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
2004-06-25
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https://www.legislation.gov.au/Series/C1968A00063
https://hdl.handle.net/10070/284441
https://hdl.handle.net/10070/408388
any such message at 11.23pm on the same day. He did not return Dr Pa t ton s call thereafter. If a message had been left then it was not unreasonable for Dr Treacy not to have returned Dr Pattons call at the time he retrieved the message. 12. Dr Treacys actions after the Deceased cancelled her appointment with him for 2pm on 20 February 2002 was not inappropriate in the circumstances and did not contribute to the death of the Deceased. 13. The Royal Darwin Hospital Accident & Emergency Department protocol regarding the contact of treating surgeons of surgical patients is ambiguous and inadequate to that extent. 14. The Accident & Emergency Department treatment of the Deceased on 21 February 2002 was appropriate. R ecom m endations. 101. Section 34(2) of the Act enables me to comment on any matter, specifically including public health or safety, connected with the death in this case. Some comment is warranted on the evidence. 1 0 2 . The death in this case was not occasioned by any blameworthy conduct on the part of the treating surgeon or any of the other medical professionals with whom the Deceased came into contact from the time that she underwent the gastric banding surgery at the Darwin Private Hospital to the time of her tragic death. Furthermore, despite there being what I consider to be an obvious shortcoming in the Royal Darwin Hospital Accident & Emergency Department protocol relating to contact of consultants of surgical patients, this shortcoming likewise, did not contribute to the death of the Deceased. Sadly, the death appears to have been unavoidable. However there will no doubt be cases where the deficiency in the protocol may assume a greater significance and may also be causative of an unnecessary death. Pre-emptive