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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56. He agreed that the absence of a diagnosis for the cause of pain meant that the Hospital should have contacted Dr Treacy and at least kept the Deceased in Hospital until the analgesia wore off. It is puzzling that he also thought there was no diagnosis of the cause of pain as clearly there was. That diagnosis was in the notes and it was confirmed also in the discharge summary given to the Deceased at the time. That view must therefore be seen in that light. He emphasised that the simplest way forward on 18 February 2002 would have been to ask Dr Treacy to see his patient. This would have been preferable because of the surgeons knowledge of the patient and the surgery. Dr Gilhome expressed the same sentiment. 57. Dr Baggoley also impressed me. I think the main thrust of his evidence is that he put great emphasis on the fact that Dr Treacy should have been called by Accident & Emergency staff on 18 February 2002. For reasons apparent in the body of these findings, I do not think however that there is any causative connection between that failure and the death of the patient on 21 February 2002. 58. Dr Peter John Treacy gave evidence on three occasions during the course of the Inquest. His evidence commenced on 14 November 2002 and concluded on 31 July 2003. In the intervening period a report was obtained from the Therapeutic Goods Administration addressed to whether the reservoir port had been punctured. This inquiry was made because of the suggestion of Dr Treacy that marks on the reservoir membrane might have indicated that the air found to be in the band at the time of the autopsy could have been introduced by this means. The Therapeutic Goods Administration report, which became Exhibit 22, ruled that out. Another document was also obtained in the intervening period and was also received. That document was the manufacturers procedure manual. It contained a recommended procedure for evacuating the band of all air before placement. The report from the Therapeutic Goods Administration also established that the specified procedure had not been followed by Dr Treacy and that also then 24
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