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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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pathologist and a colleague, and subject to those discussions would be more likely to proceed with endoscopic therapy. Post surgery, with the benefit of the new systems, I would expect earlier identification of deterioration and its likely cause and call for specialist retrieval resources in response at an earlier time." 201. There is some doubt whether those changes have occurred or are simply under consideration. For instance, under the heading of "DPH Response to the Death of Mrs Irene Magriplis" in Dr Seiler's statutory declaration of 3 March 2017 there is an outline of the changes. They are: "a. Consideration of a 'nominated VMO'. It is said, "this would require DPH VMO' s to nominate an alternate VMO to review their patients if they are unable to attend the DPH and physically review their patients". That would appear to align to the "second call" specialist that Mr Treacy mentioned. However in this case it is said only to be under consideration. b~ An updated escalation protocol. The protocol makes it clear that there is still no escalation to the Royal Darwin Hospital Rapid Response Team before a Code Blue is called and a Code Blue is only called for respiratory and cardiac arrests. In that regard nothing has changed since May 2015." 202. It is therefore not possible from the evidence before me to determine what changes have been made and whether or not they are effective in strengthening the systems such that the circumstances of this case are unlikely to be repeated. 203. Pursuant to section 34 of the Coroner's Act, I find as follows: (j) The identity of the deceased was Irene Magriplis born on 6 June 1939, in Kalymnos, Greece. (ii) The time of death was 11.30am on 30 May 2015. The place of death, Royal Darwin Hospital in the Northern Territory. (iii) The cause of death was septic complications following surgical resection of duodenal ampullary adenoma. l"1 ,,

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