Join Date: Dec 2006
Location: Out of the furnace...
Doctor shortage - Lessons for aviation (Long)
Here is a transcript of last weeks ABC NSW Stateline. It is sobering reading, & I believe holds many lessons for aviation.
Reporter: Sharon O'Neill
QUENTIN DEMPSTER: Through painstaking examination of all relevant facts, a coronial inquest into the cause of a person's death is designed to arrive at, or as close as possible to, the truth.
From the truth lessons about human error or system failure can be learnt.
Tonight, Stateline can report there's been an extraordinary revelation surrounding the death of 16-year-old Vanessa Anderson at Royal North Shore Hospital two years ago.
It concerns foreign sponsored doctors assigned by the New South Wales Department of Health, and it comes after public hearings at the inquest formally ended and findings were being prepared for release.
It appears Deputy State Coroner Carl Millovanovich may not have been told all the relevant facts.
On Monday at 10 am he has called all the parties to the inquest to a new hearing. The inquest into the death of Vanessa Anderson may now have to be re-opened, adding to the distress of Vanessa's parents, family and friends.
There are many questions arising from this new information - we'll get to them shortly, but first, Sharon O'Neill reports.
SHARON O'NEILL: On Monday July 9, three days after the public hearings at the Vanessa Anderson inquest finished, Deputy State Coroner Carl Millovanovich received a letter from a senior clinician at Royal North Shore Hospital, Dr Stephen Barratt.
At the start of the letter, Dr Barratt wrote...
EXCERPT OF LETTER TO THE CORONER: "I was present at the inquest on July 4 at Westmead Coroners Court. My name is Dr Stephen Barratt and I am an anaesthetist working at the Royal North Shore Hospital. My involvement with this case is substantial as I am the Supervisor of Training for Dr Sanaa Ismail who gave evidence on the 4th July. I was sufficiently unhappy with the events... that I felt it necessary to write to you directly. My motivation is that you need the truth..."
SHARON O'NEILL: Dr Sanaa Ismail was an anaesthetic registrar from Saudi Arabia who was working at Royal North Shore Hospital on the afternoon of November 7, 2005, when she saw Vanessa Anderson in Ward 7B for a pre-operative consultation. Dr Ismail's evidence is critical because one of the central issues for the Coroner is the amount of medication administered to Vanessa in the hours before she died. Vanessa Anderson had suffered a depressed fracture of the skull after being accidentally hit in the head by a golf ball on Sunday November the 6th.
When Dr Ismail attended the ward, Vanessa was in considerable pain despite being given Panadeine Forte and the painkilling drug endone. The inquest was told Dr Ismail made a decision to double the dose of endone from five to 10 milligrams at shorter intervals - three hourly instead of six. 30 milligrams of endone were subsequently administered to Vanessa between 7 pm and 2 am in addition to four Panadeine Forte tablets. These drugs were administered despite the fact that earlier in the day, the neurosurgeon caring for Vanessa, Dr Nicholas Little, he was "constrained in the amount of analgesia we can give."
Dr Little told the inquest when he learned after Vanessa's death about the dosage he was alarmed. I thought the does was too high, he said.
Counsel assisting the inquest, Gail Furness, asked Dr Little:
GAIL FURNESS (voiceover): "Would you have expected an anaesthetic registrar who was consulting a patient for the purpose of pre-operative check to prescribe medication?"
DR NICHOLAS LITTLE (voiceover): "No. Well, not for analgesia, no."
SHARON O'NEILL: He went on to say:
DR NICHOLAS LITTLE (voiceover): "I would not expect them to change analgesia orders and it is uncommon for them to do so."
GAIL FURNESS (voiceover): "In your experience?"
DR NICHOLAS LITTLE (voiceover): "Absolutely in my experience."
SHARON O'NEILL: The Inquest was told the autopsy report revealed that Vanessa Anderson had four times the therapeutic level of codeine in her blood. Dr Ismail told the inquest she had misread Vanessa Anderson's medication chart, thinking she was receiving ordinary Panadeine instead of Panadeine Forte, which contains 30 milligrams of codeine instead of eight.
In his letter to the Coroner, Dr Barratt wrote that in a...
EXCERPT OF LETTER TO THE CORONER: "debriefing session performed a couple of weeks after the event... I asked her, 'Did you realise when you wrote that does of endone up she was already on Paradine Forte?' At this she stared wide eyed for a good five seconds before I said, 'Of course, when you look quickly at it the order looks like Panadeine'. Her response was 'yes, yes, I thought she was on Panadeine.' I asked her at this point to make sure she was telling the truth and not to say this because I was telling her."
SHARON O'NEILL: This debriefing session was not the first time Dr Barratt had to discuss a distressing incident with Dr Ismail. In his correspondence to the Coroner, Dr Barratt attached a copy of a letter written to the Director of Anaesthesia at Royal North Shore Hospital, Dr Greg Knoblanche. It was dated the 21st March, 2005 - seven months before Vanessa Anderson died. It begins...
EXCERPT OF LETTER TO GREG KNOBLANCHE:
I am particularly concerned about the safety of Sanaa. She has had two critical incidents while you have been away."
SHARON O'NEILL: In the first incident, Dr Ismail:
EXCERPT OF LETTER TO GREG KNOBLANCHE: "inserted an epidural for labour and failed to recognise it was intra thecal. The top up for caesarean section later that evening almost proved fatal."
SHARON O'NEILL: In the second incident, Dr Ismail:
EXCERPT OF LETTER TO GREG KNOBLANCHE: "whilst giving an anaesthetic for a TOE cardioversion did not use any oxygen or monitoring."
SHARON O'NEILL: Dr Barratt then mentions another person who...
EXCERPT OF LETTER TO GREG KNOBLANCHE: "luckily wandered in and attached the oximeter which read 45 per cent."
SHARON O'NEILL: He then concludes:
EXCERPT OF LETTER TO GREG KNOBLANCHE: "I have spoken with Sanaa and there was a lack of insight into the first case. I think she is under pressure with her visa running out and she has enquired about going to New Zealand... Anyway, at the moment she is not safe, for whatever reason."
SHARON O'NEILL: Neither of these incidents were raised with Dr Ismail when she gave evidence before the Coroner, nor were they disclosed by her legal team or counsel representing Royal North Shore Hospital.
In his letter, Dr Barratt told the Coroner:
EXCERPT OF LETTER TO THE CORONER: "This letter generated a meeting without our Head of Department, though her position was considered non negotiable. I agreed to increase her supervision but accepted the fact that she was probably incapable of independent Specialist Practice in Australia."
SHARON O'NEILL: Dr Ismail told the court she was employed by Royal North Shore Hospital from November 2000, to December 2006. But Dr Barratt has told the Coroner this is incorrect. He wrote:
EXCERPT OF LETTER TO THE CORONER: "She was paid for by the Saudi Government. Our hospital paid her on-call only. She did not undergo any selection or appointment process and our role was to train her so she could take up a consultant position at a Saudi University hospital. Her training was modestly prolonged and would not have met requirements for local trainees."
SHARON O'NEILL: Dr Barratt goes on to say:
EXCERPT OF LETTER TO THE CORONER: "In addition to her base salary, which was paid for by the Saudi Government, there was an annual $30 000 education stipend. This was not spent on her training but rather used for pain research within the Department."
SHARON O'NEILL: Vanessa Anderson died at Royal North Shore Hospital on November the 8, 2005. On the last day of the inquest, counsel assisting the Coroner, Gail Furness, told Westmead Coroners Court that Vanessa died from a seizure of an overdoes of medication, or a combination of the two. On the same day, the barrister for the Anderson family, Michael Williams SC, submitted that Vanessa died from respiratory arrest, caused by respiratory depression and a seizure, following the administration of codeine phosphate and oxy codeine, and in the absence of any anti-convulsant medication or intensive monitoring.
The inquest has heard that Dr Nicholas Little had ordered that anti-convulsant medication be prescribed for Vanessa. The person responsible for carrying out that order, Dr Azizi Bakar, gave evidence via a video link from Malaysia where he now works. He did not prescribe the anti-convulsant medication because he said, "I might be too tired to think of what to do. I had been working long hours in the past three days prior to Monday."
Dr Barratt told the Coroner in his letter that Dr Azizi was:
EXCERPT OF LETTER TO THE CORONER: "Almost certainly not subject to any appointments or selection process as in Dr Ismail's case."
SHARON O'NEILL: No evidence relating to the employment arrangements of these overseas doctors was presented to the Coroner. Dr Barratt wrote:
EXCERPT OF LETTER TO THE CORONER: "The position that Dr Ismail is in is not unusual in the Public Hospital System, that there are many other like her. In fact, a few months before the Vanessa Anderson incident a bureaucrat from the DOH (Department of Health) came pleading with us to take more of these 'trainees'. Clearly there is an enormous managerial advantage to these self funded positions."
SHARON O'NEIL: In her final submission, Counsel for the Northern Sydney Area Health Service -which covers Royal North Shore Hospital, Anna Katzmann SC - while accepting flaws in Vanessa Anderson's care, urged the Coroner to record an open finding. The inquest will resume on Monday.