A family hopes the death of their beloved mother and grandmother will spark changes at Canberra Hospital so others are spared the same ordeal.
ACT Coroner John Burns has handed down a scathing report after investigating the circumstances surrounding the death of 86-year-old Mary Ellen Gilligan.
One of her six children, Eileen Stanley, said yesterday the family welcomed the coroner's report.
"We very happy with the coroner giving a finding that maybe will prompt change so that nobody else's grandmother or grandfather or even a 30-year-old would go through that," she said.
Mrs Gilligan who had six children and 19 grandchildren was an "amazing" women.
"At 86 she was very, very active [and] led an independent life," Mrs Stanley said.
Her mother was brought by ambulance to Canberra Hospital's emergency department about 5pm on March 3, 2005 suffering from abdominal pain.
She was misdiagnosed with peptic ulcer disease and sent home at 7.55pm, according to the coroner.
Mrs Gilligan was still in "significant pain" that night and returned to the emergency department about 11am on March 4.
"It is of great concern that between 2pm and 4.30pm there is no evidence of any observations of Mrs Gilligan being recorded whilst she was in the emergency department," Mr Burns said.
A simple blood test revealed that she was suffering from acute pancreatitis. She received treatment in the emergency department and intensive care unit but her condition deteriorated and she died at 11.45am on March 5.
"It is fair to say that the failure to diagnose her condition on March 3 and the failings identified in her care on March 3 and 4 diminished, and perhaps effectively extinguished, any prospects she had of recovery," Mr Burns said in his decision.
Health Minister Katy Gallagher said she would review the coroner's report. "I think that this is a very, very sad case obviously where a number of issues have been highlighted through Mrs Gilligan's experience at the hospital and a number of changes have been made," Ms Gallagher said.
There was an internal investigation into the case. As a result, senior emergency doctors must review cases before patients were sent home and junior doctors had received special training on keeping records and documentation. The Government had also "poured more money" into the emergency department, which paid for extra staff.
"I am confident that there are processes in place which will not allow that situation to occur again and they are around who can discharge [patients] and also training for junior medical staff," Ms Gallagher said.
Opposition health spokeswoman Jacqui Burke said the Canberra community must be "seriously concerned" about the comments made by the coroner.
"All in all, the buck stops with the minister and hospital management," she said. "I have argued time and time again that the Government can throw as much money as they like at the hospital system but without structural, management and cultural reform it will all be a waste of time."
Mrs Burke set up a hotline to take complaints about the health system and it had received about 50 calls to date.
Ms Gallagher wrote yesterday to her Opposition counterpart, urging Mrs Burke to pass on complaints lodged on her hotline.
"Is Mrs Burke using people's ill health and experiences to set up a dead letter office, with complaints going nowhere except as numbers into Mrs Burke's media releases?" Ms Gallagher said.
"If Mrs Burke is getting serious complaints, they need to be forwarded on so that we can deal with them appropriately."
The complaints could be investigated, resolved and lead to changes in the health system if necessary. Mrs Burke said it was curious the Government had dismissed the hotline as a "political stunt" but was now interested. She was "flat-out" collating the information and seeking advice and would pass on the complaints to the Government in "my own time".