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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

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Tabled paper 1394


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






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18 February 2002, he iterated that as of that date, there was nothing which indicated the possibility of a massive secondary haemorrhage. This is consistent with the rest of the evidence. This very much counters Mr Glascotts submissions where he concluded that had Dr Treacy seen the Deceased on the occasion of her attendance at Accident & Emergency, i.e., two days earlier, that he would have taken steps which would have prevented the death. 78. The contents of Dr M cNairs discharge letter were put to Dr Treacy. He said that he would not have thought it was necessary for him to attend Accident & Emergency at that stage. This was on the basis that the only complaint was pain, it was a pain that had been the same as during her admission and it was pain that had increased but had been relieved by panadine forte. Again, this counters Mr Glascotts submission. He confirmed that during his working time in Darwin he is not always contacted if his patients attend at Accident & Emergency. He said this applied both before and after the death in this case. He said that whether he is called or not depends on the circumstances. He said that at the least he would like to be told if one of his patients did attend at Accident & Emergency, especially if they were a private patient. He said that he has discussed this with Dr Palmer both before and after the death in question. This is very relevant in terms of the recommendations that I make hereunder. 79. Miss Stephanie Dubois was the triage nurse on duty at Accident & Emergency on 18 February 2002. She gave evidence in relation to procedures followed regarding the attendance on patients at Accident & Emergency. She said that she recalled the Deceased specifically as she had reason to have her memory jogged by her untimely death within a short time of her attendance at Accident & Emergency on that night. 80. She confirmed that the date and time on the R o y a l . Darwin Hospital Emergency Department Medical Record (Exhibit 1 Folio 8) is automatically 33