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Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017



Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017

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Tabled paper 426


Tabled papers for 13th Assembly 2016 - 2020; Tabled papers; ParliamentNT






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149. It is gratifying those insights were gained through the course of the inquest and they were put so honestly and frankly. 150. What is so striking about the treatment provided to Mrs Magriplis, however, is that at almost every point, it was problematic as noted in the following paragraphs. The failure to undertake sufficient testing to determine whether the high risk surgery was required 151. Doctor Mittal told me that in his practice they would have asked for an endoscopic ultrasound. He said that procedure provides information on the dimensions of the tumour and can also be used for a fine needle aspiration that would again confirm whether it was cancerous or not. He said: "The advantage of the fine needle aspiration is that we can get a deep ultrasound guided biopsy so you know exactly where you are targeting and that you indeed have good tissue samples. The other option, if you suspect the lesion involves the common bile duct~ we would ask for a spy glass, which is a fibre optic examination. And that can actually look into the bile duct, visualise the lesion and then take a more substantial biopsy." 152. Mr Treacy turned his mind to seeking an endoscopic ultrasound through a gastroenterologist in Adelaide. However after the results of the second ERCP he did not believe that it was required. His decision in that respect would have been assisted greatly by the involvement of a multi-disciplinary team. Failing to form or consult a multidisciplinary team about the diagnosis and manner in which to proceed with a high risk and complex case 153. In the Medical Journal of Australia on 4 May 2015 there was an editorial on the rise of pancreatic cancer. The following was stated: "An avenue to optimise outcomes for patients is to ensure that all receive high-quality care in the most appropriate setting ... it is thus important that all patients without metastatic disease are reviewed by a multidisciplinary team in a major centre to determine the resectability of their pancreatic tumours. In addition, resections

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