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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have masked the normal pain reaction. That medication would have been unlikely to affect tenderness. 44. He considered that the treatment given by Dr Patton to have been appropriate according to the circumstances. He thought that the discharge noted by Dr Patton on 20 February 2002 was an infection of the local wound and not related to the ultimate infective process leading to the secondary haemorrhage. 4 5 . He agreed that an intake of vitamised soup would be acceptable and not in breach of dietary instructions. In any event he opined that even had solid? been ingested at the time, that would not have been causative of the death. I thought this to be very interesting in light of all the discussion of pressure causing necrosis. 4 6 . He did not consider it unusual that the site of the secondary haemorrhage was unidentified in the autopsy report. He confirmed that a secondary haemorrhage can occur between 7 and 10 days postoperatively but he thought that the actual secondary haemorrhage in this case would have started in a matter of hours, possibly as little as two hours, before the patient woke screaming on 21 February 2002. This is consistent to a certain extent with the opinion of Dr Ranson on this issue. He said that the relatively instantaneous nature of secondary haemorrhage is not something that can be prepared for and this was particularly so in this case as on 18th or 20th February, there were no clear signs of a secondary haemorrhage. Hence he could not suggest that the hypervoleamic shock syndrome could have been avoided. 47. His evidence regarding the cause of the process leading up to the secondary haemorrhage is best summarised by his answer to a question from counsel assisting, at page 185.5 of the transcript. I set that out in full hereunder: Doctor, the application of the band - and I m continuing on with the subject matter that you referred to under the hearing Autopsy 20
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