An inquest into how Carmen Walker died following a procedure at Waikato Hospital is finally set to go ahead 13 years after her death. Now, claims the circumstances surrounding Walker’s death were “covered up” by the then Waikato District Health Board and the Health and Disability Commissioner have resurfaced. Natalie Akoorie examines the case.

As Bob Walker lay dying in his hospital bed, unable to speak or move after a massive stroke, his son Lance held his hand and made a promise.

“I remember telling him that we would get to the truth of what happened and get a correct cause of death recorded [for mum],” Lance Walker says. “I saw tears on his cheeks. He understood what I was saying.”

Days later Bob slipped away. That was early 2015, four-and-a-half years after his wife and “soulmate” of 50 years died unexpectedly following a procedure at Waikato Hospital.

But this is not the story of how Carmen Walker died.

That tragedy will be dissected in a Hamilton courtroom during an inquest this month, almost exactly 13 years to the day after the 78-year-old’s death following a cancer procedure that should have extended her life.

Bob Walker never got over his wife Carmen's death and when he had a stroke, son Craig found him on the lounge floor with her medical notes next to him. Photo / Supplied

Instead, this is what happened in the aftermath that led to allegations of systemic failure at Waikato District Health Board and a “cover-up” that Te Whatu Ora Waikato denies.

On August 3, 2010, Carmen Elizabeth Walker underwent an isolated limb infusion (ILI), where high doses of chemotherapy were washed through her lower leg to treat melanoma that had spread from her right ankle.

At the time, the technique, using a pump to circulate the chemotherapy drug and a tourniquet to prevent the concentrated chemo from entering the rest of the body, was provided to the whole of New Zealand by Dr Christopher McEwan in Waikato Hospital’s plastic surgery department.

However, on this day, McEwan did not conduct the procedure and another surgeon was operating. That doctor’s name is suppressed.

When the tourniquet was released, Walker’s blood pressure dropped and she had to be resuscitated. She died later that night in intensive care.

The cause of Walker’s death will be examined by Coroner Alexander Ho, but outside the Coroner’s jurisdiction are events since the procedure that continue to be raised by her family and a whistleblower doctor.

That doctor is a UK-trained plastic surgeon who was observing the procedure that day and later voiced misgivings about what he’d witnessed.

Dr Adam Greenbaum raised his concerns with McEwan who told him the truth of whatever had gone wrong would be detailed in the then Waikato District Health Board’s sentinel event report.

But both McEwan, who had been involved in Walker’s initial care, and Greenbaum, who assisted in her resuscitation and at one stage delivered the shocking news to her family that she might not survive, say they were not informed of an autopsy performed on Walker by pathologist Dr Ian Beer.

The cause of massive blood loss that lead to Whanganui pensioner Carmen Walker's death at Waikato Hospital will be investigated by the Coroner. Photo / NZME

Beer concluded Walker died of cardiogenic shock - shock that results from a failing heart.

He made this finding without Walker’s medical file which showed her haemoglobin had been so low at one point of the procedure as to be incompatible with life, meaning massive blood loss, and that large blood transfusions followed.

In 2021, Beer changed his conclusion prompting the Solicitor-General to order a new inquiry that resulted in the upcoming inquest.

Doctors and alleged dysfunction

In February 2011, six months after Walker died, Greenbaum took a case against the DHB to the Employment Relations Authority, received a settlement and left.

In April that year, Coroner Gordon Matenga convened an on-the-papers inquiry, meaning there was no inquest.

According to the findings, the surgeon’s report to the coroner identified four contributing factors to the death in order of possible priority.

At the top of the list was hypovolaemia, a decreased volume of circulating blood in the body, due to a leaking tourniquet during the washout procedure.

But based on Beer’s autopsy and the surgeon’s notes, Matenga found the cause of Walker’s death was cardiogenic shock.

Greenbaum says he knew nothing of Matenga’s inquiry until a DHB administrator contacted him about its internal investigation saying she had been alerted to his presence at the procedure by McEwan.

However, she was perplexed because while there was a record of a student nurse, there was no record of Greenbaum or any of the multiple handwritten entries he says he made in Walker’s notes during her resuscitation.

Greenbaum wrote to then-chief medical officer Dr Tom Watson and a plastics colleague pointing out the anomaly.

But instead of being included in the DHB’s investigation, Greenbaum says he, along with Beer and McEwan, were shut out of it.

To his knowledge, his entries in Walker’s notes and others made during her resuscitation have never come to light.

The DHB’s internal review panel, convened in September 2011, found no definitive cause for the death.

In June that year, with no response from the DHB to his written concerns, Greenbaum complained to then Health and Disability Commissioner Anthony Hill, in two parts:

• That Walker’s death was avoidable and happened because of avoidable errors and systemic problems at the DHB;
• And that there was compelling evidence that senior clinicians and management within the DHB had covered up the cause of her death - presumably to protect the reputations and careers of those involved.

At the same time, Greenbaum made a complaint to the Medical Council concentrating on the conduct of the doctors concerned and dysfunction within the DHB as it affected the care of patients.

Dr Adam Greenbaum has spent 13 years trying to get answers over Walker's death which he claims was covered up by health authorities. Photo / Mike Scott

Medical Council chief executive Philip Pigou referred the possible “interpersonal and/or systemic issues” in the plastics department to Hill, who said he would request more information from the DHB.

Then Waikato DHB chief executive Craig Climo wrote to Hill, claiming Greenbaum became “aggressive, threatening, litigious and vexatious” when Watson initiated a process to address issues the DHB had identified with the doctor.

“The matter referred to you has been the play out of that. Thankfully Dr Greenbaum no longer works here but it seems his vindictiveness remains.”

Patient care, not malice, was the motivation for the complaint, insists Greenbaum, who says he was never given a chance to defend himself against the comments.

The DHB’s concerns about Greenbaum’s competence were dismissed by the Medical Council and he eventually set up a private practice in south Auckland.

“My professionalism here, and previously in the UK; my surgical competence; my interpersonal skills, and my psychological stability have all been targeted by the DHB and tarnished along this journey to distract from what happened to Carmen.”

Climo, now retired, told the Herald there were no problems within the plastics department that he was aware of “until Greenbaum arrived”.

He called Watson a “very good” chief medical adviser who was thorough and fair in his investigations and he had the utmost respect for the other doctor Greenbaum complained about.

“I never had a reason to doubt their word. In all the litigiousness since, I haven’t come to change my view of the situation at all.”

The meeting

Feeding into Greenbaum’s belief he was targeted is a meeting between Hill and Watson on November 25, 2011, in Wellington.

Greenbaum claims a private meeting between the Health and Disability Commissioner and the chief medical officer of the DHB being complained about was unorthodox. Watson was also one of the doctors Greenbaum had complained about.

In Greenbaum’s opinion, the DHB “covered up” Walker’s death to “hide the dysfunction” at Waikato Hospital that led to a surgeon who had not performed an ILI since 2005, carrying out the procedure.

He believes Watson’s clandestine meeting with Hill helped to establish a narrative that influenced the conduct of Hill’s investigation.

But Hill told the Herald in 2018 it was not true the meeting had the effect of undermining Greenbaum.

“It simply did not,” he said. “I strongly reject any inference of predetermined outcomes to cases.”

After Walker’s death, the DHB never did another ILI, and patients were referred to Australia.

Former Health and Disability Commissioner Anthony Hill found Walker's care at Waikato Hospital was "suboptimal" but whistleblower Dr Greenbaum wants his conduct in the case investigated. Photo / YouTube

Climo told the Herald it was not unusual or untoward for Watson to have met with Hill.

Climo knew Hill from when he was a Deputy Director-General at the Ministry of Health, before he became Health and Disability Commissioner in July 2010.

“He is a man of great integrity so any suggestion he might have been improperly swayed I’d totally reject.”

He denied there was ever a cover-up of Walker’s death.

“Sure, you get mistakes in the system. But they don’t get covered up.”

When contacted by the Herald, Hill referred questions to the HDC.

Watson, who stepped down as chief medical officer in 2018 but remains at Waikato Hospital as an anaesthetist, says his recollection of the meeting with Hill was that it was not focused on Walker.

He says he had gone to the Medical Council with concerns about Greenbaum and on that same day, he went to the HDC and voiced the same concerns, which he believed were unrelated to Walker’s case.

Watson says he had no involvement in Walker’s care and did not lead the DHB’s investigation into her death.

He agreed there was dysfunction in the plastics department at the time.

“He [Greenbaum] was part of the plastic surgery department when there was dysfunction, but part of that dysfunction had to do with him and at least one other surgeon at the time.”

Watson says there had “never been a cover-up” of Walker’s death and the DHB had nothing to hide.

“We acknowledged there were problems in the care we gave and I think we’ve been upfront about that.”

Te Whatu Ora Waikato said in a statement the allegation there was systemic dysfunction in the plastics department that contributed to Walker’s death and that “the DHB covered up this dysfunction and her death” was not supported in any materials or statements seen by Te Whatu Ora – Health New Zealand.

The HDC investigation

The Health and Disability Commissioner’s investigation into Walker’s death concluded in March 2014 that aspects of the DHB’s care were “suboptimal”.

But Greenbaum was not satisfied with the investigation because he didn’t think the allegation of a cover-up, was investigated.

In December 2018 Hill told the Herald the two complaints were assessed separately and followed proper process.

Another reason Greenbaum was unhappy with the HDC investigation was because despite being the complainant, he claims he was excluded from it, and from being connected with Walker’s grieving family.

Linda and Craig Walker, Carmen Walker's son and daughter-in-law, said they have felt stonewalled throughout their campaign to get justice for his mum. Photo / Stuart Munro

Although he consented to having his details shared with the family, as did they their details with Greenbaum, the two parties were “kept apart” until after the investigation ended, Greenbaum claims.

The most telling example of this is a handwritten note on Walker’s HDC file released under the OIA that reads: “3rd party complainant - Dr Greenbaum. Family have given consent to release health info to him. But Anthony wants him informed as little as possible”.

As part of every HDC investigation, an independent expert provides advice to the commissioner, who is legally, not medically, trained.

In Walker’s case, this was Royal Adelaide Hospital Associate Professor Dr Susan Neuhaus, a surgical oncologist with a speciality interest in melanoma.

Neuhaus’ advice was contrary to Beer’s autopsy report, in that she believed Walker died from hypovolaemia, or massive blood loss, not cardiogenic shock.

Beer was never notified of this major difference in finding to his own conclusion and not given a chance to reconsider his report, or the evidence from Walker’s medical file that suggested massive blood loss, that Neuhaus was given.

A condensed version of her findings was included in Hill’s final decision along with the unnamed surgeon’s suggestion that an unidentified lesion could have caused the blood loss.

Hill attributed the blood loss to both Neuhaus and the surgeon’s suggestions; An “unrecognised tourniquet leak” and/or an unidentified lesion.

Health and Disability Commissioner Morag McDowell said she was satisfied with her predecessor's investigation into the care provided to Walker. Photo / Dean Purcell

Greenbaum has asked current Health and Disability Commissioner Morag McDowell to order an independent inquiry into Hill’s conduct and that of the investigators involved in the case.

McDowell told the Herald in a statement she was satisfied that at the time a thorough investigation was conducted into Carmen’s care.

“I have great respect for the former Commissioner and the work he undertook while in office. I will not open an inquiry into his conduct and, in any event, that is not my role,” McDowell said.

“HDC has a Memorandum of Understanding in place with the Coroner’s office to prevent duplicate investigations occurring.

“Following the conclusion of the coronial inquiry, we will consider the outcomes and what, if any, additional action may be required from HDC.”

A campaign for answers

In 2020, a plea by Walker’s family for an inquest into their mother’s death was declined by the Deputy Solicitor-General.

Greenbaum says authorities resisted multiple requests to reopen the inquiry and it only came about because Beer changed his conclusion.

“It never occurred to me that significant blood loss could occur in the controlled environment of the operating theatre during this procedure without the surgeon or anaesthetist knowing and informing the police and me,” Beer wrote to the Chief Coroner.

The Chief Coroner, at that time Judge Deborah Marshall, wrote to Solicitor-General Una Jagose, who ordered a new inquiry.

“The evidence available to the Solicitor-General was the same before and after Beer changed his mind,” Greenbaum points out.

In November 2021, Coroner Ho called an inquest where the cause of Walker’s blood loss and death would be the focus.

It came as Greenbaum delivered an 1166-signature petition to Parliament, now before the Health Select Committee, asking for a full and independent inquiry into the case.

Carmen's sons Craig (left) and Lance Walker describe their mum as kind and caring, and a fit and active community-minded pensioner who delivered Meals on Wheels before she died. Photo / Supplied

Together Greenbaum and Walker’s family have campaigned for justice in her memory, to ensure lessons are learned from avoidable hospital deaths.

Lance and brother Craig Walker believe the family was misled over the cause of their mum’s death.

“After years of our own investigations and official information requests I believe something desperately went wrong,” Lance says.

He hoped the inquest, where he would be a witness on behalf of the family, would provide accountability, better outcomes for future patients, and closure - finally - for the family.

“Dad never got over mum’s death and it impacted heavily on him and caused him undue stress. The love of his life died unexpectedly and he just wanted the truth.

“I remember talking with him in my weekly phone calls to him from the UK and he often said ‘Why did it have to happen? Why are we having to fight for the truth?’

“Dad died five years after mum and when my brother found him on his lounge floor he had mum’s medical notes next to him.

“The stress of the investigation and fight for the truth was too much for him.”

Lance says he is glad his father is not here to experience the distress the family feels as the inquest looms.

“No one should have to go through what we as a family are going through. This is rehashing raw emotions and grief we already dealt with.”

Greenbaum says as tragic as any death is, the bigger problem in New Zealand healthcare seems to be that the system is not set up to encourage staff to feel safe to admit mistakes and ensure they can never be made again.

“The room in which Carmen Walker was treated was crammed with doctors and nurses. They all saw what I saw and chose to say nothing. They all had 13 years to speak up but kept their heads down.

“That’s for the Coroner to address in August, but how much more concerning is it to discover the relevant statutory bodies had the knowledge to fix these gaps in the system in 2011 and failed?

“How many more Carmen Walkers have there been since then?”

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government and the regions.