Stu McPherson death: Health and Disability Commissioner investigates after TV producer dies in sleep, two days after routine surgery at Mercy Ascot Greenlane

“The following morning – I couldn’t tell you the exact time – but at approximately 7am, I woke up and he still wasn’t [in bed],” she says, through tears.

“I went downstairs and I could immediately tell that he was no longer with us.”

Her fiancé never woke from his sleep. He would never get to meet his baby girl, born just a few weeks later.

Now, four years after McPherson’s death, the Health and Disability Commissioner (HDC) has launched a formal investigation into the care provided by Mercy Ascot (now called Allevia Hospital Ascot) and an anaesthetist.

The HDC has told Oates it will consider “all relevant information received from her”.

Oates believes she and her fiancé were let down in not being fully warned about the dangers of mixing his existing prescribed medication with new drugs following his surgery.

The case has also raised questions about why alcohol was prescribed to McPherson following his operation.

Click here to read our story on McPherson’s post-surgery alcohol prescription and changes made by Allevia Hospitals after his death.

Oates is angry about what she describes as the “despicable” way the hospital has treated her, including, she says, the “insulting” offer of a $150 gift card for her newborn daughter.

However, the hospital and senior medical professionals, including McPherson’s anaesthetist, have defended their work.

The hospital has told Oates it has not found any “significant failures” in the care of McPherson and does not believe it is at fault for his death.

The anaesthetist, through a lawyer, rejected any criticism that he had acted “unprofessionally or otherwise inappropriately”.

The hospital expressed sorrow to Oates for her partner’s death.

“Allevia Hospitals is deeply saddened by the death of Mr McPherson and the profound impact this has had on Ms Oates and her daughter,” said a spokeswoman.

The hospital investigated the case internally, with a report making several recommendations. It says it will cooperate fully with the HDC.

The case raises questions for Oates over the level of detail about medications given to patients and their families, and what medical staff knew and communicated between each other about McPherson’s existing medications.

More broadly, it has highlighted the alleged lack of general support from agencies amid lengthy delays and an overflowing workload for the likes of the coroner’s office and the Health and Disability Commissioner.

Oates is seeking compensation from the hospital and says she is speaking out in the hope that no one else faces the same trauma and hurdles she has confronted over the past four years.

Meanwhile, amid a tranche of internal emails and other documents obtained by Oates, an HDC staff member shared concerns internally about the issues she has been raising.

“The complaint mentions the nurse was aware of [McPherson’s] usual medications and we need to find out how/if this was communicated,” the staff member said in one internal email, released under privacy and official information laws.

“Also, private hospitals can sometimes discharge patients with some pretty minimal review and post-op instructions. If it opens up a can of worms, that would be a good thing. It might get some improvements.”

The HDC has downplayed the staff member’s comments.

“Adequate discharge planning is a reasonably common complaint at HDC seen across the system and HDC is not aware of any current trend in relation to private hospitals discharging patients with minimal review,” an HDC spokeswoman told the Herald.

“The quote referenced appears to be the opinion of a staff member only.”

The excited dad who never got the chance to meet his daughter

Stu McPherson never got to meet his baby girl, but was excited about becoming a dad for the first time, Karee Oates says.

“He was so beautiful with her, even before she was born,” Oates says. “Obviously he never met her, but he used to sing to her all the time.

“He was the one driving, and making sure that we did all the parenting classes and was enrolling me in this and that. He came to every appointment and was just genuinely happy to have a little person to love.”

Oates and McPherson met in 2008, becoming firm friends before love blossomed a decade later. They were engaged to be married and had bought a house together.

Oates describes a loveable, cheeky partner – always the first to be invited to the party and the first who’d have himself and friends kicked out.

“He was just wonderful. He was cheeky and strong, and he was going to be a stay-at-home dad. He was good at that stuff – he was the guy who did everything around the home. He had faults, but you couldn’t find anyone who didn’t love him.”

McPherson aggravated an old rugby shoulder injury while playing Last Man Stands social cricket – “he’s a wicketkeeper and quite a terrible wicketkeeper actually”, Oates laughs.

“It would have been like a shattered teacup in there,” she says of her fiancé’s injury.

“He threw the ball – for whatever reason he was fielding – [and] the tendon snapped off the bone. He’d had multiple surgeries on that shoulder; it was problematic and he went through the physio process for a long time, trying really hard to avoid another surgery.

“We got closer and closer to our child being born and he decided that he really wanted to be her primary caregiver. He wanted to be able to pick her up, and he wouldn’t have easily been able to do that with his shoulder as it was.”

Oates says McPherson wanted it fixed.

“It was very minor, very everyday surgery with a highly competent surgeon who he’d had surgery with in the past, and who we were very comfortable with. You just trust in the system – you believe that everything will happen as it’s meant to.”

The surgery

By all accounts, the surgery and anaesthesia procedure went as planned at Mercy Ascot Hospital in Greenlane on Thursday, June 3, 2021.

According to coroner Tracey Fitzgibbon, McPherson’s surgery was “straightforward” and “less difficult” than the surgeon had been anticipating.

The surgeon saw McPherson the next day, and his patient looked “comfortable and well”, the coroner reported.

The surgeon told the coroner they “discussed the importance of not drinking alcohol in relation to the major medication he was going to be sent home with, and Stuart was cognisant of this and replied that he understood this”.

The anaesthetist knew McPherson from a previous surgery and had administered the general anaesthetic to him without any complication, the coroner reported.

The anaesthetist spoke to McPherson before the operation, asking him if he’d had any post-operative nausea or vomiting following previous surgeries.

“Stuart reported experiencing some nausea. He was asked about any history of allergies to medications and what medicines he was currently taking,” the coroner wrote.

“As part of the consent process, they also discussed alcohol use and [the anaesthetist] was agreeable to him having a glass of red wine during the post-operative period in hospital.”

The anaesthetist prescribed 60mg of duloxetine to help with the “rebound pain” in his shoulder when the regional block wore off, the coroner reported.

For McPherson’s discharge, the anaesthetist prescribed “paracetamol, diclofenac (to be taken regularly), oxynorm and tramadol”.

“He told Stuart that oxynorm is a morphine, an opiate only to be taken for severe pain. [The anaesthetist] always tells patients not to mix opiates with other sedatives such as benzodiazepines if the patient is taking them.”

McPherson was placed under general anaesthesia for the surgery, which the anaesthetist reported to be “unremarkable”.

He saw McPherson the next morning – he was pain-free.

“In accordance with his usual practice, in addition to the previous advice given to Stuart on 3 June 2021, he explained oxynorm would be required when the block wears off and not to take regular tramadol with slow-release tramadol.”

At the time of his death, noted the coroner, McPherson had been on regular medications of diazepam, zopiclone, Symbicort and salbutamol.

He had had a history of acute anxiety and depression symptoms and four years before his death, in February 2017, he had gone to his GP with chest pain related to his anxiety. There had not been any further chest pain disclosures since October 2018, the coroner noted.

According to the coroner, the anaesthetist, at the time he reviewed McPherson, “was not aware he had consumed any alcohol or taken oxynorm or zopiclone post-operatively”.

Oates told the Herald that the anaesthetist had McPherson complete paperwork before surgery, but surgery was then delayed a month.

“In the time between, Stu had resumed taking two additional medications, Stu listed these on his hospital admission form and told the nurse and other staff in the room prior to the surgery.

“This was not communicated to the anaesthetist.”

It is understood the anaesthetist also did not have access to the hospital system Testsafe – a database that includes all of a patient’s details and medication.

Cause of death

In her report dated January 25, 2023, coroner Tracey Fitzgibbon relied on a report from pathologist Dr Paul Morrow, who found two potential causes of death: “Cardiomegaly (cardiomyopathy) and the effects of recent surgery and medication ingested”.

“The mechanism of death usually associated with cardiomyopathy is either sudden arrhythmia or congestive heart failure of which there is no evidence for the latter, and therefore Dr Morrow has to consider whether the recent surgery and medication ingestion may have triggered an arrhythmia.

“On the other hand, the effects of multiple sedating medications might lead to death by respiratory depression, hypoxaemia and associated metabolic derangement, especially if there was an element of positional asphyxia.”

The coroner said Dr Morrow stated that selecting one primary cause over another was “to a certain extent, speculative and arbitrary”.

“Toxicology revealed prescribed analgesics: paracetamol, oxycodone, and tramadol. Other medications included diazepam, zopiclone and cyclizine.

“Dr Morrow says all medications appeared appropriate or at therapeutic levels and do not suggest an overdose; however, in combination, these medications are likely to have resulted in significantly increased sedation and possibly respiratory depression.

“Low levels of alcohol were detected, approximately the equivalent of one standard drink. Local anaesthetics associated with recent surgery were also detected.”

‘Extremely groggy’

Oates says McPherson came through the surgery well. She went to the hospital the next day to pick him up. He was, she says, still “extremely groggy”.

She wasn’t present for the discharge by the anaesthetist but was there for the discharge by the surgeon.

In her view, there was a “very complex regime of medications”.

“There are some indications on the packaging around how many hours between dosage and what the dosage should be. There was short-acting, long-acting, and a variety of other sorts of medications, and looking back on it now… we should have been given a much stricter regime around how to administer the medications.

“We also were told, on the discharge information, that he was to continue to take his standard medications and that’s where the problem lies. So the complex medication regime mixed with the medications that he was already on is a probable cause of his death.

“There is a chance that it wasn’t that, but there’s an equal chance that it was, and we just will never know.

“All of the medications… were taken within the therapeutic range, which means they were taken to the prescribed dosages.

“He didn’t take anything beyond what the prescription said, but the compounding effect of the multiple medications… there’s every chance that’s why he died.”

She claims neither she nor McPherson was given warnings about the mixing of medications. He was not given any deep-breathing instructions, she says.

“We weren’t given any of the Medsafe fact sheets. We weren’t given any information other than to continue to take his existing medications, clearly stated on the paperwork we were given and the hours between and dosage of the medications he was prescribed.”

Ascot Pharmacy told the coroner that as part of its standard operating procedure, it was “aware of the importance of providing advice with complex or new prescription medications such as Stuart’s. They also offer the option of additional written consumer information”.

“It is not standard practice at their pharmacy to record whether oral or written advice is provided as it is not feasible to do so,” the coroner wrote.

“Overall, the pharmacy did not consider there was anything unusual about the medications prescribed and provided a copy of the labels that would have been dispensed with the medications. This clearly outlined the dosages and when they are to be taken.”

A tragedy at home

Oates says McPherson came home on Friday, June 4, in a lot of pain. He took his medication and barely slept.

The next day, while Oates had an afternoon nap, McPherson – now feeling somewhat better – ran some errands.

“Then he sat down to watch the rugby. He loved the rugby. He was finally in some degree of comfort – he was lying on the sofa watching his sport, and he wasn’t whimpering or moaning as he had been the night before, so rather than disturb him, I walked up our stairs and I went to sleep.”

After finding him motionless on the couch the next morning, she raised the alarm with a neighbour and they called 111.

Emergency services gave instructions over the phone – “but it was just impossible – he was already dead”.

Coroner’s conclusion

The coroner said there was clear evidence in the information and reports provided to her that identified the cause and circumstances of McPherson’s death. She declined to open a coronial inquiry.

She noted Oates had raised concerns about the process before and after her fiancé’s surgery, “including medication prescribed”.

The coroner said the Health and Disability Commissioner might be able to consider these aspects – that was for it to consider independently.

Hospital’s report and response

Mercy Ascot – now Allevia Hospitals – produced a “serious investigation report” following McPherson’s death.

In a letter to Oates in July 2023, chief executive Ian England said: “You have asked Mercy Ascot to apologise and to compensate you, and we understand that you continue to hold the hospital responsible for your partner’s death.

“We need to be clear that while we absolutely recognise this is a tragic outcome for your family, and in no way downplay the trauma you are going through, Mercy Ascot has not found any significant failures in your partner’s care and does not believe the hospital is at fault for his death.”

He told Oates the care provided to McPherson “had been appropriate, without any significant contributing factors or lapses”.

“As part of Mercy Ascot’s processes, we did decide to conduct further reviews into certain procedures, including the information provided to patients at pre-admission and upon discharge. These reviews are ongoing.

“However, we do not believe that either these policies, or any failure in care, caused Mr McPherson’s death.”

The hospital’s investigation involved a roundtable discussion with the multidisciplinary clinical team, a clinical notes review and a presentation from a forensic pathologist on the cause of McPherson’s death.

Mercy Ascot’s review of the case focused on pre-admission assessment by the anaesthetist and surgeon, post-operative care and the prescribing of pain medication.

The hospital listed recommendations in its final serious investigation report, obtained by the Herald:

The Herald has also obtained draft versions of the report.

According to one draft, prior to the surgery, McPherson had listed, on an anaesthesia assessment patient questionnaire, regular medication of ventolin and Symbicort as required/daily.

On a separate hospital patient questionnaire, he listed Symbicort and as-required medications: ventolin, diclofenac, diazepam and zopiclone.

On the day of surgery, a nurse had documented on the admission assessment form and the anaesthesia assessment and consent form that McPherson took the following medications: diazepam and zopiclone.

“The patient had diazepam and zopiclone in his possession. The nurse explained to the patient that these were prescribed drugs and that they could not be in his possession following the surgery. His wife took them home. The nurse confirmed that these medications could not be administered in hospital without being prescribed and charted.”

In her complaint to the Health and Disability Commissioner (HDC), Oates said the medication McPherson was provided with was contradicted by his regular medication, and he should never have been prescribed the medication he was given.

“She is also concerned that the anaesthetist claimed that he was unaware of Mr McPherson’s regular medication despite staff screening him for it prior to surgery,” the complaint form says.

The Herald sent an email to Allevia Hospitals, outlining Oates’ position and concerns and requesting an interview.

“We appreciate that losing her partner shortly before giving birth to her daughter will have caused Mrs Oates a great deal of distress,” England said in response.

“We continue to extend our deepest condolences for her loss and the ongoing impact on her life and the life of her daughter.

“We are not able to comment on any matters related to our patients, whether alive or deceased. Allevia Hospitals also cannot comment on the ongoing investigations by the Health and Disability Commissioner.”

In a further statement, the company said it had received formal notification from the HDC outlining the scope of its investigation.

“In line with standard practice, we will await the commissioner’s final report before making any substantive comment.

“In the meantime, we will offer the commissioner our full cooperation as the investigation progresses.”

What the anaesthetist says

The Herald requested an interview with the anaesthetist.

A lawyer responded on their behalf, saying their client was “in no position to make comment in the media or otherwise, especially so when Ms Oates has made a complaint to the Health and Disability Commissioner (HDC)”.

“We should also make it clear that [the anaesthetist] rejects any criticism that he has acted unprofessionally or otherwise inappropriately in the management of Mr McPherson’s care.”

HDC inquiries

More than four years after McPherson’s death, the HDC has now launched a formal investigation.

In an email to Oates last month, Deputy Commissioner Vanessa Caldwell apologised for the “ongoing delay in working through your complaint with us and acknowledge the unnecessary additional distress this has caused”.

“In no way does HDC believe this is an acceptable situation and we are working through the considerable backlog that we have as quickly as possible and as thoroughly as each deserves, with the resources available to us”.

She said Oates’ complaint had been scheduled to move to the “notification stage of our process of investigations”.

This would take four to six weeks, and allowed for the collection of any further information from parties as well as any updates “on improvements to systems since events occurred in order to undertake the formal evidential analysis”.

Oates says the volume of cases in front of the HDC had led to delays.

“I’ve not been given an advocate, which is what’s meant to happen. Even if you ring them, you get onto a person who then passes a message on to somebody else and they’ll get back to you within days.

“Somebody’s died here. This is not how we expect Kiwis to treat other Kiwis. It’s not how I would expect anyone to be treated with the gravity of the situation.”

Oates wants to see the HDC conduct a thorough investigation.

“I’m a little concerned that we are just accepting the hospital’s word for things and I would hope that the investigation was thorough enough, that there was somebody actually assigned to question people in some meaningful way, rather than just a lawyer helping the hospital write a report which then is used as gospel. That’s not what would happen if it was a criminal matter.”

She said it seemed “wholly illogical” the hospital was able to “self-report what did or didn’t happen”.

She said the HDC had limited powers – it might instruct the hospital or medical staff to apologise.

“I have a child – if you have to instruct someone to apologise, it’s not a real apology.”

Beyond that, the HDC could make recommendations.

“The recommendations are not mandatory, so the hospital can still pick and choose whether or not they do them. Again, strange.”

An HDC spokeswoman said: “HDC’s role is to promote and protect the rights of people using health and disability services as set out in the code of rights. We do this primarily through the resolution of complaints about the quality of care provided to people.

“In more serious cases, this can result in HDC undertaking an investigation which may result in a provider being found in breach of the code of rights.”

A gift card

Oates said shortly after McPherson’s death, hospital staff visited her at home, and offered a $150 gift card.

She said she had “never been more insulted in my life”.

An Allevia spokeswoman said: “Allevia Hospitals does not have a gift card policy. However, in this instance, our team – moved by Ms Oates’ circumstances – sought to offer a gesture of sympathy in the form of a practical gift card to acknowledge the birth of her daughter. We are very sorry if this gesture caused any offence.”

Oates said she wanted the hospital’s board to start living its values, especially after she believes it spent hundreds of thousands of dollars on a rebrand.

“I’d really like for them to acknowledge that there’s a very real probability that my daughter’s father would be here if their processes were more adequate.

“And to support her financially, to actually come to the party and say, ‘look we know what has happened is unacceptable, and we would like to make sure that we can give you a small amount of comfort’.”

In his letter to Oates in July 2023, Allevia Hospitals’ England said: “We understand that you are receiving ACC coverage following Mr McPherson’s death, and that you are aware this bars any further legal claim for losses resulting from his death.

“Until the process of the Health and Disability Commissioner is complete, we will not be making any further decisions about other actions in this case.”

Oates says: “ACC approved this as a treatment injury and paid my daughter and I some compensation – based on a Covid year of being a live sports producer and editor – so not much.

“This was taxed and now excludes me from receiving any Winz benefits until my daughter turns 18. If I lose my job, or get sick, I am on my own because I was given compensation for Stu’s income.

“I also had to repay the very small amount of single mother’s benefits I was provided while on maternity leave. We are okay financially as I work hard and have always worked and saved but it’s pretty weird that the money I received – which is to support my daughter and to cover her father’s wages – means I have no social safety net.”

Under the ACC no-fault scheme, Oates cannot take any legal action against the hospital.

“The main outcome is that I want the hospital to do something for my daughter. I have made peace with the fact that they don’t care about my daughter – the board and the leadership have no regard for the life of my daughter, and the fact that she will never meet her dad. And they are doctors.”

Karee Oates’ next steps

Oates has “no idea” how she made it through those weeks in June 2021. In the heart of winter, she remembers being constantly cold.

“I know that I had beautiful people around me who showed up every day and made sure I was fed, who did my dishes and I was never alone. We had a house full of people. I couldn’t even tell you who was there but everybody was there. My brother came over from Australia, my sister-in-law flew from the UK.”

Many groups and friends have also helped her: the Remuera Golf Club, a pathologist neighbour, and an anaesthetist friend from rugby.

It was tragic enough to lose her soulmate. Oates doesn’t want others to endure the hurdles and challenges she’s faced after such a devastating loss.

Oates says she talks to her daughter all the time about her dad. She knows he’s “in the sky”.

“She’s an absolute joy; she’s funny, like her dad. She’s like a little spitting image of him actually. We’ve been really, really lucky to have lots of people who’ve helped her stay connected to her dad. I’m Australian, but that’s why we’re still here – to keep her close to her family and to his friends. She’s a little treasure.”

DISCLAIMER: Stu McPherson worked for a period as a freelance video producer for NZME.

Editor-at-Large Shayne Currie is one of New Zealand’s most experienced senior journalists and media leaders. He has held executive and senior editorial roles at NZME including Managing Editor, NZ Herald Editor and Herald on Sunday Editor.