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
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.
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.