By Shannon Pitman, Open Justice multimedia journalist, Whangārei of 
The inquiry highlighted a critical symptom oversight in the phone call to a Healthline nurse. Photo: Unsplash/ Thom
When Anthony Gooderidge called Healthline for advice while suffering excruciating back pain he was incorrectly told to self-care at home.
The next day his neighbour found the 77-year-old dead in his bed.
Now a coroner has found that even though there were flaws in the advice given by the national health phone service, prompt medical attention may not have been able to save his life anyway.
In a recently released decision, Coroner Heidi Wrigley said Gooderidge began experiencing severe back pain, cold sweats and vomiting on 27 August, 2022.
Earlier that day the Foxton retiree sent a friend a text message saying he was "crook". She called him and gave him Healthline's number after he said he could not move and had an excruciating pain going up his back.
At around 11am, he called Healthline and spoke with a registered nurse for nine minutes. During that time he described his symptoms and when questioned about his pain, advised it was the worst he had ever experienced.
The nurse advised him to continue caring for himself at home but if his back pain got worse despite medication and he started to get weakness in his limbs or numbness or tingling or difficulty passing urine, his situation would become "urgent". If that didn't happen she advised him to contact his doctor after the weekend if he was still concerned.
Gooderidge rang his friend back soon after and said he had spoken to a nurse who told him to call back on Monday if he was any worse.
But, he never made it through the weekend, with the Coroner finding he possibly died within a few hours of the call.
Forensic pathologist, Dr Amy Spark determined Gooderidge died from an aortic dissection, a serious condition where a tear occurs in the inner layer of the aorta, the large blood vessel branching off the heart. The condition can be fatal if not treated promptly.
Coroner Wrigley focused her findings on the conversation between Gooderidge and the Healthline nurse and acknowledged the nurse's advice was based on the symptoms Gooderidge reported at the time of the call.
However, the nurse did not input the critical symptom of upper back pain into the clinical decision support tool Odyssey, which ultimately failed to recognise aortic dissection as a possibility.
Dr Matt Wright, clinical lead for urgent care at Whakarongorau Aotearoa New Zealand Telehealth Services, reviewed the call and acknowledged the nurse's focus on the lower back pain symptoms, which resulted in an incorrect assessment.
He noted that if the upper back pain and associated symptoms had been considered, Odyssey would have recommended immediate medical attention.
Although the coroner found the advice given by the Healthline nurse was incorrect, she concluded it was uncertain whether the correct advice would have saved Gooderidge's life.
"I am not satisfied that, even if Mr Gooderidge had been advised to seek prompt medical attention during his call to Healthline, his life would have been saved. Mr Gooderidge may have died regardless of the advice he was given."
However, the inquiry prompted improvements in Healthline's training and procedures of Odyssey.
New training materials now emphasise the importance of recognising symptoms of aortic dissection, such as thoracic back pain and severe, sudden pain.
Healthline clinicians are also being trained to maintain a high level of suspicion when callers report experiencing the worst pain of their lives, even if the pain has subsided by the time of the call.
Wright also collaborated with the developers of Odyssey to enhance the tool's ability to distinguish between different types of pain onset and to consider the progression of symptoms.
No formal recommendations were made under the Coroners Act and the coroner determined the incorrect advice did not contribute to Gooderidge's death.
"Despite this, I observe that this inquiry has, hopefully, resulted in initiatives that may assist in more accurate clinical assessments by Healthline clinicians of callers experiencing symptoms associated with aortic dissection and the associated provision of more accurate advice, which could save lives."
Healthline did not respond to a request for comment.
* This story originally appeared in the New Zealand Herald.
Photo: Open Justice
