Families live with loss as patient deaths investigated

The mother-of-one aged 55 ate a sandwich and said goodbye to husband Valentine not knowing she would be brain dead later that day and officially dead less than a fortnight later.

Hers is one of at least two deaths of Canberra public hospital patients being investigated by the ACT Coroner.

Mrs Thurairajah died after a tube was incorrectly put down her oesophagus, according to documents obtained by The Canberra Times. Documents say the pipe pushed air into her stomach instead of down her windpipe and into her lungs.

''By the time I saw her she was brain dead,'' her 59-year-old husband said. ''I wouldn't wish this on my worst enemies.''

An interim finding by the coroner has already confirmed that the tracheal tube was incorrectly placed but the final coroner's report is not expected to be handed down until later this year after several days of hearings in November.

Mr Thurairajah said his wife went to hospital in 2011 for haemodialysis to remove waste from her blood because of kidney failure. But there were complications involving breathlessness, which is when the error is believed to have occurred.

She spent 10 days in a coma.

''They wanted me to give permission to switch the [life-support] machine off but I'm a Christian - I can't take someone's life,'' he said. ''It was terrible.''

Mr Thurairajah, through legal firm Maurice Blackburn, reached a confidential settlement with the hospital for compensation. The coroner's interim finding was handed to the hospital for a clinical review.

The Thurairajahs are just one of the families who describe their hospital experience as traumatic.

The coroner is investigating the death 12 months ago of Suzanne Smart, after she caught a flesh-eating infection and had her bowel punctured at Calvary Public Hospital.

The ACT Medical Board is investigating two doctors involved in the 75-year-old's treatment.

This follows recent reports of infections at hospitals run by Calvary. The Canberra Times revealed last week that three ACT women needed legs amputated because of infections caught following apparently simple knee replacements at Calvary Public and Calvary Private hospitals.

In an expert report prepared for the inquest into Mrs Smart's death, Prince of Wales Hospital's senior general surgeon Philip Truskett said the poor judgment of a surgeon in an elective surgery led to the death of Mrs Smart nearly four months later.

Members of the family were left shocked after what they believed was a routine surgery to remove an ovary cyst led to a further nine operations across three months.

They criticised the lack of detail they say they were provided on Mrs Smart's condition.

In his report to the coroner, Dr Truskett said the doctor should have

used an alternative surgical method during the operation in May last year.

The expert report said the doctor used a spring-loaded needle during keyhole surgery. The procedure, which involves the blowing of gas into the abdominal cavity, was abandoned after three unsuccessful attempts. Instead a larger incision was made in the lower abdomen - away from the earlier needle entries - which made it more difficult to see if the needling had damaged Mrs Smart's bowel.

"My major criticism is the inappropriate use of a Veress needle in a patient who was known to have complex adhesive disease of her small bowel in the area of her umbilicus [navel]," Dr Truskett said.

"If the subsequent laparotomy [the procedure involving the large incision] had been performed in the region of the umbilicus, then it is most likely that the injuries to the small bowel could have been recognised and safely repaired. The subsequent sequence of events and eventual demise was the result of poor decision-making at the time of the initial laparoscopy."

The second doctor being investigated by the watchdog reviewed the patient on May 6 and diagnosed necrotising fasciitis, a flesh-eating infection that destroyed an area of tissue about the circumference of a soccer ball before it was controlled.

In urgent surgery a day later, this doctor found two small holes in Mrs Smart's bowel and, with a large volume of its "content" leaking, 30 centimetres of the small bowel was cut away.

After further procedures, Mrs Smart decided to be discharged from hospital on August 23 having been told nothing further would help. She died at home seven days later.

There was no response from the surgeon after his office was contacted on two days last week.

In a letter to Calvary's patient safety and quality unit in February this year, the experienced doctor expressed sympathy and regret to Mrs Smart's daughter Margaret Hurley in relation to "apparent inadequate communication to her and her family" regarding procedures and treatment provided to her mother, but made no mention of any surgical errors. "Unfortunately, the risk of bowel injury is a recognised risk from a laparoscopy and that risk was advised to Mrs Smart in my pre-operation consultation with her," he said.

When contacted, the second doctor indicated through his office he was unable to comment because of the coronial investigations. Dr Truskett made no criticism of the second doctor in his report, describing his clinical care of Mrs Smart as appropriate.

One of Mrs Smart's sons, Stephen Smart, said the family was not told of the seriousness of his mother's condition and was not aware of part of the small bowel having been removed until she was discharged.

"With the hospital, the information given to the family was completely different from what happened. That's what I feel anyway," he said.

In a letter to the Health Services Commissioner, the second doctor describes in detail the communications he had with Mrs Smart and her family, including warnings at different times in May that there was a high risk she would not survive, and the risks of complications including death from her final major surgery on July 30, but also optimism that if she could recover from that she may have been able to go home soon.

Mr Smart said the Coroner's Court had requested another medical report from a Melbourne expert. Coroner's Court registrar Amanda Nuttall confirmed the coroner was waiting for one more report before deciding if there would be a hearing.