A coroner has found “systemic and individual failures” and treatment that “collectively fell below the expected standard of care” led to the death of a Kaikōura toddler. 

Everly Anne Dunfoy died at the town’s after-hours medical clinic on April 5, 2019. 

She was coughing, wheezing and struggling to breathe. By 8.53am the little girl was pronounced dead. 

Until today the full details of Everly’s death could not be reported. 

Now that investigations by the Health and Disability Commissioner and coroner are complete, Everly’s final hours and the mistakes made by medical professionals in the lead-up to her death can be made public. 

The investigations revealed “systemic and individual failures” in Everly’s case, and treatment that “collectively fell below the expected standard of care”. 

“Everly would have turned 9 in June,” her mother, Pip told, the Herald. 

“Everly was a beautiful and lovely little daughter and sibling. She loved spending time at the beach with family and friends. 

“She lit up the room and our lives. We miss her smile and her presence deeply. 

“We hope that no other family will have to suffer with the heartache and grief we endure.” 

Everly’s last hours 

On March 12, 2019, Everly was diagnosed with a “viral induced wheeze” and prescribed an inhaler to relieve her symptoms. 

On April 4 her mother took her to Kaikōura Health, the local after-hours clinic, as her cough had returned. 

Everly was treated for an exacerbation of asthma and discharged about one hour later. 

Everly was initially prescribed an inhaler similar to this when her mother took her to the doctor. 

At 6.50am Dunfoy took Everly back to the clinic after speaking to Dr Alexander Corbett, who was on call. 

Everly had “distressed breathing” and she was medicated via a nebuliser - a machine that converts medication into a fine mist so it can be breathed in through a mask. 

Dr Corbett arrived at 7am, and his impression was that Everly had “severe asthma” that was not settling. 

He decided to administer Everly adrenaline via the nebuliser. 

“While Everly was being given the nebuliser with adrenaline she became acutely agitated, her skin turned a blueish-purple colour and she stopped breathing,” said Coroner Ruth Thomas. 

“She had a convulsion and then became unresponsive. Staff activated the emergency button and mouth-to-mouth resuscitation commenced” 

Chest compressions and further doses of adrenalin were also administered. 

“After one and a half hours the decision was made to cease resuscitation and Everly was declared deceased at 8.53am,” the coroner said. 

Why did Everly Dunfoy die? 

Following a post-mortem examination pathologist Dr Martin Sage established Everly died from bronchial asthma, which complicated a bout of “severe trachea-bronchitis” brought on by a respiratory infection. 

The virus that caused that infection could not be identified. 

Everly's mother appreciated every effort to save the little girl but said the response was panicked and fumbled. 

The pathologist noted that deaths from asthma alone at Everly’s age were “very rare”. 

After Everly died her mother made a complaint to the Health and Disability Commissioner, saying she felt “no one took charge” as her daughter’s condition deteriorated. 

And, while she appreciated “every second of effort” medical staff put in, their response was “fumbling and panicked”. 

“And organisation ... was definitely not up to what I feel is of New Zealand hospital standard,” Pip Dunfoy said. 

Inadequacies, systems and individual issues in Everly’s care 

Coroner Thomas was provided with the commissioner’s final report, completed in 2022 and the findings of a Serious Event Review . 

“The Serious Event Review made a series of findings about system issues that impacted the care provided to Everly,” she explained. 

Everly was rushed to her local after-hours medical clinic. She died there two hours later. Photo / File 

“These findings related to training of the nurses and doctors and ongoing education and training needs particularly with paediatric emergencies. 

“The review also made findings about the inadequacy of the environment, equipment, organisation, and management issues at the facility. 

“Nineteen recommendations were made to improve the quality of systems that guide the care of patients at Kaikōura Health.” 

Coroner Thomas said the commissioner concluded that there were “systemic failures in the care provided to Everly, that collectively fell below the expected standard of care”. 

The commissioner listed a number of issues that occurred throughout efforts to resuscitate Everly. 

These included the incorrect rate of chest compressions to breaths for the first 30 minutes of CPR and the use of thumbs for the compressions instead of the heel of one hand which is usual practice for a child of Everly’s age. 

The wall oxygen at the clinic was not working - but staff forgot this and attempted to use it. 

There were “issues with communication” when help from other centres was sought. 

And, five doses of adrenaline were administered to Everly after her collapse at a level that was almost six times the appropriate dose for her weight. 

The commissioner found those issues to be a breach of the Code of Health and Disability Services Consumers’ Rights. 

“The commissioner also found the actions of Dr Corbett, amounted to a breach,” Coroner Thomas said 

“The commissioner issued a number of recommendations to be implemented by Te Whatu Ora Waitaha Canterbury and by Kaikōura Health Care Limited, and some specific recommendations for Dr Corbett. 

“The commissioner’s recommendations also required confirmation that all the Serious Event Review recommendations had been completed.” 

Coroner Thomas received confirmation that all of the recommendations had been completed and implemented. 

Further, she said, the Medical Council of New Zealand also reviewed the details of the case and changes Corbett had made to his practice and “significant” further training he had completed. 

He had also written a letter of apology to the Dunfoy family. 

“The Medical Council decided a competence review was not warranted, and instead provided an educational letter to Dr Corbett,” said Coroner Thomas. 

“I offer my sincere condolences to Everly’s family, and I apologise for the delay in concluding this inquiry.” 

‘This has been tough’ - Everly’s mum speaks 

Pip Dunfoy told the Herald she was pleased to finally be able to speak about what happened to little Everly. 

Her family had waited five years for accountability and she was “pleased” the process was now behind them. 

“To be able to comment on the finding ... this has been tough but something I am pleased to be able to voice after all these years on behalf of our family and for our beautiful dear girl,” she said. 

“Among a catalogue of errors on Everly’s third visit to Kaikōura Health, the seriousness of her deteriorating clinical picture was repeatedly missed and misunderstood. 

“On top of individual mistakes - the fragmented information environment, lack of skill, knowledge and team coordination as well as the systemic problems that aligned for numerous errors inside the medical centre that day. 

“Everly lost her life. She was nearly 4.” 

Dunfoy hoped the recommendations made during the investigations into Everly’s death would prevent other children suffering the same fate. 

“We can only hope that changes will be fully implemented, remembered and respected by all that treat and care for anyone in the medical setting, especially for the vulnerable paediatric patient,” she said. 

“I believe staff especially in a rural GP setting should feel confident in themselves and where they work - keep up to date in emergency care and know their surrounds - and be supported to provide safe and appropriate care in acute, stressful emergency situations.” 

Everly’s family had been through a lot of emotions since her death and were trying to move forward. 

“After dealing with the inquiry over the years, we have come to a place where blame and anger is destructive to our family and intuitively pointless,” she said. 

Anna Leask is a Christchurch-based reporter who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 18 years with a particular focus on family violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast, A Moment In Crime, released monthly on nzherald.co.nz