Statement From Margot Mains, Chief Executive, Capital & Coast DHB
On behalf of Capital & Coast DHB, I would like to extend our deepest sympathies to the family and friends of Nileema Sharan. Theirs is a
profound loss, resulting from a tragic chain of events in which a young life was taken too soon by meningococcal disease
- a stealthy and pernicious killer which continues to exact a terrible toll around New Zealand.
The sincerity of the health system’s concern over meningococcal disease is reflected in the nationwide vaccination
campaign which has recently been launched through the Ministry of Health and DHBs. This multi-million dollar campaign
aims to protect the youngest generation of New Zealanders, and we strongly encourage all parents and families to embrace
this vaccination campaign as a key measure to help protect the future of this country.
Meningococcal disease is a terrible illness, but it is relatively uncommon. The Wellington Hospital emergency department
sees around 107 patients each day – which adds up to around 39,000 visits each year. In the entire C DHB region there were only 21 cases of meningococcal disease in 2003, and so far in 2004 there have been just 7. In the
Coroner’s Report a GP from a private clinic is quoted as saying he has never seen a case of meningococcal disease in 30
years of practice.
As the Coroner has highlighted, it is also a notoriously difficult illness to detect, sharing symptoms with many other
more common illnesses – and with symptoms often not showing until very late in the progress of the illness.
Obviously I cannot speak on behalf of the ambulance service, the private after hours clinic where Nileema Sharan saw a
doctor, or those who cared for her on the night of her death.
But from the Hospital’s perspective part of the tragedy in cases such as this is that everyone involved is devastated,
and is left asking “what if” questions – questions for which we can never truly know the answers.
A key “what if” question from our perspective is what might have happened if a doctor in the Emergency Department had
seen this patient before she left. Would they have detected a systemic illness, or would they have reached the same
conclusion as was reached by the GP from the private clinic who later in the day saw this patient. Even if they had
detected a systemic illness, would they have been able to identify that as meningococcal septicaemia, or might it have
been attributed to a more common ailment with the same symptoms, such as the flu?
As the Coroner’s Report has highlighted, with the benefit of hindsight there are several areas where this case could
have been handled more effectively by our Emergency Department. A raft of improvements have been introduced in the
systems and processes used in our Emergency Department since the time of this incident, to help reduce the likelihood of
a recurrence. The battle against meningococcal disease is a long and difficult one, and Capital & Coast DHB is determined to do all that we can to encourage safe practise, vaccination, education and awareness to help
defeat this illness which has taken such a terrible toll on the people of this country.
I hope that the conclusion of this process will help to bring some sense of comfort and closure to the Sharan family,
who have suffered an immeasurable loss. As the Coroner notes in his report: “Whilst it cannot be said on the evidence
that Ms Sharan’s death was preventable, it can be said that she missed the opportunity which she should have had of
complete examination and assessment at the hands of Departmental medical staff. Conversely, and sadly, it has to be said
that as a result of the decision made by Ms Sharan and her supporters to leave the Department, the opportunity of
examining and treating her was lost to departmental medical staff.”
We extend our sincere sympathies to her family for these missed opportunities. We share in their sadness, and emerge
from this tragedy determined to continue working to improve our systems for the benefit of present and future patients.