We have accepted an enforceable undertaking from Hawke’s Bay District Health Board after an incident on 14 May 2018.


While being transported from Wellington Hospital to Hastings Hospital, in transit via Napier airport, the victim fell from a “lifter” on which he was seated. He suffered head injuries which were subsequently identified as a contributing to his death.

Alleged breach

Health and Safety at Work Act 2015, S 36(2), 48(1) and 48(2)(c).

The alleged contravention does not amount to an offence against section 47 (reckless conduct) which would preclude it from being accepted.

Summary of enforceable undertaking

  • Provide amends in the form of payment to the victim.
  • Appoint H&S champions.
  • Provide nurse hazard/risk training.
  • Undertake a H&S Management System review.
  • ISO45001:2018 accreditation.
  • Additional hazard ID and risk management training for flight team.
  • Appoint two full-time light nurses.
  • Appoint a clinical Nurse Manager (Flight).
  • Appoint a Medical Director (Flight).
  • Develop a Flight Nurse Handbook.
  • Purchase mechanical lifters to replace manual lifters.
  • Appoint a Load Masters/Crew.
  • Develop national patient transport plan/risk assessment standards.
  • Incident/outcomes paper.
  • A 6-Month Nurse placement (H&S in patient transport).
  • Provide St John First Aid support.
  • Purchase and distribute AEDs for the Hawkes Bay Community.

This enforceable undertaking has a total expenditure of at least $1,100,000.

Reasons for accepting the undertaking

The enforceable undertaking meets the requirements of WorkSafe’s Enforceable Undertakings Operational Policy (June 2019); noting:

  • The nature of the proposals in the application and the benefits that would be realised to the health and safety system from them: The activities in the enforceable undertaking will provide long-term sustainable health and safety improvements in the workplace; industry; and community.
  • The nature of the alleged contravention and how serious it was.
  • Information received from any interested party in relation to the contravention.
  • Mitigation and remedial action, already taken, or planned, regarding both the contravention and any person affected by the contravention (including victims).
  • The person’s past performance and history of compliance with health and safety legislation.
  • Any likely outcome if the matter were dealt with by legal proceedings.
    • A charge was filed in relation to this incident on the basis that there was both evidential sufficiency, and a public interest in initiating prosecution. A successful prosecution outcome may have resulted.
    • The undertaking accounts for the benefits that accrue to HBDHB by a prosecution not proceeding.
  • Any other matter which WorkSafe thinks is relevant.
    • The undertaking delivers benefits beyond compliance.
    • The undertaking supports WorkSafe’s strategic objectives.
    • The undertaking contains acceptable terms.

Date accepted

16 January 2020

Further information

View the full enforceable undertaking:

Enforceable undertaking — Hawkes Bay District Health Board (PDF 1.7 MB)
Enforceable undertaking variation 1 - Hawkes Bay District Health Board (PDF 160 KB)