Section One: Introduction and Context
Part 1 - Overview, key findings and highlights


[1] Safe drinking water is crucial to public health. The outbreak of gastroenteritis in Havelock North in August 2016 shook public confidence in this fundamental service. Some 5,500 of the town’s 14,000 residents were estimated to have become ill with campylobacteriosis. Some 45 were subsequently hospitalised. It is possible that the outbreak contributed to three deaths, and an unknown number of residents continue to suffer health complications.

[2] The August 2016 outbreak was traced to contamination of the drinking water supplied by two bores in Brookvale Road, on the outskirts of Havelock North. This raised serious questions about the safety and security of New Zealand’s drinking water.

[3] Accordingly, in September 2016, the Government established this Inquiry into the outbreak. The Inquiry has proceeded in two stages. This report, on Stage 1 of the Inquiry, focuses on identifying what happened, what caused the outbreak, and assessing the conduct of those responsible for providing safe drinking water to Havelock North. Stage 2 of the Inquiry will address lessons learned for the future and steps to be implemented to reduce the likelihood of such an outbreak occurring again.


[4] Hastings District Council (“District Council") supplies drinking water to consumers in Havelock North. The drinking water is sourced from an aquifer under the Heretaunga Plains (the Te Mata aquifer). The Te Mata aquifer was thought to be a confined aquifer and the water secure from contaminants and, as such, the District Council did not treat water drawn from it. Brookvale Road bores 1 and 2 were used to access the water from the aquifer and to pump it into the reticulation system, through which it was delivered to consumers.

[5] To be deemed safe, the drinking water needed to meet the requirements of the Drinking-water Standards for New Zealand 2005 (revised 2008) (“Drinking-water Standards”). Drinking-water Assessors (“DWAs”) worked with the District Council to monitor compliance with those standards and to ensure the safety of drinking water.

[6] But, as this Inquiry has shown, meeting the Drinking-water Standards was only part of the story. Where the water source was an aquifer, the delivery of safe drinking water to consumers was dependent on the security of the source from contaminants. It was also dependent upon the water supplier being aware of and managing the risks of contamination of the water supply, and competent local authority administration of the broader resource management regime.

[7] This Inquiry has found that several of the parties with responsibility for the water supply regime for Havelock North (in particular the District Council, DWAs and Hawke’s Bay Regional Council (“Regional Council”)) failed to adhere to the high levels of care and diligence necessary to protect public health and to avoid outbreaks of serious illness. A higher standard of care needed to be embraced, akin to that applied in the fields of medicine and aviation where the consequences of a failure could similarly be illness, injury or death.

[8] The failings by those with responsibility for a safe water supply are summarised in the key findings section below. The Inquiry has found that none of the faults, omissions or breaches of standards directly caused the outbreak. However, had all or any of these failures not occurred, a different outcome may have resulted. It is generally accepted by those responsible for these failings that greater diligence and co-operation is needed to ensure that a much higher standard of care is reached, and soon.

[9] Responses to the August 2016 outbreak were generally well handled, particularly by the Hawke’s Bay District Health Board (“District Health Board”). There were, however, significant gaps in readiness, such as the District Council's lack of an Emergency Response Plan, draft boil water notices, and up-to-date contact lists for vulnerable individuals, schools, and childcare centres.

Key Findings

[10] The Inquiry has made the following key findings:

(a) Contaminated drinking water was the source of the campylobacter bacterium that caused the gastrointestinal illness campylobacteriosis among Havelock North residents in August 2016. Sheep faeces were the likely source of the campylobacter.

(b) It is highly likely that heavy rain inundated paddocks neighbouring Brookvale Road causing contaminated water to flow into a pond about 90 metres from Brookvale Road bore 1. On 5 and 6 August 2016, water in the pond entered the aquifer and flowed across to Brookvale Road bore 1 where the bore pump drew contaminated water through the bore and into the reticulation system.

(c) Contamination may also have occurred when water from neighbouring paddocks entered roadside drains adjacent to Brookvale Road bores 1 and/or 2 and then entered the bore chambers. lf sufficient water had entered the chambers, it could have risen to a level where it overtopped the bore head cable holes and, because the cable seals were loose, travelled down the cables into the water supply. This scenario is regarded as much less likely than travel from the pond to the bore via the aquifer, as described above.

(d) The failings, most notably by the Regional Council and the District Council, did not directly cause the outbreak, although a different outcome may have occurred in their absence.

(e) The Regional Council failed to meet its responsibilities, as set out in the Resource Management Act 1991 (“RMA”), to act as guardian of the aquifers under the Heretaunga Plains. Protection of the water source, in this case the aquifer, was the first and a critical step in the multi-barrier approach to ensuring safe drinking water.

(f) The Regional Council's knowledge and awareness of aquifer and catchment contamination risks near Brookvale Road fell below required standards. It failed to take specific and effective steps to assess the risks of contamination to the Te Mata aquifer near Brookvale Road and the attendant risks to drinking water-safety. This included through its resource consent processes; its management of the many uncapped or disused bores in the vicinity; its State of the Environment and resource consent monitoring work; and its liaison with the District Council.

(g) The Regional Council imposed a generic condition on the water take permits it granted to the District Council, related to the safe and serviceable state of the Brookvale Road bores. This condition failed to meet the necessary standard. It then failed adequately to monitor compliance with the conditions of the permits.

(h) The District Council did not embrace or implement the high standard of care required of a public drinking-water supplier, particularly in light of its experience of a similar outbreak in 1998, and the significant history of transgressions (positive E.coli test results). As a consequence, it made key omissions, including in its assessment of risks to the drinking water supply, and it breached the Drinking-water Standards.

(i) The District Council's failings applied especially to its mid-level managers, who delegated tasks but did not adequately supervise or ensure their implementation. This caused unacceptable delays to the preparation of a Water Safety Plan, which was fundamental in addressing the risks of an outbreak of this nature.

(j) The District Council did not properly manage the maintenance of plant equipment or keep records of that work; and it carried out little or no supervision of necessary follow-up work. Specifically, it was slow to obtain a report on bore head security, a key plank in source water security, and it did not promptly carry out recommended improvements.

(k) There was a critical lack of collaboration and liaison between the Regional Council and the District Council. The strained nature of this relationship, together with an absence of regular and meaningful cooperation, resulted in a number of missed opportunities that may have prevented the outbreak.

(l) The DWAs were too hands-off in applying the Drinking-water Standards. They should have been stricter in ensuring the District Council complied with its responsibilities, such as having an Emergency Response Plan and meeting the responsibilities of its Water Safety Plans.

(m) The DWAs failed to press the District Council sufficiently about the lack of risk assessment, analysis of key aquifer catchment risks, including the link between the Brookvale Road bores and the nearby pond, and a meaningful working relationship between it and the Regional Council. They also failed to require a deeper and more holistic investigation into the unusually high rate of transgressions in the Havelock North and Hastings reticulation systems.

(n) Contingency planning by the District Council was lacking. The District Council had no Contingency Plan (referred to in various contexts also as draft boil notices, or an Emergency Response Plan), water communications plans at the ready.

(o) Consultancy firm MWH New Zealand Ltd (“MWH”), a technical adviser to the District Council, failed competently to assess and report on the security of the bore heads of Brookvale Road bores 1 and 2.


[11] Five key highlights emerged from Stage 1 of the Inquiry, which are usefully outlined before turning to the substantive sections of the report.

1998 Outbreak

[12] The Inquiry has found that the August 2016 outbreak was not Havelock North's first experience of drinking water contamination and that the lessons that should have been learned from an earlier contamination had been forgotten.

[13] In July 1998 the town had an outbreak of campylobacteriosis. Sampling of two of the Brookvale Road bores showed campylobacter in the bore heads. This was the same location that would feature in the August 2016 outbreak. An independent report by Stu Clark (“1998 Clark Report”) concluded that the two bores were a possible source of the campylobacteriosis, and that the likely point of entry for contaminated surface water was a leaking power supply cable gland.(1) The Clark Report raised doubts about the confined status of the Te Mata aquifer from which the bores drew water.(2) It recommended testing the aquifer to establish whether it was confined, along with measures to ensure the security of both bore heads.

[14] Regrettably, while the two outbreaks shared remarkable similarities, it appears nothing was learned from the July 1998 outbreak. The District Council, as the water supplier, did not take the 1998 outbreak seriously enough and implement enduring, systemic changes. Memory of the earlier outbreak simply faded.

Aquifer Not Confined

[15] The Inquiry has found that the Te Mata aquifer, from which the Brookvale Road bores drew water, was vulnerable to contamination. The aquifer was not confined (as was assumed prior to the |nquiry's process). At best. it might have been characterised as “semi-confined”, meaning its water was subject to surface influences and was vulnerable to penetrations of its rather thin and variable confining layer.

[16] The Inquiry found that near the Brookvale Road bores, the aquifer had been penetrated by a significant number of disused or uncapped bores, leaving it vulnerable to entry from contaminated water. Additionally, the confining layer (or aquitard) near Brookvale Road bore 3 had been affected by earthworks at the neighbouring Te Mata Mushrooms property, leaving it vulnerable to entry by contaminated water.

[17] The Te Mata aquifer is also no longer a source of aged water. meaning it is not a secure source of drinking water.(3)

[18] These facts have critical implications in terms of the compliance of the water supply with the Drinking-water Standards. The |nquiry’s finding of a likely direct causal link between the pond and entry of contaminated water into the Havelock North drinking water system does not detract from these concerns. Until the security of the water source and the bores can be assured (and that may never happen), in the Inquiry’s view, treatment of the water in Havelock North and Hastings is the only option.

High Transgression History

[19] The Inquiry has found that in recent years the Havelock North water supply had a relatively high number of positive E.coli readings, or “transgressions”. The Hastings supply has also had a high number of positive E.coli readings. The Hastings water supply is drawn from nine bores at five locations in Hastings and Flaxmere. These bores also draw from part of the Heretaunga Plains aquifer system. There is a known “unconfined aquifer zone” close to Portsmouth and Wilson roads. Recent positive E.coli readings from the Hastings bores have resulted in a downgraded bore status for most Hastings bores under the Drinking-water Standards. This in turn has required chlorination of the Hastings supply.

[20] The Inquiry has found that the District Council tended to underestimate the significance of positive E.coli results. It sometimes ended treatment of water before clearly establishing the contamination source. While such an approach (after three subsequent clear test readings) technically meets the Drinking-water Standards, a more rigorous approach was needed with public safety at stake.

Poor Working Relationships

[21] The Inquiry has found that the Regional Council and the District Council did not work effectively and constructively together. This was at variance with the Ministry of Health’s Guidelines for Drinking-water Quality Management for New Zealand (“Drinking-water Guidelines”), which required “maximum interaction and mutual support between the various stakeholders”. Indeed, it is fair to say the relationship between the two local authorities before August 2016 was dysfunctional.

[22] While the lack of collaboration may not have contributed directly to the outbreak, at the very least it resulted in a number of missed opportunities. The uptake of such opportunities might well have prevented the outbreak.

[23] The relationship between the two Councils deteriorated further when, following the 2016 outbreak, the Regional Council began investigating the District Council's Brookvale Road bores. Subsequently, the Regional Council filed a criminal prosecution against the District Council on 18 November 2016, which led to a lengthy delay in the lnquiry’s work. In the lnquiry’s view, such a proceeding was ill-advised and ought never to have been launched.

[24] On the evidence the Inquiry heard, the prosecution, based on proof to the criminal standard, was bound to fail. It was eventually dropped and replaced with two infringement notices. The money the Regional Council spent investigating the case, reportedly $450,000, could have been more wisely applied to gaining a better understanding of the status of the aquifers beneath the Heretaunga Plains.

[25] The two authorities were subsequently induced to partner with the District Health Board and the DWAs to form a Joint Working Group focused on providing clean, safe drinking water for Havelock North and Hastings. This group, guided by recommendations from the lnquiry’s interim measures hearing in December 2016. is making promising progress under an independent Chair. Its reports and action plans are available on the Inquiry website. Much work, however, remains to be done.

[26] The Joint Working Group’s mandate and progress will be dealt with in Stage 2 when the Inquiry examines systemic issues and makes recommendations about managing water supply nationally. This approach may provide a blueprint for collaboration elsewhere. No structural or legislative changes are needed for the Group’s operation, although the question of whether a regulatory framework should be developed will be part of the next stage.

Protozoa Risk

[28] The Inquiry has learned that a number of the major outbreaks of waterborne illness overseas have involved cryptosporidiosis, for example Westem Georgia in 1987, Milwaukee in 1993, and Northern Ireland in 2002. Waterborne protozoa outbreaks have also occurred in New Zealand in Masterton in 2003; the Waikato District in 1997; and the Tauranga District in 1995. Giardia outbreaks have been recorded in Deniston in 1996, Auckland in 1993, and Dunedin in 1991. A table of waterborne outbreaks is at Appendix 7 (page 192).

[29] Some managers at the District Council in the present case seemed to have little or no knowledge about protozoan pathogens and the significant risks associated with them. Gaining an awareness of, and education about, such risks (and how they might be identified at an early stage) will be an important part of Stage 2. The Annual Report on Drinking-water Quality 2015-2016(4) states that achievement of protozoal standards was at a level of only 82 per cent across the whole population covered by the report. While this represented a 2 per cent improvement over the previous year, protozoal achievement is still well below optimum.

[30] The risks associated with waterborne diseases in New Zealand are well recognised. The Drinking-water Guidelines emphasise that “untreated drinking water contaminated with pathogens presents a significant risk to human health". Such risk suggests it is vital that this time lessons must be permanently learned from the Havelock North campylobacteriosis outbreak.


1. Stu Clark “Hastings District Council Water Supply Contamination Investigation’’ (13 September 1998).  This report is document CB048 of the “Core Bundle of Documents" and is accessible on the Inquiry website (

2. A confined aquifer is protected by a layer or layers of impermeable material.

3. A report in August 2016 by GNS found water from three of the bores in the area (Omahu and Wilson roads in Hastings and Brookvale Road bore 1 in Havelock North) contained water less than a year old: GNS “Groundwater Residence Time Assessment of Hastings District Council Water Supply Wells in the Context of the Drinking-water Standards for New Zealand” (2016) (CB081).

4. CB192.

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