The son of a Tuggeranong woman who died after the alleged poor judgment of a Canberra surgeon has said he will write to the doctor asking for an apology, after two coroners recently refused to hold a hearing into last year's death.
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The coronial inquest confirmed Suzanne Smart, 75, died last August of blood poisoning which followed the perforation of her bowel during a surgery at Calvary Public Hospital in May to remove her ovaries.
Stephen Smart said the one-page decision the family had waited on for nine months was disappointing, as it left unanswered why the experienced surgeon Dr John Hehir had chosen a keyhole (laparoscopic) surgical procedure, a move criticised in the two expert reports prepared for the coroner.
"It's more the whys, why did this happen … why did you get it wrong, why didn't you go back and look at it, they don't ask those questions," Mr Smart said.
"[My sister] Margaret and I have decided I'm going to write a letter asking Dr Hehir for an apology - he's had ample time to come up with an apology, or else he doesn't think he's done the wrong thing."
Coroner Bernadette Boss said in her October 3 decision she had no jurisdiction to make findings or comment on the surgeon's decision to conduct an operation on Mrs Smart on May 2 last year, or the selection of technique used. Mr Smart requested a review of Coroner Boss' decision not to hold a hearing, which the coroner did but repeated her view, with Chief Coroner Lorraine Walker then endorsing the position that the manner and cause of death had been "sufficiently disclosed", and no hearing was required under territory legislation.
In her six-page reasons released on October 30, Chief Coroner Walker referred to the report of gynaecological surgeon Dr Leslie Reti, who said Mrs Smart's relevant medical history meant laparotomy (a procedure involving a large incision, which was used by the surgeon after the keyhole procedure failed) was the safer option for the ovaries removal.
"In particular he was of the view that Mrs Smart's known, or reasonably anticipated extensive pelvic adhesions, meant the laparoscopy involving 'blind entry' with a Veress needle should not have been considered," Chief Coroner Walker said.
"He expressed the opinion that 'it appears that Mrs Smart died as a result of a cascade of events which followed a potentially avoidable perforation of her small bowel by a Verres (sic) needle'."
In the other expert report, Prince of Wales Hospital's senior general surgeon Philip Truskett said the use of the Veress needle was "inappropriate", and led to the flesh-eating infection, surgeries and ultimate death which followed.
"The subsequent sequence of events and eventual demise was the result of poor decision-making at the time of the initial laparoscopy," Dr Truskett said.
Chief Coroner Walker made no criticism of either expert's report, quoting the conclusions of both, but also said the laparoscopy decision was ''clearly evidenced on the available materials''.
The family have 30 days to make an application to the ACT Supreme Court for an order for a hearing.
Stephen Smart and his father Rodney say they are not interested in civil litigation or damages, but Mr Smart senior seeks the possibility of an appeal against the no-hearing decision.
Regarding the surgeon's requested apology, Stephen Smart said: ''If he doesn't think he needs to I think he better have a hard look at himself … there's other people he has affected for the rest of their lives."
The surgeon was interstate last week and there was no response after his office was contacted.
In a letter to Calvary's patient safety and quality unit in February this year, Dr Hehir said bowel injury was a recognised risk from a laparoscopy, and that risk was advised to Mrs Smart in his pre-operation consultation with her.