Reply from the coroner's office

Yesterday I received a covering letter from the Coroner’s Office accompanied with a medical report. I had been told by their office late 24 April, that Don’s issue was to be held over till 5/6/09 after being told it would be originally November 08, Jan 09, April 09…

So therefore the letter and report received today were a surprise, considering the stamped date by the Coroner’s office on the medical report was 3/2/09 meaning that they held onto that report till now, and have done nothing since.

The report done by a Professor B addresses not one of the questions I raised, which caused the Coroner to reopen Don’s case in August 2008 . Prof. B has not even mentioned in passing this query my original query about the suction mistake made on my husband's lungs.

"It is going to be hard here to make it clear what happened to Don as it was not over in one evening, nor two, nor a week – it took five long awful weeks of suffering hell for him to finally be allowed to die from the dangerous, unnecessary surgery that was done on him; surgery which was performed on a very debilitated man with a lung capacity judged in our local hospital of over “one hundred years” with not one of the procedures normally done before surgery on anyone – then further botching when they sent him out of theatre with his suction level at 10 times the suction it should have been on and this was not noticed by cardiothoracic or spinal for 22 hours.

When it was noticed, what they should have done then was to increase their watch on him and watch his responses closely and tell us – but they then put him onto 6hr obs (which is criminal treatment for such a high level Quad on its own without anything else). It is likely that the lungs were already too damaged by the time the suction error (which he and I were never told about) was discovered to survive, but they then ignored the fact that his SATs (oxygen saturation levels) were all over the place – and quietened down or tried to our concerns by saying it was a post op reaction. In was most certainly not a post op reaction.

We were lied to about his SATs by nurses when we asked they just kept saying everything was normal. No one able to investigate seems to consider to the very real fact that they did the wrong thing at a doctor level and in Spinal. It appears that as long as they keep denying and sticking together there is little chance anyone can be called to account. They know we will wear out in time and need to take our time to grieve properly.

If my husband had been killed in a car accident, unintentionally and without negligence there would be an Inquest. If he had been killed unintentionally and with negligence then the person who did that would have a sentence or fine. If he had been killed by someone who aimed the car at him and drove straight at him relying on him to jump out of the road or for someone else put the brakes on, that’s about what I consider my husband’s death.

Those people in Cardiothoracic had the knowledge to go carefully with such a debilitated man, to check and double check, to at least do all the expected procedures beforehand. To be conservative in their treatment and to have some comprehension of what suction the lung should have been set on. That I warned them in Spinal for two days that he was in trouble breathing and that it was getting worse progressively and no one acted – what name can I call that?

If I had acted towards him as they did and so caused his death, I would be, as his wife and full time carer probably serving a jail sentence right now. I do not comprehend the difference. My negligence would be that of a layperson and the community would be up in arms about this.

How much more negligent were their actions. They acted with full knowledge of the lack of procedures neglected prior to surgery? The lack of a comprehensive care plan – because of his Quadriplegia, the lack of care after surgery which meant his lungs were suctioned at 10 times the level was covered up from he and I. Legally I would assume we should have been told everything which would affect the outcome. I could see what was happening to him but as a layperson had no idea that his bizarre breathing and a respiratory arrest would have a connection. I just knew he was suffering brutally and they all not only ignored my observations over a period of two days but they made it worse.

That a Cardiothoracic specialist told Spinal to sit my husband up in the wheelchair, going against all knowledge of Quadriplegic breathing and of post op Pleurodesis procedure beggars belief. They weren’t run off their feet in respect to my husband as I did most of the care while I was there in the day and the Spinal unit was partially empty. Sitting him up in the wheelchair they would have known as Specialists, was contraindicated for a man in such distress – but they wouldn’t admit that distress, neither would Spinal. Even when I begged the spinal nurse to help me get him back to bed, she refused and made us wait another two hours. That was plain and simple torture for him to endure and for me to have to watch.

Apparently according to all of them he just suddenly had a respiratory arrest.

When I found out in the hospital notes that my husband’s SATs were unstable over two nights (not told – never told anything) it alarmed me that they blamed his hallucinations on Post Op and did not tell me nor refer to the fluctuating SATs. He had just had for him especially but for anyone, serious lung surgery and no alarm bells were ringing in Cardiothoracic or Spinal. No one can explain this away. I was there and I know what I saw. With the hospital notes what I saw makes, sadly even more sense.

Who in this State examines, inquires and questions in a fair and open way when something so wrong is done to someone in hospital such that an avoidable death and suffering is allowed to happen, be ignored and covered up. There has to be some Body in this StateNSW which can legally investigate these issues. If not then in this State a person can be killed in the most brutalised manner, but professionals who would know the risks they were taking and would know not to ignore the warning signs that their risks had caused such dreadful lung damage so as to end a man’s life five awful weeks later are never even bought before any court, nor the victim and family ever receive any justice. Hard to believe in 2008."

End Quote from original letter

Prof B. has waffled on for 6 long expensive pages about the virtues or no of a Pleurodesis and shows his ignorance of the facts by getting the sequence of events out of order. I had provided a timeline to the Coroner’s office…but doubt that this Professor was given this.

What really upset me today, more than anything has before was this statement made by him…for what reason…considering he was paid for by the Coroner’s office…as I was told at $600 per hour (see page 5 of his report)

“Clearly Mrs M. was absolutely devoted to the care of her husband and understandably so. As a consequence any deteriorations or communication issues either perceived or real would easily have been exaggerated and take a life of their own.”

This statement in by a professor to a coroner is totally unacceptable and I will be asking for a written apology over this. It negates all the findings of the internal hospital Inquiry and an Inquiry into our public health system, plus the evidence of myself and our family. Why this appears in a coronial report has me concerned.

As well this Professor mentions two or three times in his report that he needed to have the X rays to complete his report. Why did he not ask the Coroner’s office for them? They knew where they were as they held them for some months and then they were returned to me. It is likely no effort was made by their expert or the coroner’s office to follow up and obtain the X rays and Scans which I would have hand delivered had I known they were needed.

Considering that a photocopy of the illegible notes which caused Don’s lungs to be suctioned at 10times the level needed amongst other notes was used …to recommend that electronic notes be introduced into all public hospitals so as to safeguard patient’s well being… the report by Professor B. is an insult. This is now going to be rolled out and come into effect.

For the first time since all this began with Don's illness and right down through the inquiries etc., sure I have cried many tears but yesterday for some reason the so called Professor's statements regarding my mental state and negating everything that has already been admitted and documented brought me undone.

I just started to laugh and laugh and laugh...crazy laughter, black laughter; I couldn't stop. I really couldn't stop then I started to cry out loud. Took some time and I admit a big glass of wine to calm down...then I did what i always do best when my back is against the wall... fight the bloody bastard back.

Another issue that i queried was how well did the examining doc know the doc who buggered the surgery and suctioning...HMMM turns out they went to the same Uni, did the same degree but a year apart...and i found other connections on the net...the net is a wonderful leveller for those of us who need information...

So my state MP has the lot, and the coroner's office representative has told me he will talk to the Coroner about the report. he agreed it was insulting and coloured the view. I am considering preparing a media release should the coroner's office not come up with something solid in short time...

Now i think i will vege out and watch Don's favourite "Bold and the beautiful" seriously...

And June or Rod if you are reading this and have gotten this far just bugger off and get a life in your sad sack of a world. is this small enough for the pair of you idiots?