Paul Elton Dewey, a tetraplegic, had gone into Dunedin Hospital on June 10, 2005 for a routine procedure to have a catheter reinserted.
Two days later, the man a coroner's report described as fit, healthy and active, was dead.
Mrs Dewey had received a phone call saying her husband had been resuscitated twice and did she want him resuscitated again?By the time she got to the hospital he was dead.
Mrs Dewey and her three adult children are frustrated by the lack of apology or commitment to change from staff at Dunedin Hospital, whom she believed were to blame for her husband's death.
"We have been going to the hospital and trying to get them to listen to our concerns.
''We have been stonewalled all the way.
''And there has been no apology, nothing - except for them telling me that I am wrong and they are right,' she said.
Coroner Jim Conradson, in one of the last cases he completed as Dunedin coroner, recommended in a report released recently that all the evidence surrounding Mr Dewey's death needed to be reviewed, to reduce the chances of death in similar circumstances.
A coroner's role is not to apportion blame.
Mr Conradson said he acknowledged the hospital had reviewed the death but suggested it reconsider its findings.
A medical specialist from the spinal unit at Burwood Hospital said in the report Mr Dewey's standard of care at the hospital "was less than ideal" and key mistakes made by staff may have contributed to his death.
In the coroner's report a statement confirmed the hospital's position saying the death was "regrettable" but it found "no evidence of systems errors that if not present would have avoided the death.
''Mr Dewey's death appears to have resulted from misfortune alone".
Otago District Health Board chief medical officer Richard Bunton stood by that view when contacted this week.
He said a Health and Disability Commission inquiry, launched after a complaint by the Dewey family, would decide whether the hospital had done anything wrong.
He said the hospital staff had been "open, frank and forward" by participating in the coroner's inquest as well as conducting their own review into the incident.
Mr Dewey's death was the consequence of a procedure which had been carried out properly, but had a serious complication, he said.
Mr Dewey was 48 when he died unexpectedly at Dunedin Hospital on Sunday, June 12, 2005.
He had been made a tetraplegic after a body-surfing accident in the beach opposite his family's home in Brighton, in 1998.
But being confined to a wheelchair, immobile from the chest down, did not stop her husband, Mrs Dewey said.
Since the accident he had had no other medical problems.
He was a coach of a basketball team and would travel in a wheelchair two to three times a week for up to 13km.
He was on the Saddle Hill Community Board for five years and studied for a year at university.
Mrs Dewey said it had been a nightmare few years and she just wanted some justice.
"It has been very, very difficult.
''We have struggled with a lack of closure.
''I just want to find some peace on it."
The coroner's report described the events leading up to the death.
On Friday, June 10, 2005, Mrs Dewey contacted a nurse to say that that her husband's subra-pubic catheter (passed into the bladder through a small slit in the lower abdomen) was leaking and needed to be changed.
A nurse visited and removed the catheter but was unable to replace it with a new one, so Mr Dewey drove himself to the Dunedin Hospital emergency department where a bed had been arranged.
At the hospital, he was seen by a registrar, who described Mr Dewey as "distressed, with a headache and clinically had an enlarged bladder".
Urine was cleared from Mr Dewey's bladder to ease discomfort and an attempt was made to insert a catheter.
When this failed the doctor tried an alternative device, which was also unsuccessful.
Attempts to contact the urology registrar were unsuccessful, so the emergency department specialist was called for assistance.
From there a further attempt was made to insert the catheter with ultrasound guidance but this was later abandoned.
An on-call urology consultant was unavailable and the backup on holiday, so the duty surgical registrar was called.
Several attempts were made to insert the catheter and it was eventually successful, but a nurse said the force used was excessive and noted fresh blood in the patient's urine.
Mr Dewey said at the time: "They have damaged me, haven't they?" and continued to experience difficulty.
Blood pressure problems occurred and Mr Dewey was noted as being "pale, distressed and crying".
On Saturday, Mrs Dewey visited her husband and said he was cold and grey and concerned he had lost a lot of blood.
They observed him screaming with pain and with very low blood pressure.
"I was concerned that [the urologist] didn't listen to Paul when he said there was something wrong.
''He knew there was something wrong."
Mrs Dewey went home on Saturday night expecting to take her husband home on Sunday.
But when Mr Dewey's carer tried to take him out of bed on to a chair on Sunday he suffered a major pulmonary event.
Resuscitation attempts were unsuccessful and he died on June 12, 2005.
Mrs Dewey had concerns about the lack of communication and the poor standard of care for someone with a disability.
She was concerned there was no urologist because the specialist who was on call was working at a private hospital and the back-up was on holiday, which meant the doctor who performed the procedure was not a specialist.
The postmortem examiner found the final catheter insertion procedure began a sequence of events which resulted in the cause of death - a view which differs from that in a hospital report on the death. The Health and Disability Commissioner's investigation of a complaint into Mr Dewey's death is not expected to be complete until next year.
Paul Dewey
