Thursday, January 10, 2008

Two developments and a bit of a ranting..

Just after Christmas I received two Documents from an Internal Inquiry done by Royal North Shore into my husband's treatment and death. I had received the draft just before Christmas but withheld it from the girls because of its content and of how angry their explanation of some of the issues made me. I wanted them to have a certain peace of mind for Christmas.We all felt very angry with the tone of their reply and their explaining away many issues which caused Don further suffering.I have prepared along with the girls, a response to these documents but am not happy about sending it to RNSH for the time being.

Also I was phoned by the Coroner's office after Christmas and they are now seeking all original records from RNSH, PMBH and Dr Stewart.

I forwarded RNSH's two documents and our response to the Coroner's office, to the Health Care Complaint's Unit and also engaged my solicitor to approach a friend of hers who was Cardiothoracic and a Barrister and am hoping that she will prepare a detailed report for us from all the notes etc. I am not happy about having to begin action against RNSH, because it all becomes about money. Its not about the money. Its about making all those connected accountable as with any unexplained death. So am hanging back hoping that the Health Care Complaints Unit and the Coroner's office will have the guts to do what should be done.

The issues they admit to are shocking such as instead of draining Don's lungs with a 3KPA pressure a "transcription" error...(their words) meant that his lungs were drained at 31KPA for almost 24 hours before a nurse noticed. The original mistake was made in theatre and no one spotted it for all that time.

They admit that Cardio thoracic "assumed" Don had already been seen by a Cardio Thoracic specialist in port Macquarie...that assumption which no doctor should make we believe cost Don his life, but not till he lingered for five weeks.
They seem unable to comprehend the seriousness of what they are admitting such as,

that there was no Comprehensive care plan. A Comprehensive Care plan should have been mandatory between Spinal and Cardio Thoracic. Why and how was this neglected?Why did Cardio Thoracic (CTH) assume Don had seen a CTH specialist in Port Macquarie? There is no notation towards that. It is unprofessional, unscientific and negligent when dealing with life and death issues to assume such things. How did they arrive at this false and ungrounded assumption? When did they assume that Don had had the Pleurodesis discussed with him in Port Macquarie? There is no notation of this discussion in PMBH’s notes. Why was there no full assessment by Spinal Specialists and Cardiothoracic specialists pre operatively? To not do this on someone, anyone, but someone with Don’s complications and considering the dangers of failed Pleurodesis is negligence. RNSH Inquiry says, “It would have been wise” That is offensive to us, Don’s family but to him most of all. pg2) Why did the treating team at RNSH think Don was under the care of a thoracic surgeon? Where is this information? Why would they assume further thoracic review was not required when Don had seen NO thoracic specialist? The AMA and hospitals must have some mandatory rules they are meant to follow in this way.

The RNSH Cardio Thoracic specialist had not met Don until in Theatre it appears. He had no hands on knowledge of his real situation re health pre operatively. He was the first Cardio Thoracic specialist to actually see Don apart from the brief signing of the consent form by Dr H, if that’s what he is. What quality of surgeon or specialist would do non emergency surgery on any patient at all, but especially one with all the problems Don had, without making sure that a checklist of mandatory steps were followed and in place. To not do so is negligent and shows a lack of duty of care. How could a team of trained specialist EVER assume that further thoracic review wasn't required? Why would they presume their work was already done for them by some fictitious thoracic specialist? One would think that they would value human life and do the right and mandatory preoperative tests required to properly and safely treat their patients.

Why were Don and I not told about the mistake made in theatre and continued in Spinal concerning the suction of Don’s lungs? The suction was ordered to be at 3 KPA (Kilopascals) but because as RNSH claims a transcription error by theatre staff meant that Don’s lungs were suctioned at 31 KPA for almost 24 hours till the next morning when a nurse in Spinal at 8am discovered the mistake? Surely the Specialist should have told us of this. Surely also he should have checked after surgery that all the systems were correct and being done properly. The Specialist was cavalier in his disclosure to Don and I of what had happened. I am under the understanding that doctors should provide full disclosure to patients and or their next of kin and that this is a legal responsibility. This almost never happened in RNSH.
It is outrageous to think that the KPA could have been misread so hugely. Could this have cause lungs collapse as is recorded? Fluid to build up more rapidly? ARDS? (pg4) We were never told during Don’s whole time about the condition of his lungs at the time of admittance to ICU. Why not?

Why were Cardiothoracic unable to see the signs of impending Respiratory Arrest and Acute Respiratory Distress Syndrome?

Why did the Spinal Intern “assume” Don’s agitation was due to hypoxia?

There are many many more mistakes reported in their response.

What I am left with as are no doubt my daughters and sister, are constant flashbacks. I feel I have three levels of seeing at present. What I see in front of me… the world etc., what my mind’s eye turns on for me concerning my husband’s extreme prolonged and dreadful suffering and what was between me and my lovely husband…the thirty five years of good things. Right now the images from RNSH seem to predominate.

The list of serious mistakes made in Royal North Shore is pages long and they admit these mistakes but gloss over them by saying they "assume" or they "hope" or that these could appear unacceptable. The tone of their response was one of the most disgusting bureaucratic cover up report I have ever read in my life and I have read a few, due to things Don and I were involved in.

I'm not venting here, just explaining where we are up to and I don't take a back seat when it comes to issues like these. The big problem I see is that more and more people refuse to see and accept any responsibility for any action they do or don't take and our systems and bureaucracies are masters of this sick mindset.

Its this sort of mindset which calls bombing and killing civilians "collateral Damage" go straight to hell for that thinking is my way of thinking because people who do that are fucked as far as I;m concerned.
They can kill and mutilate and imprison and go home to their homes with a smile on their faces truly believing they have done a good days work and that pisses me off.

Ah well it did turn into a rant but it sure feels good at the end of it.

You know the sad thing is what these bastards take away id not just what appears to be a human being or animal or whatever. They remove from life a spirit which was nurtured and gave love and was loved. The other night I remembered how just in the middle of the night Don who often couldn't sleep because of the pain would sense i was awake and just quietly I would hear a soft "I love you" across the pillow...or he would start singing a little song for me... how can you allow someone with that much love in his heart to be killed the way he was without fighting for justice? People assume I am doing it so no one else cops the same...that will be a nice side effect, but like anyone who is killed, I have the duty and right to try to obtain justice for a wrongful death. I consider Don's death Na negligent manslaughter, the same as if I was driving a car drunk and killed someone.

But because it happened in hospital its up to the relatives to do what the police should do. That'd fuck some of those arrogant doctors up if the police could be called in by relatives...

Why not? Their mistakes kill people and if they are honest mistakes not so bad but when there is a culture which supports negligence and covers it up...they should go to bloody jail.

They take away the eyeshine, the smile, the special things that are individual to each of us because we are human.

Run out of steam now... : )


rosemary said...

Your last words say it all...taking away eyeshine, smiles and special human things.

Ann O'Dyne said...

"I'm not venting here, just explaining"

fer chrissakes VENT away - you certainly have just cause to.

I would want to track down and torture The Erroneous Transcriber.
track down the person who blithely followed '31' without thinking first
"gee that's a bit unusual ..."
fer fkssake.

Here is why you should hammer the hell out of them all;

If somebody who suffered one of their earlier errors had done so, you would not have had to endure the continuing incompetancy.

It is frightening to think that Australia probably has the best general health care in the world.

Sara said...

"...and just quietly I would hear a soft "I love you" across the pillow..."

that made me tear up a little, MC. You're sure lucky to have had such a wonderful person in your life and of course I can see why you're fighting for justice.

And like Ann said, vent away! Sheesh, it's not like anyone is going to think you're whining or anything!

Citymouse said...

let it out woman!!!!

Middle Child said...

Rosemary... as Cazzie said in a later comment for a later post... the eyes are important... but its the spirit which lights the eyes which is all.

Ann O'Dyne Thanks for that, your comments inspired me to send a letter explaining exactly what I thought about RNSHospitals horrible excuse for an Inquiry. That letter has reopened part of an investigation by the Health care Comp;aints Commission that they were about to wrap up...
Sara... I was so lucky... and there was nothing femmy about him... he was a fella which is what makes the singing and comments nicer.. there was nothing puking and soft about him except in his compassion for others.
But he could never watch an animal movie without crying actually especially about dogs.
City Mouse - thanks I have

Ian said...

I read your posts of your husband's and family's torture by NSW Health and RNSH (and your submission to the inquiry last year). Its one thing to read these things on the news but your story really personalises just how bad things really are. I have to say the failings you wrote about (and in the Vanessa Anderson case which is where I found your blog from)are not simply procedural or systemic failures, or lack of resources or similar ... there seems to be a hell of a lot of people, doctors, nurses and others in Health, who couldn't give a rat's arse. The lack of care, and screwups you describe, don't get fixed by yet another inquiry or half baked arse covering excercise by NSW Health and the government. In fact, these things should see many people being removed from anything to do with health care, including doctors, nurses, managers, director-generals and ministers ... many people need to lose their jobs over this. There is a place for second chances, forgiveness and the like, but I think that there are plenty in the health system that deserve no further chances, and deserve to be punished - to bring some sort of justice to their victims.

Middle Child said...

Ian... I agre totally with you... I'd like to be able to get a big cudgel and deliver half the pain they caused my husband...then send them all to hell...thats how strong I feel about it. I feel they should all be prosecuted.

its all a big joke, the endless enquiries etc etc...waste of time money etc... what happened to my husband has without a doubt happened many times since he died,,,and caused by the same people....makes me bloody sick.. will trawl by your blog soon... have a squizzy