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This report, on Stage 2 of the Inquiry into the outbreak of gastroenteritis in Havelock North in August 2016, focuses on: improvement of the safety of drinking water in New Zealand;  lessons to be learned from the Havelock North outbreak;  and changes  which should be made to achieve those goals.


The Inquiry is satisfied that New Zealand’s drinking water strategy must be informed, at all times, by an appreciation of the ubiquitous nature of the risks to drinking water and the seriousness of the consequences of failing to supply safe drinking water. The existence of these risks and the severity of their consequences provide a significant part of the social policy justification for the necessary regulatory regime.

The Inquiry’s investigations during the Stage 2 phase have demonstrated that the problems revealed in the Stage 1 Report in relation to HDC’s supply of drinking water to the residents of Havelock North are not confined to that region. Water suppliers in other parts of New Zealand exhibit the same or similar problems. The Ministry of Health’s annual reports on Drinking Water over the past five years have shown that many suppliers are not compliant with the DWSNZ.

These findings point to a widespread systemic failure among water suppliers to meet the high standards required for the supply of safe drinking water to the public. The industry has demonstrated that it is not capable of itself improving when the standards are not met.

Neither has the Ministry of Health, the government body charged with administering the provisions of the Health Act governing drinking water, shown an ability to call the industry to account.

There is currently no adequate or effective enforcement of the statutory obligations on water suppliers. The DWAs are under-resourced and have not been able to discharge their statutory responsibilities. The important tool of a WSP, as used by water suppliers and monitored and enforced by DWAs, has proven ineffective to ensure ownership by water suppliers of the risks around the delivery of safe drinking water to the public.

In short, the administration of the present system of regulation does not ensure that water suppliers comply with the law and the DWSNZ. The Ministry of Health is incapable of doing so, for the reasons explained in this report. Accordingly, far-reaching recommendations have been made by the Inquiry in Parts 23 and 24. The 233 key recommendations are for the treatment of all supplies and the setting up of a dedicated drinking water regulator.

Many of the recommendations require urgent or early implementation. In the meantime, the current drinking water team within the Ministry of Health should be dismantled and replaced by a Drinking Water Regulation Establishment Unit. Pending such changes, the Ministry of Health should, through the DWAs and Medical Officers of Health, take immediate steps to enforce the current law in the hope the recalcitrant water suppliers will be called to account before it is too late to prevent another outbreak of waterborne disease.

The Inquiry has found that the drinking water industry has over at least a five year period experienced problems on multiple levels. These include source protection, drinking water suppliers, difficulties attracting qualified and experienced staff, the Ministry of Health drinking water team, lack of leadership, and the regulatory environment. All of these problems have combined to produce a lack of public awareness of the changes over recent years to the risks resulting from unsafe water.

The Inquiry believes its recommendations should enable these problems to be addressed in a manner that best secures the safety of drinking water for all New Zealanders.

For a final word in this Stage 2 Report, the Inquiry has chosen to refer to the importance of the multi-barrier protection of drinking water (Principle 3 in Part 2). A reference to multiple barriers appropriately includes the requirement to treat all drinking water in the interests of protecting the health of all New Zealanders. Hence the inclusion of recommendation (20) in Part 24. In support, the Inquiry cites the recent observations of Dr Hrudey. Speaking of his own country of Canada, he said:

British Columbia, the western most province is more like [New Zealand], there are a lot of untreated water supplies and it is basically rolling the dice. It is not a question of if somebody will get sick; it is just a question of when and how many.

Publication Details


Publication place:
Auckland, New Zealand
Publication Year: