Findings from the coroner and the Health and Disability Commission (HDC) were released yesterday in relation to Rory Nairn, who died from myocarditis found by the coroner to have been directly caused by the Covid-19 vaccine on November 17, 2021. He was 26.
The coroner found the Dunedin man’s death could have been prevented had he received information about the risk of myocarditis.
Mr Nairn’s fiancee, Ashleigh Wilson, said the release of the decisions came with a mix of emotions, "including profound grief and a lot of anger towards a system that has failed its people".
Ms Wilson said she did not attribute blame to the pharmacist or pharmacy who administered the vaccination as it was common practice among pharmacies across New Zealand to not advise consumers of heart-related side effects.
"The pharmacy was simply following the practices and protocols set out by Ministry of Health, who unfortunately did not make clear the risks associated with the vaccination and that myocarditis could be a potential side effect.
"At the coronial inquest we saw no evidence from the official sources in any documents that stated myocarditis could be fatal and instead it was called ‘rare and in most cases mild’.
"The decision brings a small amount of closure. However, it is disappointing that no-one will be held accountable for such a needless death and Rory will be missed every day for the rest of our lives."
The incident occurred at the height of the Covid-19 pandemic and the rollout of the vaccine.
Mr Nairn received the vaccination on November 5, 2021.
After his vaccination at a pharmacy, he had chest discomfort and heart flutters, the HDC report said.
"Apparently unaware that myocarditis (inflammation of the heart) was a potentially serious side effect of the vaccine, the man experienced these symptoms for 12 days before making the decision to go to hospital. Tragically, he collapsed and died before he got there."
Health and Disability Commissioner Morag McDowell said the consumer was not informed about the risk of myocarditis either prior to receiving the vaccine (as part of the informed consent process) or after (as part of safety-netting advice).
She found that, "considering the potential seriousness of harm" and "notwithstanding the low probability of occurrence", the risk of myocarditis was something a reasonable consumer at the time would have expected to be informed about under Right 6(1) of the the Code of Health and Disability Services Consumers’ Rights (the Code).
The commissioner considered that Mr Nairn also should have been told to be alert to the symptoms of myocarditis as part of safety-netting advice. However, while the commissioner considered there was an apparent breach of Right 6(1), because the consumer had not been given this information, she did not find a breach of the Code.
She considered that there were significant mitigating factors in this case, including that "official information sources did not make it adequately clear to vaccinators that consumers needed to be told about myocarditis prior to receiving the vaccination".
"In the commissioner’s view, lessons can be learned from this case about the fundamental importance, in the context of new vaccines and emerging risks, of explicit guidance to vaccinators about what information they must give to consumers," the report said.
Coroner Sue Johnson said in her findings that by the time Mr Nairn was vaccinated, "myocarditis was known to be a side effect of the vaccine".
Health New Zealand Te Whatu Ora (HNZ) Southern had known since June 2021 myocarditis was a potential reaction to the vaccine.
On June 9, 2021, it had produced a document with a heading, Safety Information "alert communication" about myocarditis.
This was a monitoring communication providing information to customers receiving the vaccine as well as vaccinators. It advised there were recent potential safety concerns.
Ms Johnson said the person who administered the vaccine told the inquest there had been material received "through a number of sources" detailing that risk of myocarditis, but also said that they were "not aware of any requirement to specifically discuss that with a customer on or before November 5, 2021".
Ms Johnson agreed with the HDC’s recommendations, which included that HNZ must update operating guidelines to clarify when providers should discuss the risks of myocarditis and report the update back to the commissioner within three months.
The Royal Commission on Covid-19 will also be forwarded a copy to enable it to consider having one centralised portal for information to be sent to health workers.
