Tony Knott’s death in Middlemore Hospital’s emergency department waiting room was preventable, family says

• Tony Knott, 82, died in a toilet cubicle at Middlemore Hospital's overcrowded emergency department after waiting for treatment
• His family believe his death was preventable and are calling for urgent health system reforms
• Coroner Amelia Steel highlighted multiple delays in his care as relevant factors in his death

The family of a man who died while waiting to be assessed at Middlemore Hospital's "severely overcrowded" emergency department believe his death was preventable, saying he "fell through the cracks in a broken system".

The Herald can exclusively reveal details of the case, which saw 82-year-old Tony Knott collapse and die in the toilet of the waiting room on 22 April 2021 after he had been waiting to be assessed for a leg injury.

Knott's wife Lynne was with her husband on the day.

"It was the worst day of my life. It was a horrible situation," she told the Herald.

The coroner's report into his death was only finalised in February this year and paints an alarming picture of dysfunction and delays while he waited for an ambulance and assessment and treatment.

Coroner Amelia Steel said the cause of Knott's death was hypertensive heart disease. However, she determined the multiple delays he faced were "relevant to the circumstances" of his death.

Knott's family is speaking publicly for the first time, not to blame any individual but to call on the government to prioritise addressing "big gaps" in New Zealand's health system.

Knott's daughter Rachel Cassidy told the Herald: "Dad fell through the cracks in a broken system.

"He wasn't someone who was ready to die or waiting to die. Two days prior, he'd been playing croquet. The following day, he was due to go trout fishing with his nephews.

"I'm 100 percent convinced that his death was preventable that day," she told the Herald.

'Code red' and the 4.5-hour wait for a hospital transfer

Tony Knott arrived at North Shore Hospital's emergency department at 11.30am on 22 April 2021 after injuring his leg at home, according to the coroner's report.

Specialists there decided the large haematoma on his leg required plastic surgery at Middlemore Hospital. A referral for treatment was accepted and a request for a transfer by ambulance was made at 2.30pm.

However, the coroner said four and a half hours passed before the ambulance arrived.

Cassidy said the wait time was "not remotely" acceptable.

"That's a big part of why Dad ended up in the state that he did. Because of that lag for the ambulance, he wasn't really under the care of either hospital."

According to the coroner's report, when Knott arrived at Middlemore Hospital, it was just before 8pm - the hospital's emergency department waiting room was "severely overcrowded" and in an escalation process known as "code red".

A total of 51 patients had arrived in the two hours between 7pm and 9pm, the report said.

Lynne, who was with her husband at the ED, said the situation appeared "impossibly chaotic".

"He was among loads and loads of people in seemingly the same situation. There was no sign of anyone acknowledging his existence, particularly above anybody else's, which I think we just accepted."

The ambulance officer who transported Knott obtained a wheelchair for him and a pillow to elevate the wound on his leg.

Lynne said the ambulance driver tried to raise concerns while at the ED.

"He went to reception and said, 'I'm really worried about my patient'."

Knott was identified as needing to be in a bed, but a bed was not available because of the overcrowding, according to a doctor who gave evidence to the coroner.

The 82-year-old and his wife continued to wait.

'Horrible situation': The moment Tony Knott collapsed

When Knott arrived at Middlemore's emergency department, his vital signs were not checked. Nor were they taken as he waited sitting upright in the overloaded waiting room.

Cassidy said there were "big gaps" in her father's care.

"I don't think anyone even visually glanced at him, let alone took [his] blood pressure or an oxygen saturation or a pulse rate [reading] or anything like that.

"And by that point, Dad was looking extremely unwell. He was, according to my brother, as white as a sheet."

About 9pm that evening, Knott said to his wife he needed to use the bathroom.

As he stood from his wheelchair inside the waiting room's toilet, Knott collapsed, telling his wife, "I feel giddy".

Lynne said she did all she could to support her husband as he fell to his knees.

"I was supporting his body, and I managed to reach the handle of the toilet door and ask one of the other patients [if they would] get me some help," she said.

"It was very difficult and a very sad, horrible place to be, and a horrible situation to be in."

Attempts by hospital staff to resuscitate Knott were unsuccessful.

The Herald put questions to Health New Zealand - Te Whatu Ora about the delays Knott endured in the lead-up to his death, but they are yet to respond.

Commenting generally, Counties Manukau group director of operations Dr Vanessa Thornton told the Herald overcrowding remains a problem.

There has been "higher-than-expected demand" at Middlemore's ED recently, she said.

"People coming to [the] ED are assessed upon arrival and prioritised based on their clinical risk and acuity, rather than by order of presentation," she said.

She said there are policies in place to alleviate pressure at the ED, including discharging patients sooner and increasing staff numbers if they are available to work.

Thornton said the team work closely with Hato Hone St John to ensure patients' needs are met.

Health 'should be a priority'

Lynne's confidence in New Zealand's health system has "completely collapsed" and she is not convinced hospital overcrowding and pressure on health staff is any better today than it was in 2021.

"I think it's possibly even worse. I think this whole system needs a good shake-up," she said.

She acknowledged there was a lot of good work being done but felt serious deficiencies remained that "should be fixed".

Cassidy agreed.

"You used to know that if you called an ambulance, it would be there in a timely manner. If you turned up at the ED, you were in the safest place you could possibly be.

"It felt like a safety net. There are plenty of people who get exactly what they need but there are those who don't, and that is not fair on anybody."

She had a message for the government.

"Prioritise health. Prioritise Kiwis, because we're not numbers. We're individuals and we're families."

She believed healthcare failures like the one her dad faced were not isolated.

"It's absolutely happening to other families, and preventable deaths in the health system are just heartbreaking."

Cassidy, who was a nurse for 30 years, said she wished she had been at the ED with her dad that day to push for better care.

"I will forever regret not being there that day to advocate for him."

Cassidy said now the family have the coroner's report, it is likely they will lay a formal complaint with the Health and Disability Commission.

The coroner's report

Tony Knott had atrial fibrillation, type-two diabetes, hypertension and osteoarthritis, but his GP told the coroner he kept in good health and managed his conditions with medication.

A forensic pathologist said Knott's leg wound would have made his already vulnerable position even worse.

"The haematoma would have decreased the overall cardiac circulation of volume of blood, which may have exacerbated the underlying cardiac disease precipitating his death."

Another doctor told the coroner blood loss, dehydration, and sitting upright in the waiting room at Middlemore also contributed to reduced circulation.

She said the delay in the ambulance transfer was a "system factor" in Knott's death, as by the time he arrived at Middlemore's ED that evening it was severely overcrowded.

Lynne is confident her husband would still be alive today had he had timely care.

"It was the stress of all those hours of neglect that caused it," she told the Herald.

Steel said the multiple delays were pertinent to what happened.

"The delay in the arrival of the St John ambulance to North Shore Hospital and the subsequent delay in Mr Knott receiving assessment and treatment at Middlemore Hospital are relevant to the circumstances of Mr Knott's death," she said.

Lynne remembers her husband as a family man who always swiftly established a friendly rapport with anyone he met.

"He was a warm, loving person. We all miss him very much."

- This story was originally published by the New Zealand Herald.