The man whose time is up

Peter Kroon expected a minor operation and a return to work. Instead, he’s living on borrowed time in an old van - and with half his face missing.

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It started with a thumping, irregular pain on the right side of his head. The pain would pulsate in brief, intense waves, then fall silent. It became more regular, more fierce. Then he found a hard lump, the size of a pea, and then he went to see his doctor.

Some 171 days later, when they finally operated on Peter Kroon, the cancer on his right eyebrow had grown. Now it was almost the size of a golfball. It had spread into his eyesocket, his skull and his nerves. The operation to extract it took ten hours. He lost his eye, his eyesocket, his cheekbone, part of his skull. Afterwards, the pain was sometimes so bad he would wake in the night, screaming.

Had the operation happened within 14 days - as it was meant to - Peter could have expected to return to work within two days.

Because it didn’t, Peter is missing half his face, sleeps in a van, cannot work, and lives off $400 a week. He was given a 10 per cent chance of surviving five years. That five years just expired; he’s now on borrowed time.

One surgeon estimates the unexplained delay cost the medical system over $1.5m to fix. It cost Peter everything.

How did Waitemata District Health Board make such a monumental mistake? And once it happened, why did Peter Kroon only get $131,000 as compensation?

He’s been asking those questions for five years - and he’s not impressed with the answers.

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Peter Kroon had a turbulent life. He’d been in jail as a young man, had bouts of depression, been bankrupted when business debts got out of control.

Peter moved around. Christchurch, where he once walked through the city and felt God speaking directly to him; up north, where he built a house single-handed from plans in Whangarei; Invercargill, where he hated the wind and cold.

Peter, right, during Christmas 2012 - just a year before his lost his eye. Supplied.

Peter, right, during Christmas 2012 - just a year before his lost his eye. Supplied.

Peter, right, during Christmas 2012 - just a year before his lost his eye. Supplied.

After his bankruptcy, he was “in a bad place, as bad as you can f…... get”. He hitched to Kerikeri, finding work on a pig farm in Matauri Bay. Suffering severe back pain, he discovered a healer working from a Kaiwaka garage, who laid his hands on him, spoke in tongues, and cured him. “He was humble. He was a beautiful person. A little short fat Māori guy in his 50s, missing teeth.”

Reinvigorated, he paid off the last of his debts, and became interested in the spiritual, particularly the writings of 18th century theologian Emanuel Swedenborg, which to Peter, were like “beams of light”.

He always worked outside, and worked hard - as a commercial fisherman, concreter, drain layer, and for the past three decades, as a self-employed roofer. Combine that with the fair skin bequeathed by his Dutch heritage, and he was a prime candidate for skin cancer. He had a couple of tumours cut out in 2009.

By the time Peter visited his GP, Dr Maelen Tagelagi, at his New Lynn general practice on April 28, 2013, he was back in a low patch.

A relationship had failed, leaving him back in debt and pursued by Baycorp. His doctor’s notes record some mental health issues, a flat feeling, and that he’d only been working part time. Peter is convinced it was this stress which caused the cancer to attack so aggressively.

The headaches had been around for months by then. Then he noticed that lump. “I knew straight away it had to come out.”

Dr Tagelagi’s notes show he immediately suspected skin cancer. Tagelagi - who declined to be interviewed for this story - considered excising the cancer himself, but because it was close to Peter’s right eye, exercised caution. Instead, he referred him to North Shore Hospital, ‘SKIN CANCER’ marked at the top of his notes.

Hospital records show that two days later, oncologist Richard Martin assessed that referral as a ‘P1’, or Priority One, the most urgent on Waitemata District Health Board’s five-point scale. It should have guaranteed Peter a specialist’s appointment within 14 days. The letter to Dr Tagelagi advising him of the grading, however, simply said ‘wait time unknown’.

This form should have triggered Peter’s immediate treatment and prevented the nightmare that followed.

This form should have triggered Peter’s immediate treatment and prevented the nightmare that followed.

This form should have triggered Peter’s immediate treatment and prevented the nightmare that followed.

Dr Tagelagi would later tell a Health and Disability Commission investigator that he understood Priority One was “considered to be very high priority.” He heard nothing more from the hospital, but wasn’t worried: “I had no reason to suspect he may not be seen within the following four weeks.”

At that point, according to Dr Peter Dady, a cancer specialist who later reviewed the case for ACC, removing the cancer would have been “a relatively conservative procedure”. Excised cleanly, taking only small pieces of bone with it, it would’ve been caught before it spread, and without any disfigurement to Peter’s face. Life would have continued as normal.

But Peter didn’t get that appointment. At the beginning of June, he rang Dr Tagelagi again, saying he’d heard nothing. Tagelagi told him to be patient.

On July 10, Peter rang again, saying the lump was increasingly painful and he was finding it hard to work. Tagelagi called the hospital to chase up. The call was logged in the hospital’s files, but didn’t prompt any action.

Then, on August 28 (or August 9, according to some records), Peter visited Dr Tagelagi again, saying the lump was still growing and now turning his face numb.

An appointment had actually been made by now, but Dr Tagelagi hadn’t been told. So he issued a second referral, saying he would be “grateful” for a review of priority as “he is getting worse”. Under the DHB’s own rules this should have triggered another review of Peter’s place on the waitlist. It didn’t.

If Waitemata had mislaid Peter’s paperwork, they still had the chance to rectify their mistake and push him back to the top of the pile on September 25, when he was finally seen at Waitakere Hospital’s outpatient surgery.

Peter walked into registrar Bevan Jenkins’ surgery, and fell to his knees, begging Jenkins to operate there and then.

He had been waiting five months, after all, and the pain was worsening. Jenkins’ notes record: “I am not quite sure if he is having acute psychosis and religious delusions, versus just an extremely religious man who is highly stressed”.

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The cancer now measured between three and four centimetres. A CT scan a week later showed “extensive destruction of the superior orbital ridge (the bony ridge above the eye) and frontal bone”. Already, it was eating away at Peter’s skull.

Jenkins contacted Dr Tagelagi and the acute psychosis team. There appears no urgency to get Peter on the operating list, although Waitemata DHB disagree, saying that they moved as fast as they could from this point.

In his notes, Jenkins’ boss, Richard Martin, appeared equally indifferent. He saw Peter on October 9, referring him to a meeting of specialist surgeons, and added a warning that he was a “very unusual and bizarre gentleman with persecutory beliefs” who “may not tolerate being seen by a large group”.

By the time Peter saw those surgeons on October 23, his notes say he was “quite agitated” and “angry, understandable at the length of time he has had to wait”. Peter told the meeting he “just wants this thing cut out”. The cancer was now 3cm by 3.4cm by 2cm. Golf ball size.

Waitemata DHB handed Peter’s care over to Auckland Hospital, covered by the Auckland DHB, and finally something began to happen. Peter has no complaints about Auckland’s care. But it was too late for anything bar major surgery.

His new doctors’ notes from there repeatedly show their frustration at how long it took to refer Peter. Dr Nick Agar wrote that his team “share his frustration” but had tried to work fast and communicate well. He decided that as the cancer was now “tethered” to the bone, Peter needed a free flap reconstruction: a complicated operation where tissue is cut from another part of the body, transplanted, and surgically re-connected to the blood supply.

On December 5, they operated, four specialist surgeons in attendance. Issues with the free flap meant it ran overtime and Peter’s father Theo recalls his anxiety growing as it went into a tenth hour.

First, they cut behind Peter’s ear to open up his face. Then neurologist Peter Heppner used a specialist drill called a craniotome to cut a hole in the frontal bone, then grind it away. He spotted an abnormal area in the dura - the outermost, toughest of the three membranes covering the brain and spinal cord - and that too was cut away and reconstructed. Then the frontal sinus bone - the nose - was drilled down with a “diamond paste burr” and sections frozen and tested for cancer.

Agar and fellow surgeon Nick McIvor took over. They cut away part of Peter’s thigh, to use for the dura reconstruction. Then skin was taken from Peter’s abdomen to repair his face. There were issues with his artery clotting when they cut the neck open. They had to “revise” the flap five times due to difficulties with his blood supply. Then he was heavily sedated on morphine.

Peter would wake up the next morning minus an eye, and most of the right side of his face.

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When Peter went into hospital, he was shaped by years of manual work; not a big bloke, but “strong as a f……. ox, mate”.

Six days after that marathon surgery, he was 15 kilograms lighter.

Peter in Auckland Hospital shortly after his initial surgery. He’d lost 15kg of weight and a strength he would never regain.

Peter in Auckland Hospital shortly after his initial surgery. He’d lost 15kg of weight and a strength he would never regain.

Peter in Auckland Hospital shortly after his initial surgery. He’d lost 15kg of weight and a strength he would never regain.

Leery of the painkillers being pumped into him, he discharged himself, and managed to walk out, but he felt numb. He’d never regain that lost strength. “My dad came and saw me outside [the hospital] one night when I was a bit angry. He said ‘you’ve just got to accept it’. And I thought ‘yes, I’ve got to accept it, I can’t change it’. Once you accept it, it’s alright. But it’s still a hole in the head mate, it won’t go away. It’s a terrible thing.”

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Kids are usually okay. They just think he’s a pirate.

With the eyepatch on and his cap jammed down low, at first glance you might not notice there was something wrong with Peter.

When he takes his hat and patch off, you can see how concave his face is, the yellow, sprouting scar tissue of his skin transplant; you notice most, of course, what isn’t there.

It took time to adapt his sense of balance (Peter can no longer climb tall ladders or ride a bike), his depth perception, and to the way people stare. Peter is shrewd, he knows what people are thinking.

“I try not to walk around in public without it [the eyepatch] on. I’ve had people ask me to cover it up. It is ugly, mate, it’s f…... ugly. People don’t want to see it, mate.”

Peter’s eye was gone. His cancer was gone. But the cost of caring for him continued to stack up.

Three months of radiotherapy came with the warning that because his cancer was so advanced, it was likely they hadn’t caught it all.

But in 2015, doctors seemed confident enough to try reconstruct part of Peter’s face, a process called cranioplasty, where a custom-made titanium prosthetic was inserted under his skin transplant, then re-covered.

It didn’t work. The skin flap died; the plate was removed, and new bone from his leg and skin from his forearm were taken to replace the flap.

Peter’s face after his initial free flap surgery.

Peter’s face after his initial free flap surgery.

Peter’s face after his initial free flap surgery.

His medical notes from that year are a confusing list of operations. Together, we tally them, and figure it’s 15 or 16. They were mostly to clean up a series of infections in his flap and to remove fluid, debris and even gas from his face. The worst, he says, was when they pushed steel surgical tools up his nostrils. “I came out of that, and oh f..., I was screaming for morphine. The pain was knocking me out.”

His doctor, David Vokes, decided after this Peter was “no longer a good candidate” for craniotherapy. He didn’t mind: “I didn’t want them to have another go.”

Later, he wished they’d adopted a less invasive approach, retaining the original flap, then fitting screws into the bone around it so Peter could attach a prosthetic part, and a $12,000 glass eye, over the top.

Peter had weeks-long stays in hospital, in between helping nurse an old friend dying of cancer, or staying with his parents at their home in a neat, well-tended retirement village for Dutch emigres in Henderson, west Auckland.

The small office by the front door became the heartbeat of a campaign for Peter to get proper recompense. It’s where Theo Kroon keeps the reinforced cardboard box which holds Peter’s file. It weighs 11.1 kilograms.

Peter’s father Theo Kroon has fought tirelessly for his son.

Peter’s father Theo Kroon has fought tirelessly for his son.

Peter’s father Theo Kroon has fought tirelessly for his son.

It’s a tiring read, page after page of petty bureaucracy and medical jargon. But what’s most noticeable when reading it - once you get past that staggering 171 day delay, and the grinding paper fight with ACC - is Theo’s quiet heroism.

He’s now 81 years old. He’s wound down his successful embroidery business (the Hell’s Angels are among his former clients), but still plays in a country music band and chairs the village residents’ committee. And writes letters.

Peter isn’t keen on computers, so it’s Theo who has doggedly pursued Peter’s case, exchanging long correspondence with ACC, then when he exhausted that avenue, with local MPs, the Prime Minister, the Health and Disability Commission, and now with the Human Rights Commissioner.

“You try to help your son… but there’s not a hell of a lot you appear to be able to do,” he says, frustrated. “If your family is in trouble, you try to help. You fight and you try to do whatever it takes to get them a better deal - because the deal he got was no good.”

And of course, for much of this time, Peter was living with his parents. “It hasn’t been the easiest [time],” says Theo. “It has been stressful; very stressful for my wife to see him like that. You try to work out what way to go.”

Carefully, sometimes checking wording with his sister in Holland because he’s conscious that English is his second language, Theo kept writing, and writing.

“Without him, I wouldn’t have got a cent,” Peter says. “I wouldn’t have got anywhere.”

The paperwork had begun without Peter even knowing, as he lay in his hospital bed and the Accident Compensation Corporation began to slowly ponder whether he was entitled to compensation - and how much.

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It’s important to note that Peter wasn’t covered by ACC for his cancer. Had he suffered the cancer, been treated properly, and lived or died, he was entitled to nothing.

It was Waitemata’s incompetence which allowed him to claim for a ‘treatment injury’: an injury sustained as the result of medical failure.

ACC first commissioned two doctors to assess what impact the delay had on Peter. Ian St John decided it was impossible to say that earlier treatment would have meant a different outcome: “A speedier response … may not have … significantly reduced the progression of the client’s present condition.”

Peter Dady’s much longer assessment said: “It is clear that the disease progression during the 170-day delay has resulted in a very considerable worsening in Mr Kroon’s prognosis.” ACC went with Dady’s view.

Then they had to decide when the injury officially happened, for the purpose of calculating Peter’s payments - compensation is based on your previous 12 months’ earnings. Peter’s tax records show his income plummeted in the two years before diagnosis, partly due to the cancer’s growth and his ill-health, partly due to his prior depression. The earlier the date, the better for him.

It fell to clinical advisor Warren Maguire to make the decision. On January 14, 2014, Maguire said he would make a decision by March 29. On March 3, he asked for an extension - to August 26. Theo wrote back asking if ACC was just waiting for Peter to die. ACC say medical failure claims “require extensive and careful investigation”. They were mindful Peter was waiting, but Maguire needed time to seek expert opinions, and by law, was allowed up to nine months to decide.

On April 29, Maguire decided that the date of injury was August 9, 2013 - the date he said Tagelagi made his second, urgent referral. Theo disagreed. He reckons by May 23, Waitemata had already slipped below their own standards for dealing with Peter’s cancer, so that was when the treatment injury happened.

Much of the weight of Peter’s 11kg case file is protracted correspondence with ACC arguing over compensation.

Much of the weight of Peter’s 11kg case file is protracted correspondence with ACC arguing over compensation.

Much of the weight of Peter’s 11kg case file is protracted correspondence with ACC arguing over compensation.

ACC’s rules, however, say the date is taken from when the patient first seeks treatment for the injury. Eventually, after several appeals and lots of paperwork over many months, they settled on July 10, being the date Peter phoned Tagelagi to complain nothing was happening.

Peter earned just $29,165 in the year to March 2013 - below minimum wage (in the year to March 2012, he’d earned $53,978; he says in better years, he was taking home $80,000). So he was entitled only to ACC’s minimum weekly compensation: $440 before tax. Pitiful, he says.

ACC now say they actually used two years of Peter’s earnings to assess his compensation, not just one - but it didn’t increase his payout.  

Part two was deciding the amount of Peter’s lump sum payment for his disability.

Assessing just how badly broken someone’s body is is a cold, mathematical process. Assessors use American Medical Association guidelines to work out the percentage loss of function of a body part, then total it all into a ‘total body impairment’.

Specialist ACC lawyer John Miller says these guidelines are tough, and quite badly injured people are often left with as little as $10,000.

Dr Ross McCormick’s thorough report encompasses Peter’s lost eye and socket, nerve damage, reduced jaw movement, wrecked right nostril and “markedly reduced life expectancy”, his 11kg weight loss, his inability to chew on one side, his poor balance (which stopped his roofing work) and perpetual fatigue.

“He is more likely than not to die within five years because his skin cancer is almost certainly not cured,” wrote McCormick. Peter had a total impairment of 88 per cent.

If the operation had been timely, McCormick said Peter’s disability would have been rated just eight per cent. So Peter’s overall impairment as a result of mistakes in his treatment was 80 per cent, McCormick found. This was crucial, because claims for 80% and above were entitled to the maximum payout. At the time, that was $131,765.

Peter was deep in debt when the cancer struck. He thought it was love, he says, but a failed relationship had cleaned him out. So he says he signed without being told he could get external legal advice. “I just had a massive sense of relief. I was out of debt. That was my thinking. I didn’t have a choice - I accepted it.” ACC says the lump sum was “an entitlement, not an offer”, therefore not up for negotiation.

The 2002 Injury Prevention and Rehabilitation Act reintroduced the payment of lump sums.  At the time, Labour’s Michael Cullen said it would be limited to $100,000 over a lifetime. Gerry Brownlee, then National’s ACC spokesman, asked: “What about a paraplegic who had received the full $100,000 and had got back to work and re-established a life? If you then lost your sight, suddenly there would be no compensation.”

That maximum has gradually crept up. But the rule you can only claim once remains. If Peter walked under a bus tomorrow and lost both legs, it would be tough luck. Or, as actually happened, he had major complications and another 16 surgeries, well, tough luck too.

Despite this, in August 2015, ACC accepted a new treatment injury claim for the failure of Peter’s free flap.

After initially declining, they also agreed to assess him again. This time, Dr McCormick increased his impairment score to 82 per cent, predicting his eventual confinement to home (if he had one). But he was denied a second lump sum.  

Miller says it’s a “rigid” system with little wriggle room. He might be able to find some around the date of Peter’s treatment injury (that’s the majority of the work his firm undertakes), perhaps argue it was a gradual condition caused by his job. But often, he says, people “spend a lot of time arguing it. And it is a pyrrhic victory, because it doesn’t advance things for them.”

In Peter’s case, while he wasn’t working at full strength for some time, that was down to the cancer, not the failure to treat the cancer.

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It’s what Miller calls the “ludicrous dichotomy” of the ACC system. Disease and illness aren’t recognised: someone confined to a wheelchair through multiple sclerosis gets nothing, someone in a wheelchair after being hit by a bus will get 80 per cent of their earnings and a lump sum. “There’s a big distinction between injury by disease, and injury by accident.”

It’s something that’s been on the mind of legislators for two decades, but without any changes being made.

Miller has more bad news. In the US, Australia or the UK, Peter could sue for personal injury. Here, he can only sue for punitive or exemplary damages. That means proving doctors either intended to harm him, or that they were not just negligent, but grossly negligent. “Negligence you fall off your chair at,” explains Miller. “In the surgeon’s case, you’d need him swigging a bottle of whisky in the operating theatre and cutting off the wrong leg.”

Legal fees might be $20,000, and your compensation? Maybe $20,000. Peter’s case? Miller considers it. “It’s just negligence,” he says. “Everything is stacked against this guy.”

ACC lawyer John Miller.

ACC lawyer John Miller.

ACC lawyer John Miller.

Through the series of appeals, and conciliation hearings and angry letters, Peter and Theo simply would not accept this was the system.

The transcript of one appeal hearing shows Theo and Peter getting increasingly upset, Peter cursing, and Theo declaring: “Rules are made to be broken”. No, says the reviewer, they’re not: “I hear your frustration, I can’t do anything about it and we as an organisation can’t do anything about it …”

Slowly, Theo exhausted all avenues. He wrote to the-then ACC minister Michael Woodhouse, then associate ACC minister Jacqui Dean, then to prime minister Bill English; he got a supporting email from his MP, Phil Twyford. This too was a dead end: Dean said it was an operational issue, ACC was acting within the law, and there was no discretion for ministers to make exceptions. There was nowhere further to go.

“ACC have got all the money and they don’t want to pay,” says Theo. “I think the system stinks. I think ACC is absolutely broken, they don’t really want to pay the money they are supposed to.”

ACC minister Iain Lees-Galloway.

ACC minister Iain Lees-Galloway.

ACC minister Iain Lees-Galloway.

The present ACC minister, Iain Lees-Galloway, does not have good news for the Kroons. He said no changes were planned to either the lump sum, or the way weekly allowances are calculated. He said the allowance was fair because it reflected people’s earnings at the time, and also the ACC levies they were paying - a lower levy reflected a lower payout. The lump sum was designed to give “more flexibility to manage funds” than a regular allowance, but there was no plan to increase it.

“You try and stay alive, really, while dealing with a system, which for the most part, seems to be against you,” says Peter. “By comparison to other countries … [I’ve not had a great deal].

“The one thing I want changed is [the lump sum maximum] to go up, and the bullshit about ‘should further injury happen you are not entitled’. That’s criminal. It’s ruthless. They [ACC] know it is wrong; they’ve told me it is wrong.”

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The Waitemata District Health Board decided that nobody in particular was to blame for what happened to Peter Kroon under their care.

Their original internal enquiry report, from 2014, is a slim document which concludes “there was no way to determine exactly why this particular referral sat for 121 days before offering an appointment’’. It didn’t name or blame any individuals, and as its recommendation, merely pointed out there was a “project underway in Booking and Scheduling. This case will be provided to the project team to help inform the work that is being done’’.

A letter on October 24, 2014, from Waitemata DHB’s chief medical officer, Andrew Brant, offered a brief apology to Peter, some nine months after he finally had surgery: “The delay was unacceptable and should not have happened”.

English is Theo Kroon’s second language, but he has argued Peter’s corner as adroitly as any lawyer.

English is Theo Kroon’s second language, but he has argued Peter’s corner as adroitly as any lawyer.

English is Theo Kroon’s second language, but he has argued Peter’s corner as adroitly as any lawyer.

The letter said the DHB still didn’t know what happened to the referral between April 28 and August 6, but they had made changes to the booking and scheduling system, added ‘electronic flags’ and alerts on priority files and are “confident it should not happen again”.

An updated version of that report said referrals were meant to be logged, triaged and updated within ten days, and admitted there was no alert system to flag the delay. Waitemata had now introduced one, including a ‘high suspicion of cancer’ flag.

The new report admitted the system was based on paper print outs being handed to consultants, and conceded: “There is a risk with a paper-based referral and triage system that a referral will be lost prior to being waitlisted for an appointment, as in this case.”

That enrages Theo Kroon. “How, in this day and age ... would anything as important as this, a person’s life [be on paper],” he says indignantly. “You flag it in a computer! You don’t just have a paper entry. I began using a computer in 1980!”

But Brant’s 2014 letter is inconsistent with Waitemata’s later explanations.

In 2016, Theo persuaded the Health and Disability Commission to investigate Peter’s case. Brant’s confidence there would be no repeat was unfounded. The HDC found two other cases between 2014 and 2016 of Waitemata patients subjected to unusually long delays in treatment, partly because of poor administrative systems. Waitemata says both of those also happened before they brought in new systems: they say they had “long identified” the need for an electronic system - and were midway through installing it when Peter was referred.

And while Brant said he couldn’t account for why Peter had to wait for so long, implying that his file must have been lost, Waitemata actually knew, even as Peter waited, that they had a problem. They supplied the HDC with an internal report from August 2013 which showed they had 23 skin cancer patients who weren’t seen within a Ministry of Health-mandated five-month timeframe.

2013
 

APR 28

Peter visits his GP, Maelen Tagelagi, with headaches and a small growth on his eyebrow. 

APR 30

Waitemata DH assess him as ‘Priority 1’: so to be treated urgently and seen within 14 days.

 
 

JUN

Peter phones his GP to say he’s heard nothing; he’s told to be patient.

 

JUL

Peter calls his GP again, and Tagelagi phones the hospital to follow up.

 

AUG

Peter visits Tagelagi again, who issues a second referral.

 

SEP 25

Peter is finally seen at an outpatient clinic, and sent for a CT scan.

 

OCT 9

Peter is seen by Waitemata oncologist Richard Martin, who refers him to a specialist team meeting.

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OCT 23

Peter meets specialist surgeons and it’s decided he needs a complicated operation called a ‘free flap’ surgery.

DEC 5

Peter undergoes a ten-hour operation - and loses his eye, and part of his skull.

 
2014
 

JAN - APR

Multiple exchanges with ACC over whether Peter is entitled to compensation.

OCT 24

Waitemata apologise for the first time for their failures.

 
2015
 

Peter undergoes another 16 facial surgeries.

2016
   
2017
 

MAY

Health and Disability Commission issue a scathing report on Waitemata DHB.

2018

December

Peter’s initial five-year life expectancy is up.

 

Actually, Peter’s case wasn’t so unusual: Waitemata told the HDC the average wait time in 2013 for Priority 1 cases for non-melanoma skin cancers was 121 days. That September appointment was actually the first one available to Peter.

So they knew wait times were long, but didn’t warn Peter. The HDC’s specialist reviewer, Dr Iwona Stolarek, wrote that it wasn’t clear what “risk mitigation had been undertaken”.

And while Waitemata claimed they had reviewed their system, Stolarek found they still operated a “largely manual process” which while improved, was still “at risk of human error from noisy environments, distractions and interruptions etc.” Waitemata now deny they were still operating a paper-based system when Stolarek visited.

The HDC’s report is scathing: it notes that Waitemata had no electronic alerts, no way of tracking referrals, no way for GPs to access the system; that Tagelagi’s second referral was never logged. (Here’s a link to that report; some of it has been redacted and Peter is referred to as Mr A.)

“There’s a whole lot of hypocrisy and contradiction in there, I know that,” says Peter.

Peter has never counted that first letter from Brant as a formal apology, probably because most of it was actually about the investigation into Waitemata’s failings. Peter met with some Waitemata officials in 2017 (they say they apologised again then too), but the apology that he counts is the one which arrived in May 2018, the apology which the HDC instructed Waitemata to send.

That apology from Brant says Waitemata “fully accepted” the HDC findings and “deeply regret” what happened. The letter says they didn’t communicate the delay in treatment to Kroon and Tagelagi and assures him that lessons have been learned and we “have made significant improvements”.

Waitemata DHB was given ample opportunity to be interviewed for this story. Through a spokesman, they declined, instead offering to provide written answers to a series of questions from Stuff.  But they only sent a four paragraph statement, attributable to Brant, which said the DHB “deeply regret” Peter’s sub-standard care, accepted the HDC report entirely, had cut wait times for his type of cancer to 30 days and in March 2018, had moved to an entirely electronic system.

When it was pointed out they had ignored a series of key questions, seven days later Waitemata delivered a longer statement. That says if Peter turned up now, their systems would have picked him up and he would have been treated in a month. “We are deeply sorry to him and we will forever wish that delays in his initial treatment had not occurred.”

However, this statement still didn’t answer why Brant told Peter he was confident no further cases would occur, when in fact two did, why the DHB continue to maintain nobody was at fault for the mistake, whether they thought Dr Jenkins’ and oncologist Richard Martin’s observations of Peter were professional and respectful, and why they told Peter his care was a mistake and yet told the HDC he received the first possible appointment.

The HDC, however, has no power to issue punishments. The indefatigable Theo is redirecting his energy towards the Human Rights Commission, arguing Peter’s human rights have been breached, and thus should be compensated.

Peter is still irked that nobody has been blamed. “I was accountable for the thousands of roofs I installed, accountable to my clients, workers, the tax department. Who is accountable for me?”

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It was Christmas 2017 when Peter realised he was hooked on morphine. He lost his pills. “After three days, I realised I had a problem.”

The nerve pain had finally settled down, as the doctors said it would, but his body was still craving the morphine hit. “I knew I had a problem, I knew I had to get out of society.” His answer was the Anahata Yoga Retreat in Golden Bay, near Nelson. ACC wouldn’t fund his stay because it was not medically-ordered. But Peter went anyway, and kicked his morphine habit.

The yoga retreat seems to have had a long-term benefit. Each time we talk, conversations are punctuated by sniffs because the surgeries have ruined his sinuses. Peter gets angry about what has happened, but then he’s able to quell the anger and replace it with an icy calm.

He’s probably handling it better than most of us would. He doesn’t accept it though.

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We first met when I was working on a story about Auckland’s homeless. We saw Peter’s 1993 Toyota Citizen van parked up at Little Shoal Bay, on Auckland’s North Shore, looking across at the lights on the Harbour Bridge. Yes, he said, swinging down from the cab, he had a story, if we had time to listen to it.

Peter now lives in that van, which shuttles between friends’ driveways and public car parks around Auckland.

In one letter he sent to various officials last year, Peter wrote: “This is my last chance, if I was seeing you face to face, I would be on my hands and knees pleading ...”

In it, he set out his goal: “I long for my own small house in the North with a letterbox and to be a rate-paying citizen.”

This month, Peter’s five years are officially up. But MRI scans, so far, are showing no return of the cancer that was predicted to come back and consume him. So instead of dying, he’s started going to the gym, trying to rebuild the strength he once had, with plans in October to walk the length of New Zealand, along the Te Araroa Trail, to raise money for the Cancer Society, for his own health, “and for my own salvation, and for some inspiration, maybe, for others so they can overcome whatever has happened to them”. Oh, and he’ll have his phone with him, if anyone wants to call up and ask what he thinks of ACC.

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The man whose time is up


WORDS Steve Kilgallon | VISUALS Chris McKeen


DESIGN & LAYOUT Suyeon Son

EDITOR John Hartevelt