I sent this out to my email list this morning after a suggestion from an old friend of enlisting those I know to put pressure on the NSW Health Minister.

Your help would be appreciated
30/10/11
Dear All,
Please excuse this bulk email but needs must if I am to be able to put any pressure on the Health Authorities in New South Wales to bring about an Independent Inquiry into the death of my husband Don at the hands of Royal North Shore Hospital in 2007. In the past before the change in Government, the leader of the Nationals Mr Andrew Stoner and now Deputy Premier, was very helpful to me in exposing the shocking treatment Don received in RNSH which caused his death which would never have happened had his doctors had a duty of care towards him.
Mr Stoner Andrew helped me to launch my petition in NSW Parliament . The Petition was headed:
“We, the undersigned residents of and visitors to NSW request that the NSW State Premier and Health Minister ¬ begin a full, independent and open investigation into the surgery, treatment, care and subsequent death of Donald William Mackay, as a result of the five weeks he spent in Royal North Shore Hospital between 11th April 2007 and 17th May 2007 (the day he died). We ask that those responsible if found culpable then be subject to disciplinary action. Our reasons are briefly – A RNSH Internal Investigation into Donald Mackay’s hospitalisation and death, signed by RNSH’s Dr Hoyle who in writing, admitted many failures in Donald Mackay’s care; such failures, which we believe led directly to his death after five weeks of unimaginable suffering.“
I collected 2000 names on that petition and it was not a simple “Yes” or “No” – the issues had to be explained and most people were appalled upon understanding the gross neglect and medical error he suffered.
Since the change in Government in March this year, I have written to my MP Ms Leslie Williams and as well to the Health Minister Ms Jillian Skinner asking for this Independent Inquiry. Ms Skinner replied to the Port Macquarie News 3rd August 2011, a month and half before I had her written response,
"Mrs Skinner said there would be no further inquiry into the case. The matter has been investigated by NSW Health and the HCCC, and unfortunately there is nothing to be gained by opening this case for further investigation," said Jillian Skinner Minister for Health."
I would like to ask that you might be able to take five minutes to write a short letter to Ms Jillian Skinner MP, Minister for Health and Minister for Medical Research to call for an Independent Investigation into Don’s treatment and death at the hands of Royal North Shore hospital and most importantly the process followed by the Health Care Complaints Commission which allowed that treatment and found it “ all acceptable”. The fact that I had the support of the now Deputy Premier before he came to power but have no support now they have power is predictable but it is not good enough.
I have recently written to my local MP Leslie Williams – She and Andrew Stoner both came to my book “Without Due Care” launches and spoke about the dreadful treatment and outcome which was my husband Don’s death. All avoidable.
I believe pressure needs to be put upon the Government to back up what they supported in Opposition and I would appreciate any help you can give. A simple paragraph would be helpful. If there are issues you are not clear on please feel free to contact me for explanation or have a look at my website www.withoutduecare.com
If you do write to the Health Minister could you as well email me a copy for my records. I thank you in advance.
Her contact details are below,

Mss Jillian Skinner MP
Minister for Health
Minister for Medical Research
Level 31, Governor Macquarie Tower,
1 Farrer Place,
SYDNEY NSW 2000  Jillian Skinner's email     northshore@parliament.nsw.gov.au  

Without Due Care

withoutduecare.com.au

My own Craggy Island

A peaceful Sunday morning here. The sun is out and its so quiet. I can't even hear the trucks out on the Highway. The neighbour's cattle are out in my paddock peacefully eating or just chewing the cud - the bird song is just amazing - all sorts. I can see and hear all this from this room and know how lucky I have been to have been able to live here for this time. All going well I have a little over a month left here before I move and although I will miss this place, not the town so much but out here - I am hungry to move on - I have beautiful memories here, also some terribly sad ones as Don struggled so much health wise in the last years here - a good day for us was a day when we both woke up alive - we had near misses almost daily in the last year. You know when its time to move, because as beautiful as it is, I no longer look forward to coming home. There are many beautiful places but have learned that compared to the people in your life who you love, husbands, parents, children, friends, places are not so important. Its the people who make the difference.

Cuss and Tiger

UNBELIEVABLE

Some of you know about my two cats, Cuss on the left and Tiger on the right. Cuss is a bit of the moody one - about 10 and poor Tiger never knows how she's going to be. Both were dumped cats but Cuss came here first. Tiger is a lot younger being about three.


These two NEVER sit close without Cuss hissing and spitting at Tiger. Tiger is like a big silly dufus of a kid and just wants to play with cranky.


I was on the phone yesterday morning (they act up usually when I am on the phone) and I looked out through the window - here they were both close together watching me balefully - it was cat creepy - but of course as soon as I got the camera on them they turned away.


Our family knows that this is about the only photo we ever will have of them in sync and not running or sending fur flying - maybe things are changing though.

This is long - needs must - it is a response to the NSW health Minister's disgraceful decision not to investigate the Health Care Complaints Commission's (HCCC) inept investigation of my husband's medically caused death in 2007. I also asked for an Independent Inquiry into his death as mentioned in a petition launched by the now deputy Premier of NSW Mr Stoner - that is also denied. Things change when they get into Government


13th October 2011
 Ms Jillian Skinner
 MP Minister for Health Minister and  for Medical Research
 Level 31, Governor Macquarie Tower,
1 Farrer Place, 
SYDNEY NSW 2000 
 Dear Jillian,
 I am in receipt of your letter dated 29th September 2011. I am sorry to say that the response is not good enough. Whilst in Opposition I was given excellent support by Mr Andrew Stoner and as well Mrs Leslie Williams who is now our MP. Both of these supported me by helping launch my book which outlined the series of avoidable medical disasters which led first to Don’s shocking, brutal and prolonged suffering and then his death. Obviously they thought that there was something terribly wrong in what was done to Don and wrong with the investigation. Andrew Stoner called it “disgusting” when the HCCC claimed in their letter to me that Don wouldn’t have felt the pain of having his lungs suctioned at ten times the required value for 22 hours, “because he was a quadriplegic”. 
 The HCCC's interpretation of an "investigation" is clearly different from any other. There was no investigation for there was no outcome. Did the HCCC report Don's investigation to the Joint Parliamentary Committee on the HCCC? If so, when? Where is it in the Hansard? What recommendations came out of that “investigation” that will ensure not one other repeat occurs? The Internal RNSH investigation found multiple areas of fault and made a series of recommendations which hopefully went some way to protecting the next poor vulnerable disabled person who travelled down from the country, but the HCCC went totally in the other direction. This is the same body, paid for by taxpayers who allowed Dr Reeves to practice when he should have been de registered and jailed years before. That in itself should be enough to bring their efficiency and neutrality into question. The medical ignorance evident in their final letter to me was breathtaking. Whoever their medical expert was, they had no medical knowledge of Quadriplegia and couldn’t even get the timeline right. It was a real dog’s breakfast. 
 Recently I had to have routine day surgery. I am a well person and I was given blood tests, ECG and a multiple of tests. I was pleasantly surprised at the thoroughness of the Pre Op care given. This in Port Macquarie Base Hospital. As this was being done I couldn’t help wondering that if only some of what I was receiving had been done for Don how different the outcome would have been. None of these basic Pre Op’s were done in RNSH for Don who I remind you was not an emergency, even though the HCCC for some reason tried to generate a state of urgency to explain these serious issues away. I have to wonder why they would do this if they were acting to investigate. How can the HCCC excuse this behaviour from a Cardiothoracic Surgeon who would have known better? Please explain to me how that is acceptable? 
Please read the following quote which was the cover sheet of the Petition which Mr Stoner launched in Parliament in 2008, “On behalf of Don my husband of thirty-five years, our daughters, and myself, I request authorities begin an independent, open investigation into the surgery, treatment, care and subsequent death of Donald William Mackay. His death was a direct result of five weeks he spent in RNSH between 11th April 2007 and 17th May 2007 (the day he died). I request that the Cardiothoracic surgeon and team, the Spinal Ward doctors and nurses who ignored my husband’s worsening condition receive disciplinary action because of their negligence, which led to Don’s first Respiratory Arrest and inability to come off ventilation. ICU and Cardio Thoracic Specialists who withheld full disclosure of his condition from us should receive disciplinary action. Their non-disclosure led to Don being subjected to unnecessary torture, which lasted five long weeks. I request that the filthy practices and deplorable conditions he endured without choice in ICU be exposed. Legally, ethically, why and how are the medical practitioners protected from criminal charges?” Andrew Stoner was supportive when we launched the Petition outside Parliament House as well so I took it that he would have the support of the Coalition in this. I am disappointed that now the Coalition is in Government that support is not evident. I would like to know why the change? 
 If you as Health Minister accept that all Don’s treatment was acceptable as the HCCC claim then you must think that the dreadful treatment Don received and the covering up of their mistakes is good enough for the people of NSW. 
 On 11/4/07, Don arrived at RNSH at 10pm from Port Macquarie on Wingaway’s non urgent transport plane. It was not an emergency. A doctor whose English was very limited signed him up for the dangerous and unnecessary surgery within the hour that night (Pleurodesis). This doctor cannot recall what he told my husband about that surgery. We spoke with him later and had to ask a nurse to translate what he was saying. I know it was dangerous and unnecessary surgery because I spoke with Don’s Spinal Specialist after Don was killed and she was shocked he had had a Pleurodesis, as she knew his weakness – she said and I quote, “All that he needed was a simple lung drain and biopsy, and if fluid re accumulated in a few months to do the same again.” 
Don’s lungs were not strong enough and a responsible cardiothoracic surgeon would have known this had he bothered to do even the most basic of pre op observations. The next morning as I was driving from Port Macquarie, Don was being given dangerous and unnecessary surgery (Pleurodesis) by the RNSH’s Cardio Thoracic surgeon who just “assumed” Don had been examined, by a cardiothoracic specialist in Port Macquarie? This was not only unprofessional but was gross medical negligence especially in such a vulnerable and defencless patient. 
 The HCCC say it was acceptable that there was no ECG prior to surgery although Don had Pericardial Effusion (10 months). Do you as health Minister believe that this is acceptable practice for anybody? 
 The HCCC say it was acceptable that Don had neither blood tests nor any pathology before surgery. Do you as health Minister believe that this is acceptable practice for anybody? 
 The HCCC say it was acceptable that the Cardio Thoracic Specialist who was also the surgeon saw no X-rays or Scans prior to surgery. (They were still in Port Macquarie Base Hospital.) Still acceptable to you? 
 The HCCC say it was acceptable that the review by the Anaesthetist is admitted by RNSH to be “limited”. He was not seen before theatre. Limited why? Don had complicated medical problems and required proper assessment. Would you expect even your dog to be treated like this? 
 The HCCC say it was acceptable that the Cardio Thoracic surgeon had not seen Don before Theatre and had not done a detailed examination. The person who signed him up the night before was not part of the surgical team. No one knew anything about his multiple conditions before surgery. How irresponsible and dangerous was that? Still happy with the HCCC findings? 
The HCCC say it was acceptable that Ungraded Talc known to be connected to Acute Respiratory Distress Syndrome (which Don developed) was used. Since his death, they no longer use this. They were aware it was linked to Acute Respiratory Distress Syndrome (ARDS). Why was it used? Was it cheaper? If you are not disturbed by now by the HCCC finding all was acceptable I would like to know why. 
The HCCC say it was acceptable that my husband’s right lung which was meant to be suctioned until all the fluid was removed at the gentle suction of 3KPA. Was suctioned (vacuumed) at ten times that value at 31KPA. This was left like that for almost 24 hours and was not spotted by Cardiothoracic Doctors, and the Spinal Unit’s nurses till 8am the next day. All RNSH staff involved are culpable as this was covered up and I did not find out for seven months after Don’s death. They knew what they had done to him and we should have been told. Instead they lessened their observation frequencies, ignored my panic as he got worse, and his lungs collapsed. This was an event Don as a Quadriplegic was never going to survive. Any lung injury is disastrous for Quadriplegics. We consider that this covering up and hoping for the best was criminal behaviour. What do you think? Is this acceptable as claimed by the HCCC? 
The HCCC say it was acceptable that Cardiothoracic were ignorant of “Quadriplegic breathing” which makes it harder to breathe while sitting up when there are problems. These specialists ordered him sat up in his wheelchair. He rapidly deteriorated. I begged the Spinal Nurse to return him to bed she refused. He suffered three hours of extreme torture trying to breathe against gravity. He had a Respiratory arrest that night. Why were they all so ignorant of his condition? Jillian I still have the images of my lovely husband struggling to breathe, hallucinating, frightened only to be lectured to by a nurse that he’d have to stay in the chair for hours. If we are on the same page, surely by now you yourself must have concerns. Cardiothoracic should have known not to sit up someone with suctioning of the lungs in progress as this can cause the Pleurodesis surgery to fail and can lead to Acute Respiratory Distress Syndrome. This happened. Why did they allow this? No answers? The HCCC say it was acceptable that the surgeon was irresponsible and did not bother to see that all procedures pre and post surgery are followed. Almost none of the regular procedures were followed. There is no excuse for this? From the moment the specialist laid hands on Don, Don had no hope at all. It was such a huge botch up. All acceptable to the HCCC and any who support their claims. 
The HCCC say it was acceptable that Spinal nurses, Doctors and Cardiothoracic were grossly negligent over the next days. He was treated badly as his condition became dangerous. He began to hallucinate and gasp for breath. This was extreme cruelty and shocking for him to experience. 
The HCCC say it was acceptable that on the night of the first of his respiratory arrests, he called my name for three hours according to his roommate and they did nothing. They only took notice of him when he was close to Respiratory Arrest. I spoke to his roommate that day and he was really upset by what he had seen Don go through with only intervention when he was close to Arrest – he was ignored all the time he was calling out. I was five minutes away next to the hospital and had given them instructions to call me at any time if he needed me or things got worse. I was only called when he was taken to ICU. 
The next five weeks in RNSH’s Intensive Care Unit were horror-filled. Dreadful images to carry, but how much worse for him? I try to see him as he was before their negligence allowed him to be filled with infection, sepsis, fluid and God knows what. I cannot. I see my beloved husband tied and gagged by tubes. Both lungs drowning and full of fluid. MRSA and Klebsiellia Pneumoniae filled them with bloody mucus. I still see him with his tongue being forced painfully in and out, as he reached yet another respiratory arrest. One time he was breathing 50 breaths per minute. He was so frightened and I could not help him. An ICU nurse stood and did nothing. “I think he’s trying to talk”, she said blithely. An ICU nurse! 
It went on like this for five weeks. If I feel like I have been in a war zone how much worse for my husband? Is this acceptable as the HCCC claim? 
 What I have relayed here is sadly for Don just the tip of the iceberg as to the dreadful suffering inflicted upon Don. Finally, he was allowed his wish, which was simply to get out of the filth and chaos, go home and die. Even then, after all they had done to him, it depended on conforming to their demand that the home respirator be taken away as soon as he got home. Apparently, there was not one other home respirator in RNSH or at Port Macquarie or anywhere else in the Northern Areas’ Health Service. So even having a little time to spend with us here at home before he died was denied to him. 
 Jillian, Don was killed, he didn’t just die. It was a death caused by gross negligence, ignorance, stupidity, arrogance, filth and cost cutting. I should not have to be chasing justice on behalf of my husband, daughters and myself. Those responsible should be prosecuted and or receiving disciplinary action for killing my husband Don Mackay and robbing our daughters of their wonderful Dad. Those most responsible should not be still practising inside Royal North Shore Hospital. It would be better for NSW residents if they were not in the health system at all but Royal North Shore Hospital buries its mistakes with the approval of the HCCC who have turned a blind eye to some of the most outrageous of medical error, medical negligence and cruelty I have ever come across. 
I read of medical error in the media and my heart goes out to those involved as I know what a battle they will have if they want to change things and not just be compensated. I do not know of anyone who suffered for as long as Don did and he experienced the worst medical care I have ever come across. All avoidable had they taken care of him professionally. The Spinal unit and ICU were and probably still are a disgrace. The treatment Don received was consistently bad. I can not remember their making any decisions which improved things for Don – everything they did to him from his first moments there added to his suffering and brought about his death. This is not acceptable. 
The HCCC’s decision that it is all acceptable is wrong and unjust. I know what we saw and what we discovered and not once have I been proven wrong in any instance. I have to wonder what the HCCC actually exist for and how come they have been not been called to account. 
If it is acceptable that in 2007 a resident of NSW, a physically disabled man who has already had more to bear than most of us can have his suffering and death as mentioned all avoidable – called acceptable by the authorities, then there is long way to go before we can call ourselves civilised. If this were any other death apart from medically caused there would already have been justice done.  
Nothing I see leaves me with any hope that things will improve. As far as I can see the problems with medically caused death and injury can only get worse because no one is taking to task those who are supposed to investigate with neutrality, not in the adversarial way many of us who have dealt with the HCCC experience. For me the issue is sadly becoming clear, that the life of one frail disabled man is not worth upsetting the Medical Specialists and Health Department. I see nothing that tells me this is not true. 


You have suggested that I respond to your letter to Mr Paul Russel from the North Sydney Local Health District, but as I wrote my letter to you I prefer to continue as you are the Health Minister. 

Lookin out my front door
- how amazing is this - It was just pouring pure golden light in through my front windows into the lounge room - I have never in my whole life seen the sunsets like I see here - must be blessed...





I signed the contract yesterday - a really odd feeling - a big lump in my throat nearly threatened to bring me undone but I got control and didn't disgrace myself - at least this person had the good common sense not to go racing off for a box of tissues like so many even before there is a tear - she just sat there and gave me time. The search and pest report are finalised and it appears everything is fine - so...just waiting for them to sign and deposit.

Pretty sure the house is sold - nowhere near what I wanted but these are the times - a weird feeling sort of an anticlimax - papers still to be exchanged - but agreed on terms - may wait till tomorrow to tell the girls - I think I need to have it gel  first - 

Looks like I may be close to a sale. I am going to miss this place very much and I know I will never be able to live anywhere as beautiful as this place, but truth is it absorbs money and money I don't have...needs a family here as even though the quiet is wonderful, sometimes it can just be a bit too quiet. I just need to move as I have marked time too long and need to be somewhere where nobody knows me well.

When we came here in 1976, Don was 26 and I was 22. I must post a story about that and shots of our first 12 a week home and you will be impressed with out 'hippy" van - it was an old -  1950's dodge van which had been the ambo for a small West Australian town called three springs .
Hopefully I will know by tomorrow but until the deposit is down I am not counting my chickens - I burst out crying after the real Estate agent told me but were it to fall through no doubt would shed a few more... its getting so I don't want to come back here and I know Don didn't want me to stay here - certainly not for as long as I have.

Just back from Melbourne
I arrived home late yesterday after a wonderful week at Ali and Andrew's place - She celebrated her birthday  - (by the way Foxymoron - a very happy late birthday to you too) and was pretty pleased with some of her pressies - the shoes came from her big sister - and yes she can walk in them (just) - We really splashed out and Andrew booked us into the Rockpool - (Neil Perry's for those who care - it was excellent but I am a bit of a peasant and not terribly impressed by the names of places and the chefs as long as it is cooked well that's all that matters and as long as I don't have to cook it or wash up - but can't afford too many at that price or I may have to wash up...
Some shots of Ali and Andrew and one of me with an almost empty wine glass - and no I wasn't singing - although I was pretty happy. Andrew made her the birthday cake - the first cake he has ever in his whole life made and it tasted great - he was pretty pleased with himself. Its so good to see the little family traditions being carried on such as the chocolate freckles on the icing. Off now out to Beechwood (near Wauchope) to get my cats back from the cattery -

Thanks Jin

Off the Melbourne my favourite place this week
My youngest  has another birthday this week so am off to Melbourne to help her celebrate - after I clean up hereabouts - a massive wind storm on Thursday which brought branches etc down and knocked out he power from 4.30pm till mid day the next day - but alls well now - no doubt I will have heaps of photos when I come back and the kids are giving me a tour of their new home so am looking forward to this. 
Not an interesting post but of late these acres have been taking my every spare waking minute because of all this wild weather


I am so much looking forward to just not being responsible for a short while..
Oh and thanks Jin for your quote about "Apologising"...


"Apologising does not always mean you are wrong and that others are right, it just means you value your relationship more than your ego."
So whats the point of anyone asking for an apology - one should only be freely given without demand or how can it be genuine. But I love how the Irish got around it when the Poms wouldn't apologise to them for 800 years of bastardry - they said "we forgive you" Now that works for me