4K34KT6_Morag_McDowell_jpg.jpeg\")
<\/p>\nA woman who arrived at hospital for a routine outpatient procedure became ill soon after and died. Her son, Gareth Lowndes, who waited four-and-a-half years for a report on what happened, said it resolved little. Lowndes is calling for an overhaul of the health watchdog that investigated, believing the office of the Health & Disability Commissioner was no longer fit for purpose. Tracy Neal reports<\/p>\n
Gareth Lowndes still grieves for his mother, who died at Auckland’s Middlemore Hospital following complications after the routine procedure in December 2021.<\/p>\n
She had undergone an endoscopic retrograde cholangiopancreatography (ERCP), used to diagnose and treat problems with the biliary system, such as bile ducts, gallbladder and pancreas.<\/p>\n
She was discharged the same day but developed pain and was readmitted, where she was diagnosed with pancreatitis.<\/p>\n
She then suffered “significant complications” and died.<\/p>\n
“She went in for an ERCP and didn’t come back,” Lowndes said.<\/p>\n
He raised concerns with the Health & Disability Commissioner about care provided by the gastroenterologist who carried out the procedure and by Health NZ.<\/p>\n
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.<\/p>\n
The HDC report arrived in June, and left Lowndes “pretty angry” for several reasons, including his belief that the doctor involved had not been held to account.<\/p>\n
“There’s nothing in the report that couldn’t have been decided upon four years ago,” he told NZME.<\/p>\n
Lowndes said the failures led to the hospital not picking 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 “adverse comment” over his failure to document an aspect of the procedure.<\/p>\n
<\/p>\n
Health and Disability Commissioner Morag McDowell.<\/p>\n
HDC \/ Supplied<\/p>\n
McDowell found Health New Zealand|Te Whatu Ora – Counties Manukau in breach of the Code of Health and Disability Services Consumers’ 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 “long and fulsome discussion”.<\/p>\n
Adverse event<\/p>\n
As a thin tube was inserted into the woman’s bile duct, the guidewire initially entered her pancreatic duct and a small amount of contrast was injected.<\/p>\n
Health NZ’s Adverse Event Report noted this happened inadvertently in at least 10 percent of ERCP procedures.<\/p>\n
The doctor did not document it in the woman’s 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 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
“We accept that the systems and processes supporting the assessment and referral pathway for this procedure did not meet the standard expected at the time,” group director of operations Dr Vanessa Thornton said.<\/p>\n
The HDC apologised for delays in investigating Lowndes’ complaint and acknowledged his feedback about its report, but did not accept the notion the HDC was not fit for purpose.<\/p>\n
“We are confident that people who make a complaint to HDC today will not encounter the same delays Mr Lowndes experienced,” acting commissioner Rose Wall said.<\/p>\n
HDC findings taken ‘extremely seriously’<\/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 “extremely seriously” by health and disability providers and played a key role in affecting systemic change.<\/p>\n
Around 90 percent of HDC’s recommendations were complied with by providers, Wall said.<\/p>\n
“Many complainants report that HDC’s process of independent inquiry has helped them to understand what occurred and brought them a sense of accountability and closure.<\/p>\n
“Complainants also express a strong desire to prevent their experience from happening to other consumers,” Wall told NZME.<\/p>\n
HDC ‘still needed’<\/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 “far-reaching consequences” for families, healthcare professionals, and the integrity of New Zealand’s healthcare system.<\/p>\n
The government provided additional funding of $1 million in 2025\/26 to help reduce the backlog of cases.<\/p>\n
![\"Simeon](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/09\/4JJNEG6_260819_Bridge_5_jpg.jpeg\")
<\/p>\n![\"Labour](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/09\/4JMU6F7_Image_23_jfif.jpeg\")
<\/p>\n![\"\"](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/09\/1788621017_505_4LTMYVF_copyright_image_291122.jpeg\")
<\/p>\n