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Lessons from NZ's 2016 Havelock North water supply outbreak

By N Roberts, J Graham and A Watson.

First published as an Ozwater'18 Conference Paper.



A waterborne disease outbreak occurred in the town of Havelock North in the Hawkes Bay region of the North Island of New Zealand in August 2016. 5500 of the town’s residents became ill with campylobacteriosis, 45 were subsequently hospitalised, and there was a possible contribution to four deaths. A public inquiry was established in September 2016 to firstly consider the causes of the outbreak and who was responsible, and secondly to recommend measures to prevent similar incidents in the future. The paper describes the setting up of the inquiry, the inquiry process and findings; and finally the likely sweeping changes anticipated for the regulatory framework for drinking water in New Zealand.


In August 2016 a waterborne disease outbreak of gastroenteritis occurred in the town of Havelock North in the Hawkes Bay region of the North Island of New Zealand. 5500 of the town’s 14,000 residents were estimated to have become ill with campylobacteriosis, and 45 subsequently hospitalised. It is possible that the outbreak contributed to four deaths, and a number continue to suffer health complications.

A public inquiry was established to firstly consider the causes of the outbreak and who was responsible (report published in May 2017), and secondly to recommend measures to prevent similar incidents in the future (report published in December 2017).

The paper describes the setting up of the inquiry, the inquiry process and findings; and finally the likely sweeping changes anticipated for the regulatory framework for drinking water in New Zealand.

[Because the government’s response to the second stage report public is not expected until the end of February 2018, this version of the paper is not able to include those details. By the time the final version of the paper is due, the government’s reaction should be known, and the likely direction of regulatory change will be clearer.]

Water supply organisational structure

The regulatory framework for drinking water in New Zealand is established under the Resource Management Act 1991 (RMA), the Local Government Act 2002 (LGA), and the Health Act 1956 (Health Act).

Each Act deals with different, but often overlapping, aspects of supplying drinking water.

The RMA is targeted at protecting the sources of drinking water and assigns primary responsibility for protecting these sources to regional councils through their prescribed functions under the Act and through a national environmental standard for protecting sources of human drinking water.

The LGA provides local authorities with mechanisms and responsibilities for protecting the needs of their communities in relation to the sourcing, treatment, and supply of drinking-water.

In the case of Havelock North, the supplier is the Hastings District Council (HDC). The regulatory framework for water supply is set out in the Health Act (which references the Drinking Water Standards for NZ (DWSNZ)), which is administered by the Ministry of Health (MoH). The assessment of compliance is undertaken by a Drinking Water Assessor (DWA) who is based in the District Health Board (DHB). The DHB in this case is the Hawkes Bay DHB (HBDHB).

The Regional Council responsible for the RMA in this region is the Hawkes Bay Regional Council (HBRC).

Outbreak event

Contaminated drinking water was the source of the campylobacteriosis outbreak in Havelock North in August 2016, with sheep faeces the likely source of the campylobacter. It is highly likely that the heavy rain that inundated paddocks neighbouring Brookvale Road caused contaminated water to flow into a pond about 90 metres from Brookvale Road bore 1. On 5 and 6 August 2016, this water entered the aquifer from which the Brookvale Road bore 1 abstracts, and the well pump conveyed the contamination into the reticulation. The first evidence of a substantial number of illness cases was on the morning of 12 August, and that coincided with the confirmed presence of E. coli in the bore water. That evening chlorination was implemented and the network fully flushed. A boil water notice was released at 6:40pm. Gastroenteritis cases continued at high levels until 17 August. By 25 August no further fresh cases were reported.

Public inquiry

In September 2016 the New Zealand government established an inquiry into the outbreak. The Inquiry Panel comprised three members: Hon Lynton Stevens QC, Dr Karen Poutasi CNZM, and Anthony Wilson ED.

Due to a high level of public interest in the matters being considered, the hearings were open to the public and held in the local district court. Early in the process it was decided to break the inquiry in to two stages.

Stage 1 of the Inquiry focused on identifying:

The cause(s) of the outbreak

  • Whether any person or organisation was at fault.
  • The adequacy and appropriateness of responses by all parties.
  • Prior to 12th August 2016, what was known, or should have reasonably been known, by all parties
  • Was the level of contingency planning for a contamination event appropriate?

The Stage 1 report was released in May 2017.

Stage 2 of the Inquiry was focused on the systemic issues with drinking water supplies, and measures that could be taken to reduce the likelihood of such an outbreak occurring again.

In order to provide focus for Stage 2 of the Inquiry, a list of issues and questions was published by the Inquiry Panel, and submissions invited. The issues included:

  • Drinking water partnerships and collaboration.
  • Drinking water safety and compliance levels in New Zealand.
  • Nature and extent of regional council's responsibility for drinking water.
  • Type and level of regulation of drinking water suppliers (e.g. Are systems needed for licensing, competency, training, etc.?). Should there be dedicated drinking water supply entities?
  • Are changes necessary to monitoring and testing, regulation of analytical laboratories, protozoa risk, secure groundwater, and wellheads and casings?
  • Regulatory framework – Health Act, DWSNZ,and supporting regulatory tools.
  • Outbreak management.

The report from Stage 2 was published in December 2017.

Government processes

The existing drinking water regulatory regime was introduced by an amendment to the 1956 Health Act in 2007 and updating of the DWSNZ in 2008. A feature of DWSNZ is that it allows for what is classified as “secure bore water” to not need treatment.

The Health Act and DWSNZ changes were phased in, based on supply size, with mandatory DWSNZ compliance albeit with the proviso of a need to take “all practical steps” to achieve this. The Health Act also made the preparation of a water safety plan mandatory for supplies serving more than 500 people. The government opposition at the time (the National Party) opposed the introduction of the regulatory regime, but an election in 2008 saw the National Party become the new Government. Sensitive to the political risks of stringently enforcing the new Act, the MoH advanced a “softly, softly” regulatory approach to the DHBs which resulted in an absence of any regulatory enforcement. While that approach may have been prudent in 2008, the question that has been raised by the inquiry is whether it should have continued until the present.

In September 2017 a general election returned to Government the party that had introduced the original regulatory regime in 2007 (Labour). The new Government has described itself as a Government of change and is now considering the far reaching and bold recommendations from the Inquiry.

While some of the recommendations from the inquiry can be quickly and easily implemented, the major changes will require new legislation, the establishment of new organisations and changes to the way in which regulation is carried out. They may also legislate for water suppliers to carry out actions that water suppliers (Councils) oppose (e.g. mandatory chlorination). If it chooses to do so, implementing the major recommendations from the Inquiry will take time and commitment from the new Government. But it highlights the rarely discussed role that central government politics can play in the delivery of safe drinking water to communities.

Stage 1 inquiry findings

The Stage 1 report was released in May 2017. It identified that HDC, HBRC and the DWAs failed to adhere to the high levels of diligence necessary to protect public health. No individuals were named, but a key finding was that “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”.

The HBRC failed to meet its responsibilities as set out in the Resource Management Act (RMA) as guardian of the aquifers. This was evident by the number of unknown, disused and uncapped bores in the immediate vicinity of the Brookvale road municipal bores; failure to inspect bores, and having a primarily quantity-focused consent monitoring regime rather than also including quality.

HDC did not embrace or implement the high standard of care required of a drinking-water supplier, particularly in light of its experience of a similar outbreak in the same supply in July 1998, and the history of positive E.coli results. As a consequence it made key omissions including its assessment of risks to the supply, and it breached the DWSNZ.

[Note that the supply has been assessed as compliant with the DWSNZ for the period covering the outbreak because the DWA incorrectly assessed the supply as compliant when it was not. In addition, over the 12 month compliance period, the very large number of E. coli samples taken in the distribution system has meant that the positive results became transgressions rather than non-compliances.]

HDC’s failings also included the maintenance practices of its bores; this includes bore head security reports, required by the DWSNZ and critical to the Water Safety Plan (a requirement of the Health Act). Inadequate Emergency Response Plans or contingency planning was also identified as a failing.

The DWAs failed to have a hands-on proactive approach to managing HDC’s drinking water compliance, and in particular HDC’s approach to managing the high number of transgressions in its supply zones.

The inquiry found that, as a whole, the incident was handled reasonably well by HBDHB and HDC, but a number of improvements were identified, including the need for a pre-prepared boil water notice that would have meant that the message to boil drinking water would potentially have reached consumers 2 hours earlier than it did.

One of the main recommendations in the Stage 1 report was the need for collaboration between parties. In particular it was noted that the relationship between HDC and HBRC before August 2016 was described as dysfunctional. As these two parties have vested interest in the first barrier of protection in a multi-barrier water supply system, (the first barrier being the protection of the water source) the need to have a constructive relationship to manage the issues is high and is even prescribed in various acts.

On the basis of this need to collaborate, Justice Stevens prior to the release of the Stage 1 report instructed HDC, HBRC and HBDHB to form a Joint Working Group (JWG) to discuss issues that could or were affecting the water supply. This included current and planned activities in the source water zones that have the potential to cause issues, as well as treatment and operational issues.

Later in the Stage 2 report recommendations, the need to form JWG’s was identified as a systemic issue that a number of other regions across New Zealand also need to action.

Stage 2 inquiry findings and recommendations

The Stage 2 report was released on 5 December 2017. This report was informed by a lot of research as well as a number of submissions responding to the 188 issues covering 24 categories raised by the counsel assisting the Inquiry Panel prior to the Stage 2 hearing in August 2017.

The inquiring hearing began with an expert panel convened by the Inquiry, discussing Dr Steve Hrudey’s six principles of water treatment (similar to those that form the basis of the Australian Drinking Water Guidelines):

  • Pathogens pose the greatest risk to drinking water safety, making pathogen removal and disinfection the paramount concern.
  • Robust and effective multiple barriers to suit the contamination challenges of the raw water source.
  • Trouble is usually proceeded by change.
  • Operators must be capable and responsive.
  • Drinking water professionals must be accountable to consumers.
  • Ensuring safety is an exercise in risk management, requiring sensible decisions in the face of uncertainty.

The report includes 51 recommendations, some of which are very bold. Of these, 19 are classified as “Urgent and Early”.

The recommendations include:

  • Minster of Health to remove the secure bore water status from the DWSNZ without consultation.
  • MoH and DHBs to encourage universal treatment of all water supplies until it is mandated.
  • Establish an independent water regulator. The regulator’s role should include licensing, required qualifications of water supply staff, standards, laboratories, samplers, compliance and enforcement.
  • Until the regulator is established the MoH and DWA should enforce the current requirements. It was noted during the Stage 2 Inquiry that the softly-softly regulatory approach of the MoH where no prosecutions or enforcement action was taken for failing to comply with the DWSNZ or Health Act, had not been successful in improving the standards of compliance over the last 10 years.
  • That the Resource Management Act is amended to recognise drinking water source protection and the review/rewriting of the National Environmental Standard for drinking water source protection be given a high priority.
  • Encourage the formation of JWGs until they are mandated by law.
  • 27 changes were recommended to the Health Act, some of these are:
    • Removing the reference to “all practicable steps”.
    • Create a standalone DrinkingWater Act.
    • Mandate water supplies to have at least one effective form of treatment, with very limited exemptions.
    • Establish a licensing system for suppliers.
  • Compliance with the DWSNZ should be mandatory. The DWSNZ should be reviewed by experts, with a few sections requiring urgent attention, i.e. secure bore water classification and remove presence/absence testing of E.coli to a quantitative test.
  • Other changes to the DWSNZ include the addition of advisory on when to issue boil water notices and assessing the requirement of treatment for plumbosolvency.
  • Review of the standard for drilling soil and rock (NZS 4411) should be carried out, covering the design, construction, as-built records, supervision, operation, inspection, maintenance, refurbishment/renewal and decommissioning of all bores that draw water from any groundwater source water intended for drinking or that penetrate the aquitard of any drinking water catchment. No new wellheads should be constructed below ground.
  • The inclusion of Critical Control Points (CCP) in Water Safety Plans (WSP) is a strong recommendation with a suggested implementation by 23rd February 2018. A CCP is a short 1 page description of a critical process identifying thresholds for certain key water quality parameters along with duration, actions that need to be taken and who is responsible for carrying out those actions.
  • A gap in both how laboratories are added to, and removed from, the water supply register has been identified during this inquiry along with a gap in training people in the collection of samples. There are a number of recommendations to improve this area.
  • A mandatory qualification system that addresses the different disciplines involved in water supply and provides for qualifications, experience and continued professional development. Water New Zealand has started a consultative project to support this recommendation.
  • Recommendation for dedicated drinking water suppliers. Although structural changes to local government were not included in the terms of reference of the Inquiry, the terms of reference did include the consideration of any changes in the management of drinking water across New Zealand. On the basis of this, the report strongly recommended a further review of various models that could be adopted for water supply as there is clear evidence that increasing the size of a water supply entity provides the critical mass that results in higher levels of competency, resources, compliance, efficiency, and etc. These things then lead to improved public health outcomes.
  • The Stage 2 report also recommends that the Auditor General audits the implementation of its recommendations over the next 5 years.

Throughout the Stage 2 report there is a strong message about the need for leadership, timeliness and action. It will be interesting to see what recommendations central government decides to accept and how quickly they are implemented.

Regulatory framework changes

While New Zealand was an early adopter of providing treatment for protozoa and a leader in the development of water safety plans, and our standards are well regarded internationally, this was not enough to prevent a major outbreak.

A number of problems, which put New Zealand water supplies at an unacceptable risk were identified by the Inquiry. Some the major problems are:

  • Poor DWSNZ compliance rates.
  • An unacceptable level of complacency across the industry.
  • A serious lack of leadership within the industry.
  • Use of untreated groundwater for municipal drinking water supplies.
  • Inadequate resourcing of regulators and water suppliers.

Perhaps the most far reaching recommendation from the Inquiry is to establish a single national regulatory organisation. Currently, responsibility for regulation of drinking water supplies rests with the MoH who contract out the provision of regulatory services to 12 different DHBs. Regulation is not core business for DHBs. The main functions of the DHBs are the provision of health services including hospitals and mental health facilities. DWAs perform a range of functions in addition to drinking water regulation; including border protection, enforcing smoke-free legislation and communicable disease investigations. There are currently 34 DWAs working on drinking water regulation part time. The Inquiry was advised of a need for 45 full time DWAs.

The inquiry recommendation for a single drinking water regulator is seen as going some way to resolving the leadership question. The Stage 2 report identified that leadership encompasses a range of roles including thought leadership, strategic planning, coordination of agencies, promoting collaboration between agencies, publishing updates of templates and guidelines, maintaining centres of expertise, providing data, reports and updates on various industry indicators, pursuing research, overseeing and providing guidance in relation to compliance and enforcement, maintaining links with international bodies and keeping abreast of international practice, and assessing and, where desirable, promoting changes.

This would be the role of the new regulatory organisation, but additionally it would be provided with a mandate to issue compliance orders and take prosecutions where water suppliers were not actively trying to meet regulatory requirements. It is envisioned that creation of such an organisation would improve DWSNZ compliance rates to more acceptable levels.

Additionally, if treatment was to become mandatory and the secure bore water criteria removed from the DWSNZ, it is considered that a strong organisation would be needed to enforce these provisions against potential resistance from some water suppliers.

The recommendation from the inquiry was to extend the functions of the new regulator from assessing compliance of water suppliers to some oversight of laboratories, sampling, licensing of water suppliers, certification of operators and oversight of education and training within the industry.

It goes without saying that such an organisation would need to be well resourced and staffed by highly competent people in a range of disciplines. But such a regulator would not be able to successfully perform these functions in a vacuum and the support of the wider industry to the idea and establishment of such a regulator would be essential to it achieving the outcomes desired.


The public inquiry into the 2016 waterborne disease outbreak in Havelock North in New Zealand, in which 40% of the town became ill, has identified failings, most notably by the water supplier, the environmental regulator and the drinking water regulator. The Inquiry’s final recommendations are bold and far-reaching. These include changes to the regulatory framework (DWSNZ, Health Act, and RMA), the introduction of a new regulator, a licensing system for suppliers and their staff, and investigation of the aggregation of small water suppliers to form larger water supply entities.

In hindsight, the Havelock North supply should not have been assessed as compliant with DWSNZ at the time the outbreak occurred – most significantly the groundwater source and wellheads were not actually “secure”. The event itself would not have happened if HDC had applied the necessary duty of care (as well as other players such as HBRC and the DWA). Despite this, the Inquiry has found many faults with the DWSNZ and recommended that the concept of secure groundwater (use of groundwater without treatment) should be abandoned.

While it is very unfortunate that poor performance by a number of local agencies led to the event itself, and that it has in turn led to significant disruption to the entire water industry, it has uncovered a number of systemic issues in the New Zealand approach to ensuring drinking water safety. We consider that the event represents a once-in-a-generation opportunity to improve New Zealand’s regulatory framework and supporting systems for drinking water.

Given New Zealand’s new Coalition (including Labour) Government’s reform agenda and the demands this will place on its finances, it will be very interesting to see over the next month or so how many of the Inquiry’s recommendations will be adopted and implemented.


To those people who died as a result of the Havelock North campylobacteriosis outbreak, those that fell ill, and those continuing to suffer long term consequences.

Ozwater is the Australian Water Association's annual international water conference and exhibition which takes place in alternating cities each May. To find out more, visit the Ozwater website.


Government Inquiry into Havelock North Drinking Water, 2017. Report of the Havelock North Drinking
Water Inquiry: Stage 1. May 2017.
Government Inquiry into Havelock North Drinking Water, 2017. Report of the Havelock North Drinking
Water Inquiry: Stage 2. December 2017.


DHB - District Health Board
DWA - Drinking Water Assessor
DWSNZ - Drinking Water Standards for NZ 2008
HA (also Health Act) - Health Act 1956.
HBDHB - Hawkes Bay District Health Board
HBRC - Hawkes Bay Regional Council
HDC - Hastings District Council
JWG - Joint Working Group
LGA - Local Government Act 2002
MoH - Ministry of Health
RMA - Resource Management Act 1991