An amendment to this notice was published on 30 March 2017, Issue No. 35, Notice No. 2017-go1513.

Notice Type
Notice Title

Establishment of the Government Inquiry into Havelock North Drinking-Water

Pursuant to section 6(3) of the Inquiries Act 2013, I, The Honourable Christopher Finlayson, Attorney-General, hereby establish the Government Inquiry into Havelock North Drinking-Water (“Inquiry”).


The following persons are appointed to be members of the Inquiry:

  • The Honourable Justice Lynton Laurence Stevens, qc (chairperson);
  • Dr Karen Olive Poutasi, cnzm (member); and
  • Anthony Edwin Wilson (member).

Terms of Reference

Background and Matter of Public Importance

On or about 12 August 2016 Hastings District Council and the Hawke’s Bay District Health Board became aware of a widespread situation of gastroenteritis in Havelock North. Due to the nature of the outbreak and the receipt of an initial “positive presence” test for E. coli in the water supply, suspicion fell on the Havelock North water supply. Subsequent analysis confirmed the presence of E. coli in the water supply, and sample testing through the health system led Council and District Health Board staff to suspect that Campylobacter was the primary infectious agent.

As of 21 August 2016, there had been 168 confirmed cases and 355 suspected cases of campylobacteriosis, with current estimates suggesting that approximately 4,500 people have been affected. The length of the incubation period (up to ten days) and secondary spread mean that further cases are still being reported despite chlorination of the tap and tanker-provided water, and the ongoing advice to boil tap water. Gastrointestinal illness caused by microorganisms with longer incubation periods (eg cryptosporidiosis, giardiasis) may also start to be reported. In addition, about 1% of people with campylobacteriosis (approximately 40 people) may develop reactive arthritis and 0.1% may develop Guillain-Barré Syndrome (approximately three to six people). The testing of the Havelock North bores continues to show faecal contamination and the District Council is considering the options for restoring a safe supply of drinking-water to Havelock North.

Drinking-water supplies across New Zealand rely on different methods of take and treatment, depending on the nature and security of the water source. Drinking-water supplies are regulated under the Health Act 1956 and the source of drinking-water is regulated under the Resource Management Act 1991 and National Environmental Standards for sources of drinking-water. The National Environmental Standards are given effect to by the Hawke’s Bay Regional Council. New Zealanders expect that water reticulated to their homes and businesses for drinking purposes will be safe to consume and use. The Havelock North water contamination incident risks damaging public confidence in local drinking-water supplies.

This Inquiry is about determining the cause of the current contamination in Havelock North, whether relevant parties complied with their obligations, how local and central government agencies responded to the public health situation that occurred as a result of the contamination, and how to prevent future such occurrences.

The Inquiry will also consider the potential for similar situations to occur in other New Zealand water supplies and the lessons for local and central government agencies with relevant responsibilities, including whether the regulatory regime is operating effectively.

Appointment and Order of Reference

This Inquiry will inquire into and report (making recommendations that the Inquiry considers fit) upon the following:

Inquire into how the Havelock North water supply system became contaminated, how this was subsequently addressed, how local and central government agencies responded to the public health outbreak that occurred as a result of the contamination and how to reduce the risk of outbreaks of this nature recurring.

In relation to this incident of contamination of water at Havelock North in August 2016, to inquire into:

  1. the causes of this incident including, but not limited to, engineering, catchment and infrastructure management, containment and process management, aquifer management, district and regional consenting processes, and monitoring and enforcement activities;
  2. the timing and adequacy of steps taken by the Hastings District Council, the Hawke’s Bay District Health Board and any other party, with regard to testing and diagnostics, reporting, public communication and ensuring a safe water supply in the short and long term;
  3. the practices used at each stage, from identifying that a contaminant was present, through to (and inclusive of) the response and recovery stages of the public health incident, including, but not limited to, timeliness, adequacy, effectiveness, coordination and information sharing, readiness of systems, and triggers for action;
  4. the response by central government agencies and the adequacy of support provided by them at the local level;
  5. the actions that should be taken in response to any identified and confirmed contamination source, and actions to ensure a safe water supply can be provided to Havelock North;
  6. practices and strategies to ensure the prevention of future such occurrences;
  7. the implementation of contingency plans for responding to water contamination and public health outbreak incidents by the relevant agencies;
  8. any lessons and improvements that can be made more broadly in the management of the water supply network in Havelock North and/or more broadly across New Zealand;
  9. the regulatory regimes under which various agencies operate and any lessons and improvements that can be made to local and central government systems or practices to expedite and deal effectively with the identification of public health outbreaks; and
  10. any improvements that can be made in any future response to emergency events of this nature.

Matters Upon or for Which Recommendations are Required

The Inquiry will report on and make any recommendations it considers fit on:

  1. The cause(s) of the Havelock North outbreak and whether any person or organisation was at fault or failed to meet required standards;
  2. the adequacy and appropriateness of responses by all relevant parties to the outbreak;
  3. the adequacy of the management of drinking-water supplies for Havelock North, the implementation of drinking-water standards, contingency planning, preparedness and the responses of local and central government agencies;
  4. any legal or regulatory changes or additions necessary and desirable to prevent or minimise similar incidents;
  5. any changes or additions to operational practices for monitoring, testing, reporting on and management of drinking-water supplies, implementation of drinking-water standards, contingency planning and responses by local and central government, to address the lessons from this incident; and
  6. any other matter which the Inquiry believes may promote the safety of drinking-water and/or prevent the recurrence of similar incidents.

Exclusions From Inquiry and Scope of Recommendations

The Inquiry is not to inquire into, determine, or report in an interim or final way, or otherwise prejudice any of the following matters:

  1. Subject to sections 11(1) and 11(2) of the Inquiries Act 2013, questions of civil, criminal, or disciplinary liability;
  2. the structural arrangements for local government; or
  3. issues relating to water, aquifer and catchment management which are unrelated to the contamination of specific sources of drinking-water supplied to Havelock North.

Other Investigations May be Considered by the Inquiry

The Inquiry may take account of the outcome of any other investigations into these matters undertaken by local or central government agencies, but is not bound in any way by the conclusions or recommendations of any such investigation.


Operational ‘Practice/s’ or ‘arrangements’ include, without limitation, each of the following:

  • Decision-making;
  • capability and capacity;
  • procedures;
  • processes;
  • services; and
  • systems.

Reporting Sequence

The Inquiry is to report findings and opinions, together with recommendations, required and otherwise, that it considers fit to make in respect of them, to the Attorney-General in writing no later than 31 March 2017.

Consideration of Evidence

The Inquiry may begin considering evidence on and from 15 September 2016.

Dated at Wellington this 12th day of September 2016.