In a deeply distressing case that has prompted calls for urgent reforms, New Zealand’s Health and Disability Commissioner (HDC) has found “systemic failures” led to the preventable death of three-year-old Alexzander Sutherland-Hunt at Grey Base Hospital in Greymouth.
According to a report by RNZ, Alexzander, affectionately known as Zandy, died of septic shock in July 2020 after critical opportunities to save his life were missed by both a junior locum doctor and a nurse who was left in sole charge of the children’s ward despite insufficient paediatric training.
Deputy Commissioner Rose Wall, in her report released on Monday, said the failures reflected broader problems within Health NZ’s rural hospital systems, where resourcing challenges often leave inexperienced staff working alone.
“The staff did not have adequate CPR and paediatric-specific emergency training,” Wall said. “This was a system failure by Health NZ,” quoted RNZ.
Zandy was brought to the hospital’s emergency department by his parents, Matt Hunt and Sapphire Sutherland-Hunt, with fever and vomiting. Initially admitted for suspected early appendicitis, he was placed under the care of a registered nurse, identified only as RN A, who was not current with paediatric emergency protocols and had trained overseas.
Throughout the night, Zandy’s condition continued to deteriorate. His mother repeatedly raised concerns as he vomited and became hot and clammy. The nurse, however, downplayed the symptoms and continued to record zero scores in the Paediatric Early Warning System (PEWS), despite the child’s worsening vital signs.
At 3.30 am, another nurse noticed a rash on Zandy’s face and trunk—an alarming sign of sepsis. The on-call doctor, identified as Dr B, reviewed the boy but decided to delay administering broad-spectrum antibiotics while waiting for a lab result, contrary to the Starship Hospital fever guidelines he had just consulted.
An hour later, when Zandy went into cardiac arrest, IV fluids that had been prescribed still had not been administered. The HDC found that RN A drew up incorrect doses of adrenaline during the prolonged resuscitation effort.
HDC expert Dr Sarah Clarke, a rural medicine specialist, described the failures as “a severe departure from the accepted standard of care,” saying that the lack of immediate IV fluid bolus and delay in antibiotics were catastrophic for a child in septic shock, according to a report by RNZ.
Wall ruled that both Dr B and RN A breached the Code of Health and Disability Services Consumers’ Rights, along with Health NZ itself for inadequate training, rostering, and oversight.
Zandy’s parents described their son as “gentle, cheeky, and outrageous,” recalling how he suddenly went limp and stopped breathing in his mother’s arms moments after speaking.
RNZ quoted that, “the lack of care he got, right down to when he passed away, was heartbreaking,” said Sutherland-Hunt. “We were just left in that room for hours. Nobody said sorry.”
The couple said they had to relive the trauma through multiple investigations and felt unsupported throughout the process. They criticised the hospital for poor aftercare and expressed doubt that recent reforms would prevent similar tragedies.
Health NZ’s West Coast chief medical officer, Dr Brendan Marshall, issued an unreserved apology, admitting that the organisation “failed to meet the standard of care that this child and his whānau deserved.”
He said the agency had since made significant changes, including ending sole-charge night shifts for nurses, improving emergency and CPR training, rotating nurses across departments for wider experience, and introducing new escalation and family support pathways.
“We are committed to learning from this event and taking every step necessary to ensure it does not happen again,” Marshall said, RNZ quoted.
The HDC has written to Health NZ urging continued oversight to ensure that clinical staff working alone in rural hospitals are appropriately qualified and supported.
For Zandy’s parents, however, the pain remains. “No words can mend the deep wounds we carry,” they said. “We just want other parents to know, they can question, they can speak up, and they can demand care,” quoted RNZ.