Letter sent to
Health Minister Skinner, NSW Parliamentarians and Media for your information.
My aim is to make the Coalition honour their support whilst in Opposition. If
they have to be shamed into it then so be it. Some people have suggested giving
up the fight and getting on with life – I have moved on with life but as the
relative of someone killed inside a Government system which then covered up
that killing disgracefully, I have a last duty to do my best to ensure justice
is done. This is what for me it means to live in a civilised society. I live
better and happier doing this than pretending and letting it go - Therese
16th March 2013
Ms Jillian Skinner, NSW Health Minister
Parliament House
Macquarie St
SYDNEY NSW 2000
Dear Ms Jillian Skinner,
Before the Coalition came to power I had been supported
by Nationals Andrew Stoner and the National candidate for Port Macquarie Leslie
Williams. Both of them became actively involved and spoke at my book launches
in 2010. That support petered out after the Election. You, Jillian Skinner when
in Opposition bought a copy of my book from me when I was selling it in our
local shopping centre and you were was visiting Port Macquarie. You were very
polite and supportive, that time.
Now all three of you are in Government. I am in receipt
of letters from you and Leslie Williams. You wrote “I believe there is
nothing to be gained by opening this case for further investigation and
consider the matter now closed.” Leslie Williams replied in almost
the same words. Considering Ms Williams passionate speech at my book launch I
am wondering what could have changed as she is now in a position to do
something about it. If feels like hypocrisy to me.
We have a Health Minister and MP for Port Macquarie who find it
acceptable and not worthy of justice that a frail disabled man was brutalised
and killed in the shocking way my husband was and you consider “there is
nothing to be gained” by investigation.
What about Justice, something I believed we had a right
to expect in Australia? Justice for my husband who suffered horribly for five
weeks after the cardiothoracic surgeon sent him out of theatre with his Pleural
Lining being suctioned at ten times the safe amount (31kpa instead of 3kpa) and
left it like this for 22 hours till a nurse discovered this. Then compounded
their negligence by not telling us what had happened till I found out 7 months
later. What about justice for those of us who love him and who will never heal
from what we saw being done to him, no more than any relatives of people killed
by crime or accident? For my husband to have Justice then the Specialists
involved would have to be questioned and inconvenienced. Nothing much would
happen to them as it is rare for any doctor in Australia to be made
accountable. You see Ms Skinner, I believe that in a civilised country the
worth of the vulnerable, such as my husband Don is more than that of the rest
of us. And it is because he was so vulnerable he should have been treated
carefully and with dignity by the Specialists involved – not the opposite. If
this sort of behaviour is condoned by not investigating we are on a slippery
slope backwards.
By your statement, that “there is nothing to be gained”
it appears to me that a value judgement has been made. That judgement that the
doctors involved have more worth and rights than my husband. That my husband’s
quality of life was not considered high enough to be worthy of any real
investigation apart from that of the HCCC which is a joke. Their medical person
was such a fool he/she declared my husband would not have felt any pain because
he was a Quadriplegic – when in normal life his pain levels were so dreadful
and intense he was on Opiates just to enable him to sit up in the wheelchair.
I have proven on many issues what was done to Don. There
is no doubt as it is in their notes what a disaster their “care” of him was.
Surgeon Dr Rodney Woods in the Jayant Patel case in
Brisbane states in regard to Patel’s patient Mervyn Morris, “If he hadn’t
had the surgery then I don’t believe he would have developed the various
complications and the subsequent death.” Patel spent time in goal.
Please help me to understand the difference in what
Professor DuFlou wrote in his report to the NSW Coroner in regard to the death
of Don Mackay, “it is most unlikely that the deceased’s rapid,
but lengthy, deterioration would have commenced when it did but for the patient
undergoing the various transfers and treatment.”
Or of what Dr Phillip Hoyle
Director of Clinical Governance RNSH wrote in his letter 2/1/08
“The very rapid progression from admission to
operation meant that there was no assessment by the Spinal Unit or with the
respiratory Unit preoperatively. I recognise that given the complexity of Mr
Mackay’s condition, a more comprehensive assessment, with input from the spinal
and respiratory teams prior to surgery, would have been wise.”
I challenge you Health Minister Jillian Skinner and Ms
Leslie Williams to justify your weak stand. Justice should be for everyone, the
same – not a convenience to be dispensed with because they consider there is
nothing to be gained.
Lorraine Long from the Medical Error Action Group states
that in Australia one Jumbo Jet full of people are killed weekly by medically
caused deaths. God only knows how many are permanently injured. You would think
a Health Minister would want to help find out why – one has to ask why you do
not.
Please find attachment below with a brief
outline of what was done to Don Mackay. This attachment was the flyer I
produced to support the Petition which Mr Andrew Stoner delivered to NSW
Parliament. On any one of those few points there is a case to answer – all
together it is clear that the doctors involved acted negligently and as
mentioned worse than that they covered it up.
After reading this Ms Skinner, please explain to me why
you wrote to me, “I believe there is nothing to be gained by opening this
case for further investigation and consider the matter now closed.” Please
explain to me why any one of those points is deemed acceptable and not worthy
of investigation in Court.
You have a duty to us the Taxpayers who pay for the whole
system of government, before the doctors involved, before the Health department
and before your own party. Either Don’s treatment was excellent or it was not.
If it was not excellent and if it led directly to his suffering and death then
whether or not you think anything is to be gained does not matter. My husband
and us his family have a right to justice and you the Health Minister have a
duty to bring this about.
Just as you have this duty, so I have one last honourable
duty to my husband and our daughters, that of obtaining justice as he deserves.
Yours sincerely,
Mrs Therese Mackay
cc Mr Andrew Stoner, Ms Leslie Williams, Mr Barry
O’Farrell, Parliamentarians and Media
Royal North Shore Hospital Shame.
Donald William Mackay’s cruel death cries out for justice.
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?
This could happen to your
loved one or yourself. I have no reason to think it has not since my husband’s
criminal mistreatment inside RNSH.
1.
My husband, Don
Mackay had been a Quadriplegic for 25 years. On 11/4/07, he arrived at RNSH at
10pm from Port Macquarie. It was not an emergency. A doctor whose English was
limited signed him up for the surgery within the hour that night. He cannot
recall what he told my husband about that surgery. Why?
2.
The next morning
as I was driving from Port Macquarie, Don was being given dangerous and
unnecessary surgery (Pleurodesis)
3.
How could RNSH’s
Cardio Thoracic surgeon just “assume” Don had been examined, by a
cardiothoracic specialist in Port Macquarie? This was unprofessional.
4.
There was no ECG
prior to surgery although he had Pericardial Effusion. Why was that?
5.
He had neither
blood tests nor any pathology. How can they justify this?
6.
The Admitting
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.) What
was going on?
7.
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.
8.
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?
9.
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?
10. My husband’s right lung was meant to be
suctioned until all the fluid was removed at the gentle suction of 3KPA. RNSH
admit that a transcription error caused his lung to be suctioned (vacuumed) at
10 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.
11.
Cardiothoracic
were ignorant of “Quadriplegic breathing” which makes it harder to breathe
while sitting up when there are problems. They 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?
12. 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?
13. It is the responsibility of the surgeon 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?
14. 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.
15. 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. I was five minutes away and had given them instructions to call me
at any time if he needed me or things got worse.
The next five weeks in RNSH’s Intensive Care Unit were
horror-filled. I cannot these get
these dreadful images out of my head. 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. I feel like I have been in a war
zone.
What I have relayed here is
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. Why
was this?
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.
