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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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and prompt attention to rectify the ambiguity I have identified to prevent that situation occurring is warranted. 103. In addition, in my view, consideration ought be given to having provision for a back up precaution inserted into the protocol. The provision I suggest is to require routine notification to, as opposed to routinely contact of, treating surgeons of an attendance of an operative patient at Accident & Emergency in all cases even where no other action is warranted or required. This should be able to be achieved quite simply. I am not suggesting anything such as that which Ms Sievers described as an unworkable dogma which would routinely see surgeons unnecessarily troubled in the middle o. the night. I concur that that would be unreasonable. I also accept that the Accident & Emergency Department do not have the capacity or resources to routinely keep surgical patients in hospital until they can be seen by their treating surgeons. The notification I am suggesting would not have to occur immediately in the majority of cases and should not therefore have to be an administrative problem. Certainly it would not have to unnecessarily upset the routine of the Accident & Emergency Department. In the subject case for example it could have been achieved simply by providing Dr Treacy with a copy of the discharge summary. Ms Sievers was prepared to concede that the Hospital could have done that in this case. She also acknowledged that Dr Treacy could have been advised later that morning at handover. That therefore is two simple ways that notification of attendance could have been given in this case. There are no doubt many other simple and appropriate options, eg a copy of the notes could have been sent to Dr Treacys private rooms. A simple pigeon hole system could be set up in an appropriate place. E-mail notification should be easily achievable. In this case the typed discharge summary could easily have been made an attachment to an e-mail to Dr Treacy. The rather unique position of the Royal Darwin Hospital and the Darwin Private Hospital, not only their proximity but also that many of the surgeons practising at Darwin Private Hospital are also consultants at the 46