Something In The Water.

August 12, 2015. A day like any other at Hastings District Council, but for an email. Chief executive Ross McLeod was sitting in his office when he was informed key staff members had to get to the District Health Board for a meeting – there was something in the water.

Sophie Price02 December 2016


“Good Afternoon. This is just to give you all an update on a developing issue we [are] just becoming aware of,” the DHB’s Maree Rohleder said in a 12.53pm email. The issue was that the HDC had alerted the DHB to a positive E.coli test, and public health services were reporting “many diarrhoea and vomiting cases” presented overnight. “Please note we are still very much in the preliminary stages of the investigation and have not made any firm associations,” she wrote.

Before the 3pm meeting, McLeod informed Hastings Mayor Lawrence Yule of the “public health alert” and said the DHB had asked the HDC to take water samples in Havelock North and potentially chlorinate. “We do not know yet whether there is any problem with the water supply. Staff are working on the issue with urgency. Will advise when we know more.”

At 3pm the staff were sitting in the meeting. By 5pm chlorine had hit the affected water supply. By 6.30pm the first press release (containing the boil water notice) went out. It missed the 6pm news cycle.

It was not until the following Saturday that it was confirmed that the water was the cause of whatever it was making people sick.

“Testing has confirmed the source of the gastro outbreak in Havelock North was water borne, but the type of bug is not yet known,” authorities said. “Hastings District Council chlorinated the water on Friday, August 12, afternoon. Chlorination is effective at killing most bugs, however Havelock North residents should boil water for one minute before drinking it until the type of bug is confirmed.”

By now the storm was raging. People were still getting sick, the authorities had no answers, except the bug’s name, and people still wanted to know why they weren’t told sooner.

By that stage a storm had broken out across the district. As each hour crept by, dozens more people reported with symptoms – the young, the elderly, the healthy. The illness did not discriminate.

The community may have started out as restless on Friday evening, but by the Saturday stressed anxious residents had turned to social media demanding answers from leaders who had little information on what was happening in Havelock North.

On the following Monday campylobacter was established as the cause of the outbreak which would eventually see 5,200 people crook with the bug, several suffer the latent effect of Guillain-Barré syndrome, and two, albeit with underlying health conditions, dead. By Monday afternoon, a horde of national media descended to shine a light on our province as we braved the weather.

The perfect storm
The storm was brewing long before August 12. An extended power outage. An extreme weather event. A false negative E.coli test. An increase in gastroenteritis cases not being reported, or at least linked to one another. A breakdown in communication.

It may have been all of these things; it may have been a combination of a few. While no definitive answers about the cause of the outbreak had been found at the time of this writing, one could sit back and rattle off everything that could go wrong. On Friday August 12, it did.

“Most likely there would have been a perfect storm of things that allowed this to happen,” Yule said. “A whole lot of little things have contributed. I suspect, there’ll be a number of factors that have led to this, and at the moment there is no obvious one leading to how it happened, what caused it. All we know is it was campylobacter in the bore.”


The infamous Brookvale bores… at the centre of ‘whodunit’ mystery

By now the storm was raging. People were still getting sick, the authorities had no answers, except the bug’s name, and people still wanted to know why they weren’t told sooner. There was no real answer so all authorities could do was update the community, and the country, on what they were doing to address the problem. Reassure them that the council had followed its Water Safety Plan.

“It [the plan] was effective, that’s the point. It was followed. Most of our emergency planning is not around water contamination; it’s about the loss of water in the event of an earthquake or fire. It has never really been thought about to plan for a contamination event.”

He said an updated one would look at the contamination of water, beyond the physical loss.

Meanwhile, the much maligned communications were muddied further by false reports that the council knew sooner than it did, with one Hastings councillor citing a six-month-old newspaper report on a national breakfast show as his source of information. And then a test from a tanker which was meant to provide safe water for the village came back positive for E.coli. It turned out to be a false positive, but it rubbed raw on the already frayed nerves of the community.

Meanwhile, the much maligned communications were muddied further by false reports that the council knew sooner than it did, with one Hastings councillor citing a six-month-old newspaper report on a national breakfast show as his source of information.

Havelock North, the once vibrant village, had come to a standstill. Students were held back from school, cafes had closed, and people were finding reasons not to go to the village. The week cost local business in excess of $80,000 in trade, not to mention what was lost in overheads.

“It has been really damaging to Havelock North,” Yule said. “Havelock North’s a fantastic place. Vibrant, quirky, got great people.” He said the village had taken the biggest hit in terms of reputation, then Hastings. “There has been some damage done.”

Public meetings were staged, press conferences held and still no one knew how the bug got into the water supply and why it wasn’t known about earlier. So the Government, who had been relatively quiet on the situation so far, stepped in on August 18 and announced an independent inquiry into the crisis.

Water sleuths
In making the announcement Health Minister Jonathan Coleman said government wanted “a clear understanding of what has happened in Havelock North, as well as any learnings from the situation.” So Hastings Council set about gathering the required information for such an investigation.

One week later, the HBRC followed suit, a single misplaced document triggering the regional authority’s action.

“We are writing to notify you that the Hawke’s Bay Regional Council is undertaking an investigation of the Brookvale bores to determine whether they comply with the relevant resource consents and conditions granted by the HBRC,” regional chief executive Liz Lambert wrote in a letter to McLeod on August 25.

The regional council was “very concerned” that that its district counterpart had withheld a document reporting ‘young water’ in the bores, which indicated the bores might be in breach of the consent. “The HBRC is also concerned about other information it has gathered supporting possible breaches,” Lambert wrote.

The HDC has said that the information just got missed, with McLeod saying at the time that the incident was very unfortunate; he didn’t think the ‘young water’ email said anything new.

So, as the HDC was preparing for the government inquiry, Lambert contacted McLeod and advised him of her council’s investigation. This was followed three minutes later by a formal letter to that effect and a national press release. Five minutes after that, HBRC-warranted staff stormed the HDC building to question district council officers on information needed for their investigation. It only added to the already stressed situation.

Outwardly calm, the Mayor said at the time that the HBRC was not the right authority to investigate the outbreak because it had a massive conflict.

“They are responsible for the aquifer and the quality of the groundwater and the issuing of all the consents. So how can they objectively test our bores when they have a vested interest in proving that it’s either us, or not them?” he told John Campbell at the time.

McLeod said the HBRC investigation showed the regional council was doing its job, that the bores had stood up in other investigations and he remained confident they would do so in this one.

However, questions have surfaced about the strong reaction HBRC had to the situation. Could it be because the regional council should have inspected the bores sooner, such as in May of this year?

Havelock North, the once vibrant village, had come to a standstill. Students were held back from school, cafes had closed, and people were finding reasons not to go to the village. The week cost local business in excess of $80,000 in trade, not to mention what was lost in overheads.

According to an email written by HBRC’s principal ground water scientist Dougall Gordon on December 24 last year, regional council staff detected E.coli levels of 120 Conly Forming Units (CFUs) per 100mL at their monitoring site 10496, located near the Brookvale bores.

Gordon informed the HDC that these levels were unusually high for this site. He said that the HBRC retested the site on December 14 and the levels were 20 CFUs per 100mL, which was still elevated but not totally unusual for the site overall as there had been a few elevated results in the past.

Moreover, Gordon reported that the chloride levels, another reliable chemical indicator of water contamination, at site 10496 were “a bit higher than normal” for the December 14 sampling compared to the time series data set. “Which suggests there is some contamination coming into the aquifer from somewhere in the vicinity of the site.”

He notified the HDC that the HBRC would take a closer look at the results early in the New Year, 2016, and would let them know if the HBRC came to any conclusions as to the possible cause.

The HBRC never did follow up with the HDC directly regarding these tests, despite having the authority to investigate under its consent issued to HDC for the Brookvale bores.

“Routine monitoring inspections will be undertaken by Council officers at a frequency of no more than once every year to check compliance with the conditions of the consent. Non-routine monitoring will be undertaken if there is cause to consider, for example following a complaint from the public, or routine monitoring that the consent holder is in breach of the conditions of this consent,” the consent reads.


A major storm event can overwhelm drains

The Resource Management Act states clearly that every person has a duty to avoid, remedy, or mitigate any adverse effect on the environment arising from an activity carried on by or on behalf of the person.

Service of notice of any review of the HDC consent made by the HBRC is to made “during the month of May of any year”.

In any event, Yule was clear that at this point there was no culpability being declared.

“We have as a council tried to do the right thing by people, on the basis that we provide the service that they pay for. But, I haven’t yet found anything that the council has done that would indicate culpability, or anybody else who’s done anything, that’s indicated culpability. I’m not saying that won’t happen ultimately … it’s part of the investigations.”

Treatment in store?
As time moved on, the thousands of people who were ill were getting better and were demanding to know what the authorities were doing now, beyond the inquiries, to ensure this would never happen again.

“In hindsight I’d say we could have done a little bit better, but it’s only a matter of a couple of hours, not anything more than that. I think we’ve learnt from that, and I take some of criticism on board, but it’s not as bad as what people say.” Hastings Mayor Lawrence Yule

HDC chief executive Ross McLeod says his staff worked around the clock to get Havelock North’s water supply safe again. Then it was on to preparing for not only the pending investigations, but how council are going to handle water for the village this coming summer.

“It is likely that over the summer period we may need to use the Brookvale bores again,” he says. To ensure the security of the water, he indicates a UV treatment system will be used in conjunction with cartridge filters and potentially chlorination.

And it is this last water treatment that the community have been most vocal about. As this report is written (October), the Havelock North and Hastings water supply is being chlorinated. This will continue for three months after the event, perhaps longer.

Long term Yule does not want the water supply chlorinated. “We have got some of the best water in the world. We have what’s called a ‘secure supply’. I want to find a way of keeping that source secure, making sure we minimise any future risk.” He advocates the use of UV technology and a daily testing regime.

McLeod notes that the council has turned off the Brookvale bores; if they were brought back online, he says he would not have the same level of confidence in the aquifer that he once had. “While there may be a problem with the bores that is contributing to this we are certainly suspicious now of the groundwater supply in that particular part of that aquifer.”

HDC asset manager Craig Thew, the man charged with the management of the HDC’s water reticulation system has a similar view. “If Brookvale comes on and stays on as a permanent facility, it will have the whole treatment that’s required as far as I’m concerned, despite whatever criteria there are in that field,” he says. Even if tests come back clear for a year, in his mind the source is no longer secure and so he would want to leave the chlorine in.

Thew says it is a discussion to be had with the community – to chlorinate or not.

“If chlorine gets added, this plan changes. If chlorine is not added, this plan will get some extra controls put in it: a running system without pre-chlorine has its risks.”

Meantime, ongoing testing of the water continues. “There is a lot of work currently going on in assisting with the investigations,” Thew says. “We are also doing our own investigation, looking at everything and making sure everybody was doing what they should have been doing.”

Longer term, Yule says HDC’s approach will be based on what is found over the course of the investigations. “If we find out that those bores are contaminated to the point that they cannot be used again, then we will have to look at other options from Hastings. That will mean a major new main line from Hastings into Havelock North and the obvious disruption and cost that that causes.”

However, future use of the Brookvale bores seems already a moot issue. HDC’s consents expire in 2018, and HBRC has previously signalled concerns that these bores are having an adverse impact on the nearby Mangateretere Stream, and indeed because of that effect HDC and Ngati Kahungunu had signed an agreement to shut the bores down.

Mathematician Morris Kline once wrote: “The most fertile source of insight is hindsight”. So what lessons have been learned by the HDC from this crisis?

McLeod says there may be things to be learned around whether or not the HDC needs a better early warning monitoring system; Yule expects a much more rigorous water testing regime will be required.

Says Yule: “If we’d known, if that actually had been tested daily, we might have picked it up on the Monday, and we would have minimised the amount of illness, because we would have chlorinated days ahead of when we did. The fact of the matter is … we were doing more than the New Zealand Drinking Water Standards require us to do, but I think those standards need to be beefed up, particularly in untreated supplies. If you haven’t got chlorine in your system, then the only way of minimising the risk, is to have a far greater level of testing.”

Turning to communications, which many have criticised, McLeod says: “There is definitely room for improvement in terms of what we do to get the message out to people, but in terms of health and the council responding it was virtually a seamless response.”

He compares the response in this crisis to that of Sydney’s cryptosporidium outbreak and the E.coli contamination in Walkerton, Canada.

In those two examples, the utilities’ providers actually tried to hide or hush up the fact that there was an outbreak or did things to obfuscate the situation, which then saw them fighting with the health authorities over what happened. The openness of HDC’s communications did not allow this to happen in this instance.

“I think in terms of an initial response and coordination between health and the council I don’t think you could have got much faster than that,” McLeod says.

Yule conceded that there were lessons to be learnt around the communications. He says the notification process could have come two hours earlier.

“In hindsight I’d say we could have done a little bit better, but it’s only a matter of a couple of hours, not anything more than that. I think we’ve learnt from that, and I take some of criticism on board, but it’s not as bad as what people say.”

Looking to the upcoming investigations, which will cost the HDC an estimated $300,000 (on top of the $410,000 compensation promised to affected Havelock North residents), Thew says, like everyone else, he just wants to find out what caused the outbreak, whatever the outcome is. He says there is every chance that a single cause may not be found, which will only make it harder because it leaves uncertainty.

“Whilst this is a massive and significant event, a horrible event that we have learnt from, we need to take a wider perspective on it because otherwise you can react to one thing and create another problem or forget about other things.”

At the end of it all, Thew just wants to find out what happened, an answer he hopes the concurrent investigations, currently being handled for HDC by Matthew Casey QC and barrister Asher Davidson, will provide.

“I want to find out, and my team want to find out, like everyone else. What exactly happened, how do we stop it ever happening again, none of us want that ever, ever, ever to happen again. So we’ll be there; we’ll front up, we’ll answer whatever we have to answer. And hopefully see things that come out that will help us help the industry, and help the country.”

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Sophie Price02 December 2016


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