Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017
Tabled paper 426
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132. It is sought that I accept that Mr Treacy in not disclosing his discovery about the 400ml was simply trying to shield nurses from being blamed or perhaps shield himself from looking as if he was blaming the nurses or both. 133. It is an interesting proposition. It seeks to join, as if inextricably linked, the failure to detect the fluid and the blame of the nurses. Yet just the day before his Counsel had not linked them. He had told me that Mr Treacy was not making excuses and accepted his errors. 134. What Mr Treacy said he discovered was that Mrs Magriplis had a significant amount of fluid draining from her abdomen 17 hours after the operation. At the point he is said to have discovered it, he had already made declarations that were factually incorrect. 27 135. If the discovery of the fluid was not linked to blaming the nurses there was no reason not to rectify the incorrect declarations. If the discovery was linked then I am asked to accept that he chose to leave those incorrect declarations as part of the record before me rather than blaming the nurses. 136. I note the advice to Mr Treacy was to be open with his answers only "if" the fluid chart became significant. I find it difficult to accept that he did not correct those false accounts for fear only of laying blame on the nurses. 137. Even on the most favourable view of the facts (for Mr Treacy) there are significant issues. The most favourable view would be that the nurse failed to seek permission to change the drain and didn't write up the Fluid Balance Sheet until after Mr Treacy had seen Mrs Magriplis just prior to 8.00am on 28 May 2015. 138. However, there is no doubt that at that time the notations in the 'drain' column of the Fluid Balance Sheet had been made up to midnight. The notations in the drain column added up to 280ml. The last entry at midnight 27 Although the time when he said he made the discovery was variously 'months' or 21 months after the death of Mrs Magriplis.