Outrageous document from the NSW Coroners Court
reveals what Tara Norton Senior Coronial Advocate, State Coroners Court, Glebe NSW wrote in an Internal document giving her opinion of me after I had approached the NSW Coroner to have my husband Don’s Death certificate changed. That death certificate was changed to add “Treatment” as a cause of death. I recently received some documents after requesting Right to Information which has replaced Freedom of Information. It is always wise to obtain such documents. I am reproducing pages 4 and 5 of this document and after that a copy of my letter written to request the statements from the doctors involved in don’s treatment and death. None of these were released and it appears to me they didn’t even take their statements. My comments in response to Tara Norton’s outrageous claims appear in italics and red.

“...Since receipt of the expert report, Mrs Mackay has written to a number of people within the Coronial jurisdiction, requesting that a further expert report be obtained. Mrs Mackay has spoken to a doctor by the name of Dr John MARX. (Dr John A Marx MB BS, BSc. (Hons) Pressure Medicine Institute Melbourne, Australia – he is a medical aviation specialist). Evidently this doctor has written about the effects of air pressure on the human body. Mrs Mackay spoke with him about the effect transporting the deceased by air ambulance would have had on his lung capacity. From the information passed on to Dr. Marx by Mrs Mackay, he has informed her that the pressure in the aircraft could be a factor in the deceased’s death. I have contacted the Medical director of the Air Retrieval Unit of the NSW Ambulance Service at Bankstown Airport, Dr Koel HOBIG. Dr Hobig states that a patient such as the deceased with quadriplegia is not automatically a problem to transport by air simply because of his quadriplegia. He stated that the main issue is the patient’s oxygen saturation level which is an immediate indication of their lung status. He states that in some cases in fixed wing aircrafts the pilot will be instructed to fly at 20,000ft instead of the 30,000 but this is only if the oxygenation is poor and the weather conditions permit it. He stated that the pleural effusion is not really a problem unless it has compromised the deceased’s oxygen saturation level. From the medical notes, I have established that when the deceased was admitted to Royal north Shore Hospital his oxygen saturation level was 95% on room air. He had no ventilation or oxygen support and was maintaining a reasonably high O2 sat level. Following the procedure his saturation levels started to decrease but at the time of transfer were stable and not an issue. (I spoke with Kathy Sheppard who worked with Wingaways and she told me he was given Oxygen when aboard the plane – and I have those written records – sadly Kathy was killed last year when the ambulance plane she was on crashed.)

Dr Marx has evidently also commented on whether the Pleurodesis being conducted the day after he was transported was appropriate. I feel that Dr Bannon has commented on the appropriateness of the attempt to drain the fluid, and the Pleurodesis that followed. (It was the other way around –Pleurodesis first then drainage. This is of vital importance– clearly Tara Norton is confused about the whole procedure) He stated that the procedures were appropriate but also placed the deceased at high risk because of his quadriplegia and associated medical conditions. (well that explains why they went into his lungs minus ALL normal and expected pre operative procedures as noted in the chapter in my book called “A catalogue of errors” One would have thought they would have been even more careful with an at risk patient – not less careful. But Tara is convinced she has the truth) I do not see that an expert report from Dr Marx will assist in this regard. (Dr Marx is very highly qualified but he is not one of their doctors - Dr John A Marx MB BS, BSc.(Hons)Pressure Medicine Institute Melbourne, Australia)

I am of the opinion that Mrs mackay continues to struggle with the death of her husband and comments from persons such as Dr Marx, who appears to have been given a distorted picture of the deceased’s treatment by Mrs Mackay, are compounding her grief. (Unbelievable! and defamatory. Ms Norton was not in the room when Dr Marx and I talked - how would she know what was said –but appears comfortable with what appears very unprofessional comments. She was not at the hospital and appears not to have even taken statements from anyone who was there apart from me. All who visited can back my statements up –but then it was a medical death and that gets special treatment) Mrs Mackay obviously loved her husband dearly and provided an exemplary level of care to him over the 25 years he was a quadriplegic.(I did ,but again MS Norton has no knowledge at all of what our lives were like and she “assumes” what the situation was)It is clear from his medical records that the deceased had suffered with respiratory problems since September 2006 (Make that Christmas 2006 Tara – and how come it took so very long for him to get treatment? No one has answered that) He developed the pleural effusion which despite attempts to drain it, failed. (There was one half hour attempt to drain it – not attempts Tara! It was done quickly in Radiology in Port Macquarie so they could do a CT scan. They stopped because they did not want to take too much quickly – or might collapse the lung. He was sent home that day with less than half taken off – and left to our own devices TILL the Pleurodesis over a month later. It was a reaccumulation not a recurrence – a big difference.) The next treatment was a Pleurodesis which carried with it significant risk given the deceased’s medical history. (Well then why the big hurry after we had waited too long without any care at all in our home – also Don’s Spinal doctor said it should never have been done and she would know) His deterioration appears to have been one of the possible consequences of such a procedure. (BINGO! Finally they admit this – they have denied this up until this very statement) I feel that the expert report obtained by Dr Bannon shows that the treatment was appropriate, however when MrsMackay receives this report, I am sure she will read the report differently to the way in which I have interpreted it and will raise a number of issues in her own mind about the decisions made during the management of the deceased. (As it was Dr Bannon couldn’t even get the timeline in order and his report was a dogs breakfast – something which could have been corrected had anyone thought to talk to me about it. Its nice to have your reactions prejudged by someone who has never met you. The whole family and friends must have also been similarly afflicted as we all reacted the same at Dr Bannon’s badly researched “report”) I am of the opinion that, other than the cause of death that was to be slightly amended as suggested by Dr Duflou, there are no other avenues of investigation that could be conducted that might assist in this matter. “was to be “it was amended and I consider adding “treatment “to the death certificate as no small amendment – why the adjective in what should be a professional opinion) I do not feel that Mrs Mackay will be happy with the outcome of (their typo) in this jurisdiction, regardless of the enquires that are conducted, as she appears determined that the deceased died in horrific circumstances that were entirely caused by the medical system. Ms Norton relies a lot on things that “appear” assumes much and used “in my opinion” and thats all it is “her opinion about a person she has never faced, based on what? I do not consider this a responsible way for anyone working for the NSW Coroner to act.) It is never a good outcome when we fail to assist families in coming to terms with the death of a loved one, but I cannot see what else can be done at this time to assist Mrs Mackay. Further expert reviews by Dr Marx (there were none at all so how can there be “further reviews” or any other medical practitioner will no doubt just raise further questions and at the end of the day, the outcome will not be altered. (How can she possibly know this?) The deceased was at high risk when he underwent the procedure, however the procedure was necessary (not according to his Spinal Specialist) As her correspondence indicates, Mrs. Mackay continues to raise various issues in just about every aspect of the care and treatment provided to the deceased and in addition to that, is still raising new issues as potential “causes” of her husband’s death. (Please Tara Norton list all the issues I raised which have been disproven. I am sure Mr Peter Garling QC would be very interested in your “opinion” of his Garling Inquiry which gave my evidence credibility) A copy of Dr Bannon’s report should be sent to Mrs Mackay as soon as possible as she has been waiting for this report for some time now. If we were to send a 30day letter with the doctors report, I predict Mrs Mackay will send a lengthy submission to Your Honour requesting multiple experts look at various aspects of the care. (Now she is making “predictions” –very neutral and scientific of her)It is for this reason that I respectfully recommend that this matter be dispensed with.
Tara NORTON
Senior Coronial Advocate,
State Coroners Court
Glebe
14 April 2009.

I am pleased to finally receive this document and to see the sweeping lack of neutrality. Tara Norton makes sweeping statements about my actions as if I was the only one involved in pushing my husband’s case. Our whole family both sides and over 2,000 local people who signed a petition asking for an inquiry agreed with me and my actions. Every single thing I claimed I have proven – and as far as I know the Coroner has not even obtained statements from the hospital involved in the mismanagement of my husband’s care – a mismanagement which caused him a lingering and horrible suffering and death. I am awaiting response from the NSW Coroner’s office as to any statements from doctors involved in Don’s time at the hospital. I believe they do not exist. I believe they never even were asked to give statements. Such is justice in Australia in these times that the victim’s family are “judged” but those who had the care of that victim are treated with kid gloves. A medically caused death is still a death. The person is just as dead. When it is caused by “Treatment” they don’t just die – they are killed. The victim and relatives close by are left just as traumatised as if the person was tortured and killed out on the street – but have to pursue their own justice as there are no “police” to act for those who suffer medical malpractice. But just because we are traumatised doesn’t mean we are unhinged and can’t think straight and research as per normal. The research our family did during Don’s mismanagement and after his death was clearer and more succinct than that done by the Coroner’s Office and the Health Care Complaints Commission. Both bodies had a woeful idea of the timeline and an incomplete understanding of proven and admitted facts which were recorded by the doctors and nurses themselves in the notes.

Therese Mackay

12/2/2011

NSW Coroners Office – Mr Paul West
31st January 2011

Dear Mr Paul West,
I am in receipt of the documents mailed to me by you 27/1/2011. Thank you

What appears to be missing is any response from the Cardiothoracic admitting specialist and/ or from any of his staff. Also missing are any statements at all from ICU doctors and/ or the Hospital. Also I see no statement from the local GP.

It would be assumed that any investigation of gross medical error, which it was would include at the very least taking statements from the doctors involved. Were doctors approached by the Coroners’ office? If so I would like to see all that documentation. If not then there is real cause for concern for those of us who go to your office reporting wrongful death.

I now seek all documentation contained in mine or my husband’s file 107/08 - Also I request a list of all documentation generated out of both approaches to your office.

As well I am disturbed by Tara Norton’s statement 14/4/2009 – in which she gives an opinion of me; a person she had never met. I gave evidence at the Garling Inquiry and Peter Garling QC thought my evidence truthful enough to include in his report. He even went so far as to copy the crucial part of the notes where the Cardiothoracic doctor’s handwriting was so bad – a gross medical error followed and went unnoticed for 22 hours – causing a noticeable decline in his condition prior to the first Respiratory Arrest.

I think what your office got wrong was that what was done to my husband was so bad and so prolonged that it was unable to be believed. All was true as stated in my book “Without Due care” Launched in NSW Parliament House by Mr Andrew Stoner and Mr. John Hatton. They obviously thought I had a grasp on the truth. Even Dr J who had been my husband’s Spinal doctor many years ago gave credence to what I wrote after reading my book. As well Dr G my husband’s spinal specialist said to me directly that Don should never had the Pleurodesis – just a lung drain and biopsy and then if it reaccumulated to drain it again because his lungs were so fragile. Against the opinions of the above Spinal Specialists , Tara Norton and Dr Bannon cast aspersions at to my credibility because of my loss.

I would assume that when someone you love is wrongfully killed to become emotional is a sign of good mental health –but it does not mean you are untruthful, nor than you can set known facts down. As it was Dr Bannon couldn’t even get the timeline in order and his report was a dogs breakfast – something which could have been corrected had anyone thought to talk to me about it.

I hope to hear from you as soon as possible and I certainly expect to hear that the doctors mentioned above provided statements as a matter of course.
Thank you

CC Lorraine Long Medical error Action Group and Eve Hillary author of Sarah’s Last Wish