Assignmen Task :
INTRODUCTION
1. On 4 April 2012, Helen MacFarlaine (the deceased) underwent elective surgery at Sir Charles Gairdner Hospital (SCGH) on her right sided carotid artery. The surgery was uncomplicated and technically successful. She remained at the hospital for post operative care for a number of days and was discharged home on 8 April 2012.
2. The following morning, the deceased suffered a catastrophic stroke and returned by ambulance to the Emergency Department of SCGH. She was diagnosed with a devastating and non-survivable intracerebral haemorrhage and was transferred to the Intensive Care Unit, where she was treated palliatively until she died on the morning of 12 April 2012. Her death was reported to the Coroner and police officers from the Coronial Investigation Unit commenced a coronial investigation.
3. As part of the investigation into the death, on 10 to 12 March 2015, I held an inquest into the death. The evidence at the inquest hearing was primarily directed towards the deceased’s post operative management at SCGH, particularly in relation to monitoring of her blood pressure, and the decision to discharge the deceased on the morning of 8 April 2012.
4. The documentary evidence comprised a volume of materials obtained during the coronial police investigation,1 the deceased’s original medical file,2 and a number of additional exhibits tendered during the hearing.3
5. Oral evidence was heard from Professor Knuckey, the neurosurgeon who performed the deceased’s initial surgery, and then from a number of the doctors and nurses involved in her post-operative care in the Neurosurgery Ward at SCGH. In addition, Dr Baker, the intensive care specialist who cared for the deceased on her re
admission to SCGH, and Professor Bryant Stokes, a Clinical Professor of Neurosurgery, gave expert evidence in relation to the overall care of the deceased leading up to her surgery and from then until her death.
6. At the conclusion of the hearing, a letter from the deceased’s husband was provided to the Court in lieu of submissions.4 Written submissions were later filed on behalf of Sir Charles Gairdner Hospital, Dr Mahindu, Nurse Watt and Professor Knuckey. I have
THE DECEASED
7. The deceased was a 52 year old Anglo-Indian woman, having been born on 7 November 1959 in Calcutta, India. She moved to Western Australia with her family as a teenager. She qualified as a teacher and at the time of her death she was working as an English
teacher in South Hedland.5
8. The deceased had a son from a previous marriage and had remarried a couple of years before her death. She had not taken her new husband’s name to avoid confusing her students with a name change.6
9. The deceased’s husband described the deceased as strong willed but easy going, although she could come across as quite blunt because she would usually say what she thought.7
10. In relation to her general health, the deceased smoked up to a packet of cigarettes a day and was slightly overweight.8 She drank approximately half a bottle of wine a night and smoked a small cone of marijuana every night to help her sleep.9 She was apparently not on any medication until it was prescribed in the lead-up to her surgery,10 although she had an ongoing anxiety disorder.11
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