Leonard Collett was a popular publican, a family man, and a straight-shooter with a great sense of humour.

While his loved ones continue to honour the memory of Collett, known as Len or Lenny, with tales of a life well-lived, his death has also become a significant chapter.

“I want to make sure that what happened to Len never happens again to a patient,” his wife, Vicky, said in a statement this week at an inquest into his death.

Coroner Ian Telford, who described the circumstances of Collett’s death as “extremely traumatic”, has already concluded that it was preventable. He said Vicky’s point “hit the nail on the head”.

Collett died in July 2020, aged 78.

He was suffering from shortness of breath and was taken to Taranaki Base Hospital’s Emergency Department (ED) by ambulance.

While waiting to be transferred to a ward, he was seen struggling to get back into bed after visiting the toilet unassisted.

Leonard Collett, known as Len or Lenny, in his earlier years.

A nurse went to get him a wheelchair. He was then seen sitting at the end of the bed.

Shortly after, he fell and was found on the floor. It was immediately assessed that he was in a critical condition from the fall, and he died soon afterwards.

An investigation into his death

While the coroner has already drafted his findings, he held the inquest in the New Plymouth District Court yesterday to help in formulating his recommendations to prevent future deaths in similar circumstances.

Collett, who also had anaemia, a recorded drop in blood pressure and a history of atrial fibrillation, was at a high risk of falling, the coroner’s court heard.

Coroner Ian Telford held an inquest in the New Plymouth District Court into the death of Leonard Collett.

However, it was believed that this risk was not assessed while Collett was in ED.

The inquest, which was initially set down for two days but concluded in one, examined Health New Zealand (HNZ) Taranaki’s falls risk assessment of patients, falls prevention measures, staff communication, documentation, and auditing processes.

ED over capacity, understaffed

In evidence, Claudia Matthews, HNZ Taranaki’s service lead for medical and acute services, said a falls risk assessment was a nursing duty. However, she conceded that falls prevention was a shared responsibility among ED staff.

She acknowledged that several issues came into play in Collett’s care.

They included ED being consistently over capacity, leaving patients in waiting rooms and door nooks, and making it difficult for nurses to see their patients.

Matthews said the ED currently operated with 15 fewer fulltime equivalent staff than it should have had.

Business cases had been submitted to HNZ, but it had not received any funding for recruitment.

Claudia Matthews, HNZ Taranaki’s service lead for medical and acute services, gave evidence at the coronial inquest into the death of Leonard Collett.

“So we continue to run shifts in the emergency department with excess presentation and still have baseline staffing that we had in 2020 when this happened with Len,” Matthews said.

“We’ve had no increase in staffing since then, which continues to be problematic when we’re caring for an over-capacitied emergency room.”

On the evening Collett was in ED, there were 32 patients, despite the department having only enough cubicles to treat 23, she said.

Often, the ED treated more than 40 patients at one time.

She said audits of compliance with the falls risk documentation used to happen regularly.

However, because of staff constraints, there were now no clinical staff designated to undertake departmental audits.

In 2022, an audit showed that only 18% nursing staff completed fall risk assessments.

Matthews said the staffing issues meant nurses prioritised direct patient care over paperwork.

Addressing Vicky Collett directly, she extended her condolences on behalf of HNZ Taranaki.

She said she wanted to ensure the circumstances in which Collett died never happened again.

“I’ve heard some great stories about Len,” Matthews said.

“As you know, Taranaki is a small town. I’ve heard he’s driven some great cars and thrown people out of taverns with one hand. He does sound like a great man.”

A respected publican

Vicky Collett’s statement spoke of the pair having been married for 39 years, describing “a wonderful, lovely life together.”

In 1974, the couple went into the publican business in New Plymouth together.

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They started the Breakwater Tavern, before later taking over the Ngāmotu Tavern, and eventually the Rāhotu Tavern.

Vicky said her husband, a father of four, was well-liked and respected by everyone.

“He was sociable but a straight-talker. He treated everyone the same, regardless of their background.”

The couple retired from the publican business about 20 years ago and moved to South Taranaki.

Len Collett, who moved on to other work, retired at 67 because of health problems, she said.

“Len didn’t like going to the doctor’s because he never wanted to be a problem to anyone. He never wanted to put anyone out with his care or to be disruptive.

“From this inquest, I want to make sure that what happened to Len never happens again to a patient.”

Coroner Telford will release his findings at a later date.

Tara Shaskey joined NZME in 2022 and is currently an assistant editor and reporter for the Open Justice team. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.