Territory Stories

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



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

Other title

Tabled paper 1394


Tabled Papers for 9th Assembly 2001 - 2005; Tabled Papers; ParliamentNT






Made available by the Legislative Assembly of the Northern Territory under Standing Order 240. Where copyright subsists with a third party it remains with the original owner and permission may be required to reuse the material.




Tabled papers

File type




Copyright owner

See publication



Parent handle


Citation address


Page content

organs. Although she is more positive than Dr Ranson on this issue, v iewing the evidence as a whole, I cannot rule out that any air in the band was introduced inadvertently during the post mortem. 3 8 . Dr T reacy s evidence on this issue is also important. He pointed out that photograph 16, which self evidently was taken before the photographs 19 21, shows the band apparently deflated. The rather obvious conclusion he drew is that the tube was cut between the time when photographs 16 and 19 were taken. That conclusion seems inescapable to me. I was also impressed by the reasons that Dr Treacy gave to explain why it was not possible that there was air in the band at the time of the surgery. Firstly he said the band would not fit through the keyhole incisions with any air in the band. Secondly he said that he would have clearly seen if the band had air in it given that he has a magnified view through the cameras inserted into the abdomen. Thirdly he said that it would not fit properly around the stomach and could not be properly fitted if it had air in the band. These reasons seem quite plausible and logical in my view. If I accept that the presence o f any air in the band would have been obvious to Dr Treacy at the time of the surgery and that its presence also meant that installation into the abdomen and proper placement would have been hampered, then there is no reason why Dr Treacy would have proceeded with the fi tment in that event. The extensive evidence heard by the Inquest really presents only two alternatives to explain the air in the band namely, inadvertence by the pathologis t or fault on the part of the surgeon. On the evidence before me I do not hesitate to rule out the latter and as I cannot rule out the former, the resulting conclusion is obvious. 3 9 . That then leaves the question of what commenced the chain of events leading to the secondary haemorrhage. I think that Dr Gilhomes evidence is central to that issue given the findings I have made to date. As all other options explored in the evidence having been dismissed it leaves only the normal risk of surgery which Dr Gilhome referred to. Dr Gilhome has 17

Aboriginal and Torres Strait Islander people are advised that this website may contain the names, voices and images of people who have died, as well as other culturally sensitive content. Please be aware that some collection items may use outdated phrases or words which reflect the attitude of the creator at the time, and are now considered offensive.

We use temporary cookies on this site to provide functionality.
By continuing to use this site without changing your settings, you consent to our use of cookies.