Matthew "Matt" Gunter died in November 2012 from a brain injury caused by a lack of blood flow and oxygen while he was recovering from emergency surgery.
The Nelson College boarder from Greymouth on the West Coast had had his appendix removed at his home-town hospital.
After surgery, he had a "laryngospasm", in which the vocal cord muscles tighten, closing the airway. The lungs keep sucking and the negative pressure pulls fluid into them. The heart then has to work harder and the blood has less oxygen.
An autopsy report said the laryngospasm was successfully treated but it appeared the lung fluid problem wasn't recognised.
Matt was on supplemental oxygen overnight in Grey Base Hospital's children's ward. The sole nurse turned off his oxygen saturation level monitoring machine at 5am - because she had to attend to another patient - and did not assess him again until 6.30am, when she found him in respiratory arrest.
Resuscitation was attempted and Matt was flown to Christchurch Hospital's intensive care unit. He died there days later.
Yesterday, his mother, Heather, in a family statement with Matt's father, David, recalled that moment.
"As I hugged my son, I will never forget the sound of his heartbeat slowing down before stopping forever. My heart broke that day too. I hope that no one ever has to go through what we have, and I encourage all of you to feel empowered to ask questions as patients, family, nurses and doctors.
" ... Matt's death should not have happened. The health care providers trusted to look after Matt failed to give him the care that he needed. In fact, it was total neglect of care.
"This was a totally avoidable death and a waste of a young man's life," said Mrs Gunter.
Matt has three siblings, now aged 12 to 20.
Releasing his report on the case yesterday, Health and Disability Commissioner Anthony Hill said two nurses, an anaesthetist and their employer, the West Coast District Health Board, had breached the Code of Patients' Rights. He did not publicly name the health staff.
Mr Hill made five recommendations to the DHB, including a review of staff training.
He also notified the Nursing Council of both nurses' names and the Medical Council of the doctor's, and referred the night nurse to the prosecutor in his office for a decision on whether to take disciplinary proceedings. He said both nurses had shown a lack of critical thinking.
Mrs Gunter said the health workers were "clearly accountable for the death of our son and the result is just lip service".
"The truth of it is this: if you shoot someone in New Zealand you will go to jail, but if you die in our health system, those responsible just get told off. Where is the justice in this?
"I am disheartened and disappointed. I believed in this system but it has let us down in the worst way possible," said Mrs Gunter, a district nurse for the DHB.
The night nurse told the commissioner that she turned the oxygen level monitor off because the probe had been falling off Matt's fingers -- triggering an alarm -- and she would not be able to respond as she would be attending to a new patient. Also, his oxygen level had been at 95 per cent for six hours, 1 percentage point above the level requiring medical review under a standard protocol.
Mr Hill said this nurse's failings were "serious departures" from expected standards.
She had also failed to make a full, prompt and truthful explanation to Mr and Mrs Gunter and the DHB about when she ceased the oximeter monitoring.
Mrs Gunter told the Herald: "I have read every report I was able to read. In each report the stories changed. You tell me what's the truth."
She said Matt had the kind of personality that meant "everyone knew who he was".
A Nelson College boarding houses' rugby team had come to the West Coast to play "Matt Gunter Memorial" matches against school teams in Greymouth and Hokitika.
Countdown to tragedy
* Thursday, November 15, 2012: Normally fit and healthy Matthew Gunter falls ill
* Friday 16: Admitted to Grey Base Hospital. Emergency surgery to remove appendix. Suffers breathing problems after operation.
* Saturday 17: Found at 6.30am not breathing. Resuscitation attempted. Flown to Christchurch Hospital in the afternoon.
* Tuesday 20: Dies in intensive care unit.
* Saturday 24: Funeral in Greymouth attended by more than 400 people.
* Friday, September 19, 2014: Matt Gunter Memorial rugby game, Greymouth High School v Nelson College boarding houses
- By Martin Johnston of New Zealand Herald
