Coroners Act In the matter of Coronial Findings and Recommendation into the Death of Ms Souzana Afianos pursuant to section 46B dated 1 January 2004
Tabled paper 1394
Tabled Papers for 9th Assembly 2001 - 2005; Tabled Papers; ParliamentNT
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with the gas. He said that the Deceased was asking to go home and he agreed to discharge her for a number of reasons. Her pain had decreased and her blood pressure was at reasonable level. He was satisfied with his diagnosis and lastly he was aware that the Deceased was to see Dr Treacy that Wednesday. He prepared a very detailed discharge summary for the Deceaseds GP and he provided a copy to the Deceased. The Deceased left the hospital about 6.15am that morning i.e., Monday 18 February 2002. 19. One of the issues that arises at this Inquest is the appropriateness of the discharge at that time. This was because, as Dr McNair conceded, pain was one of the symptoms complained of and the effects of the analgesia given during the admission had not worn off by the time the Deceased was discharged. Accordingly the success of the treatment, and consequently the existence of other possible causes of pain, had not been determined at that point. This issue can be quickly dealt with. Both Dr Gilhome and Dr Baggoley, an expert in emergency medicine, agreed that the analgesia would not impact on an adequate abdominal examination. Similarly, Dr Baggoley at least, dismisses the impact of analgesia on temperature and he supports the conclusion later to be made by Dr Palmer on that account. The discharge of the Deceased at that time must also be looked upon in light of her then persistent requests to go home. Dr Baggoley agreed this was a relevant consideration. 20. Another issue which arises is whether Dr McNair should have called Dr Treacy to seek his views. It appears from his evidence that Dr M cNairs training in England put a different emphasis on the need to contact treating surgeons in these circumstances. He said in evidence that he did not think it necessary to contact Dr Treacy given that he was satisfied with his examination and with his diagnosis. The evidence reveals that although the Deceased may have then had some minor bleeding which was of no consequence, the secondary haemorrhage which resulted in her death had then not apparently commenced. It appears from the overall evidence, and 8