Still no inquiry action into decades of death

Hospital death shocks family

Lack of information: Taiene Takitaki is one of thousands of Cook Islanders to have a relative die a sudden and unexplained death at Rarotonga Hospital. A 2003 promise from the coroner to investigate all such deaths has never been upheld. 
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by Jason Brown, Editor, Avaiki Nius Agency

. . .

Over 13 years ago, a young man made tragic history for his homeland. 

John Atuatika died in the Rarotonga hospital in February 2002, a week after a suicide attempt. He initially recovered but became agitated and was restrained. After his death, his family spoke out about many unexplained issues they had with his treatment. In particular, a report from one of his nurses that there was particulate matter in a urine sample. 

Those two words stay with me to today - "particulate matter".

Vivid lagoon

Young John was a neighbour at my mother's home in Titikaveka, overlooking their family home, overlooking the vivid turquoise of Vaima'anga lagoon. My mother was overseas, but friends were visiting, including former nursing legend, Ina Powell, and her husband William. We heard screams and turned down the music to see what was going on. Rushed down when we realised something awful was going on. 

John had gotten a bit drunk, had an argument with a family member, got so angry that, like so many murders and suicides, he likely suffered a temporary insanity. Can happen to anyone, given the right stress.

Over the weeks following his death, I spoke with John's father, Atua Atuatika and his brothers, girlfriend, nurses, doctors, and downloaded pages from the internet on all the drugs that were used in his treatment, and we pieced together a picture that pointed to adverse reaction to drugs, and severe dehydration.  

That was the particulate matter - he was so dehydrated his organs were breaking down and emptying through his bladder. But not according to the New Zealand pathologist who ignored that evidence in his report, decreeing brain damage as the likely cause of his death.

Inquiry promise

At the time, we comforted ourselves, the families in both homes, that we had caused a major controversy, including the first ever exhumation for a proper autopsy. That the coroner at the time promised there would be a proper inquiry into every sudden death at Rarotonga Hospital.

That was 13 years ago, and since then not one inquiry has ever been held to this day.

The memory of Atuatika and that promise from the coroner often comes back, when I meet someone from home and they tell me about another death at Rarotonga Hospital. One was Ngahuinga Teaurere, a woman who came home for a wedding and died within days from a severe cold. Looking through my email I see that I forwarded a story prompt to Cook Islands News.

Remembering her

The misspelling in the story (above) caused a small moment of humour for the shocked family, who were further dismayed by a lack of official action after she died suddenly, having been sent home, twice, by an onduty doctor. 

"I remember her," says a family member looking over my shoulder at the story on my screen this morning.

"She had hair down to here," he says, indicating his calf. 


Now Teaurere is just another memory, one of the many dying without question over the decades at Rarotonga Hospital, resisting multiple inquiries, investigations and even police prosecutions. The code of silence survives.

Reported Cook Islands News:

“When she was in a coma, what I don’t understand is one doctor said ‘she is getting better slowly’. Then another doctor said ‘if she comes out of it it’s a miracle’. Why are they saying different things?” said Taiene Takitaki. The family are upset at the lack of information given to them during Teurere’s hospitalisation. Takitaki said they want a report done into what treatment was given and how it got so bad she died. The family wanted to speak out to make sure changes are made at the hospital.“We’re not just doing this for us. We’re doing it for everyone who has to go through this,” said Takitaki.”


So many people have said that kind of thing, so many times over so many years.

Today, barely half a dozen mentions of deaths like Atuatika and Teaurere remain online. Their sacrifice is forgotten, and lessons remain unlearnt. There are no official reports, and now the government does not even bother to hold inquiries anymore. This haunts me still. 

Both Democratic Party and Cook Islands Party are equally, shamefully, responsible for this continued whitewashing of hospital deaths at Rarotonga Hospital. So too most of the police force, who fail to investigate criminal negligence, right under their nose. The only time deaths are investigated by a coroner is outside the hospital, when foul play is suspected.


One thing that has improved is the level of reporting from the ministry of Health, whose audited accounts for last year are already online. Along with a current strategy plan! However there are no references to any issues relating to Rarotonga hospital, aside from renovating accident and emergency, and relocating the pharmacy. The only other study with health data is one relating to domestic violence.

No reference to the 2011 NZ aid-funded review that called for the ministry to link "its planning more clearly to identified needs and priorities as shown in Cook Islands morbidity and mortality data and the objectives of the Cook Islands Health Strategy."

A 2012 review by WHO, the World Health Organisation, refers, stealthily, to the "effects of political influence," and "policy inconsistency". 

10% target

To be fair, the strategy does refer to a target of 10% decrease in morbidity - lethal disease - from lifestyle illness, and an unspecified reduction in sudden deaths from accidents.

It also refers to  "increasing cases of ... attempted suicide and suicide cases."

The strategy states that the "majority of youth suicides are as a result of a relationship issue, between peers and between youth and parents."


This may be so, but I also remember the young man who was bullied for hours at the police station. He was denied legal representation, or the presence of any family or friends, and physically interrogated; verbally and mentally abused by as many as six intimidating cops. 

The young man was in such a state of trauma and shock that when they finally let him go, he drove down to the Nikao petrol station near Parliament, poured petrol over himself straight from the pump, then set himself alight. 

He died too, a week later. No investigation, no inquiry.

Public pressure

Meanwhile, back in strategy land, there is no clear acknowledgement of any problems, or how big they might be, just a bland assurance that problems will be reduced. 

We can't solve problems pretending there are none. 

Public pressure is the only thing that will force governments to admit to health problems and bring lasting reform to Cook Islands health systems. The lack of public pressure is partly due to news media, for failing to consistently follow up on such important stories. How do I know this? More suspicion, really.  


The owners of the daily paper routinely ignore my emails, including one I sent asking if I could do a follow up on Atuatika. 

The owners of the other main media group are dominated by a family that still face ethics issues, with many reported instances of conflicts of interest, historic and existing. Overall, Cook Islands news media suffer credibility issues, at home and across the region. Meantime, I am persona non grata within the very 'industry' where I started created my career. 

The sadder thing is, so are my stories. For the kind of debate we need to have about reforming the health system, we have to go all the way back to 1911.


Yet Atua Atuatika proved you can move mountains when you have faith. I still remember feeling astonished at the bravery, and persistence, of a father. Few families are as dogged as news hound when they get the scent - most people just want to grieve quietly, privately. Not this baker.

He kept pushing. And got results - a historic autopsy. Others could too. But they do not. There must be dozens of sudden death cases that have gone without proper review, investigation or inquiry. Perhaps hundreds by now. Even family of those whose deaths are straightforward wait months, years, for a death certificate.

For that, I also blame myself, for not pushing harder, for not writing on the anniversary of his death, for not being able to stay brave, and to persist.

. . .