Lynn Dring received coronial praise after advocating for change following the death of her husband Nigel.
A coroner has commended the widow of a Tamahere man for helping expose gaps in care provided by Health New Zealand after her husband’s death.
Nigel Dring, 65, a retired Windscreens Direct manager, died at Tamahere Eventide Home and Village on July 22, 2023, eight days after being diagnosed with atrial fibrillation at Waikato Hospital and two days after being seen at the hospital’s pilot atrial fibrillation clinic.
Nigel Dring
Nigel was awaiting an echocardiogram ordered at that clinic when he died.
His widow, Lynn, raised several concerns about his early care, prompting coroner Ian Telford to widen his inquiry. It was Mrs Dring who alerted him that Health NZ was reviewing the clinic and its safety, prompting further investigation.
Telford criticised HNZ Waikato for poor processes and inadequate documentation.
The atrial fibrillation clinic’s initial assessment sheet had never been formally adopted and was kept in a nurse’s desk file.
It was inaccessible to other clinicians and not part of the official record.
He found multiple deficiencies, including a non-robust assessment form with no clinical governance approval, a heavy workload placed on a 0.6 FTE nurse covering two specialist roles, undocumented verbal oversight by a cardiologist, and inadequate recording of assessments and reasoning.
Clinical information was also not electronically visible to other providers, posing risks to patient safety. There was no structured quality assurance process for the clinic.
Telford emphasised that Mrs Dring brought crucial issues to light and helped drive systemic reviews and changes aimed at improving safety.
“It is noteworthy that Mrs Dring’s advocacy was instrumental in alerting me to the issues that have become central to my inquiry,” the coroner said.
“Her complaints to HNZ Waikato have led to systemic reviews that have led to changes to clinical practice that are designed to enhance patient safety. It is my fervent hope that real change now flows from this tragic incident that has left a family traumatised and living with the loss of a man they cherished.”
He recommended strengthening governance of nurse led, and clinical nurse specialist led clinics, including consistent use of approved documents, clear assessment records, reliable escalation pathways, explicit supervision, and adequate staffing and administrative support. He also urged Health New Zealand to work with professional bodies to ensure nurses in advanced roles understand scope limits and that expectations for medical oversight and collaboration are clearly defined.
The coroner highlighted the urgent need for a shared digital record, saying many failures could have been avoided with real time access to clinicians’ assessments and plans.
“My doctor rang me and said I should be proud of myself,” Mrs Dring told The News.
She felt the coroner had been more understanding of the emergency department than he could have been, as they could have done more tests, but his concerns with the atrial fibrillation department were justified.
Lynn Dring received coronial praise after advocating for change following the death of her husband Nigel.
