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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6.15am and this would have been at quite a suitable time to contact the consultant surgeon having regard to regular routines. 53. He was concerned that there might be ambiguity and differences of interpretation with the existing protocol which obviously therefore would require rectification. Subject to that, he considered that the protocol in place was a good one. 54. He acknowledged that doctors trained overseas might have a different culture to that in Australia in relation to contact of consulting surgeons. Indeed, given Dr M cNairs evidence, it is clear that it is his different training more than the protocol which resulted in Dr Treacy not being contacted that day. Dr McNair said that had he known then that Dr Treacy would have wanted to be contacted or informed, he would have done so, presumably whether or not the matter was or was not out of the ord inary. This assumes importance in the context of the recommendations I make hereunder. 55. Dr Baggoley confirmed that it would have been difficult for Accident & Emergency staff to detect slight bleeds. He defined a slight bleed as less than 500mls. He based this on 500mls being the typical amount donated by a blood donor and Which does not cause an erratic pulse. He said that a 15% loss of blood is required before the pulse is affected and before there are other signs which would also indicate bleeding. A 15% loss translates to a loss of 750mls on average. In his view it would not have been possible to discern the events occurring at the date of death from the events on the presentation on the 18 February 2002. He pointed out that on 21 February 2002 the Deceased had a major abdominal bleed of the order of two litres. He noted that it was not old blood according to the autopsy report and this suggested therefore that the severe bleed was recent to the time of death. There was however no evidence of any significant bleeding on 18 February 2002. This is consistent with Dr Gilhomes opinion. 23
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