The family of Carmen Walker still want answers about the mistakes that lead to their beloved mum's death after a complicated palliative treatment went wrong at Waikato Hospital. Photo / Stuart Munro
The family of Carmen Walker still want answers about the mistakes that lead to their beloved mum's death after a complicated palliative treatment went wrong at Waikato Hospital. Photo / Stuart Munro
A plea for a new inquest into the death of a woman following treatment at Waikato Hospital, has been denied.
Deputy Solicitor-General Virginia Hardy has decided not to order a second coroner's inquest into the death of Carmen Walker, who lost so much blood during a procedure in 2010 that she suffered a cardiac arrest and died soon after.
Walker's son and daughter-in-law Craig and Linda Walker, and a whistleblower doctor who observed the palliative melanoma treatment, have appealed to Hardy to reconsider her decision.
They want all of the details of what happened during the isolated limb infusion [ILI], and how the cause of Walker's death was investigated by Waikato District Health Board and the Health and Disability Commissioner, formally investigated.
"I'm not surprised at the outcome but disappointed," Craig Walker told the Herald.
He said his family felt stonewalled in their efforts to uncover the full version of events that day and without the help Dr Adam Greenbaum they would have had "no hope of fighting this bureaucracy".
"Adam has doggedly pursued this case and presented pretty compelling truths to the Solicitor-General's office."
Carmen Walker, 77, had the ILI on August 3, 2010, to treat metastatic melanoma in her right ankle.
Walker lost too much blood during the procedure and died later that night.
Instead of holding an inquest, Coroner Gordon Matenga determined the cause of death based on the surgeon's report and an autopsy.
Carmen Walker was a fit pensioner who delivered meals on wheels to the elderly before she was diagnosed with melanoma in her ankle that had spread up her leg in 2010. Photo / Stuart Munro
Matenga found Walker died from cardiogenic shock, where the heart suddenly can't pump enough blood around the body, but he did not examine why this happened, or whether the care given to Walker was satisfactory.
It wasn't until after the coroner's ruling that the DHB held an internal review of the sentinel event which found no "root cause" for the death, but a number of issues including that Walker's washout fluid was not measured which "possibly" led to a delay in accurately assessing the blood loss.
Greenbaum, who observed the procedure, lodged complaints with the Health and Disability Commissioner and the Medical Council over Walker's care and the subsequent investigation.
The plastic surgeon, whose employment with the DHB ended in dispute, also complained that his handwritten notes had been removed from Walker's clinical file and was concerned he had not been interviewed for the internal review.
In 2013 Health and Disability Commissioner Anthony Hill found aspects of the care given to Walker were suboptimal but because the DHB was no longer performing the isolated limb infusion he took no further action.
In her letter declining to open a new inquest, Hardy said new facts had emerged since Matenga's inquiry including two competing theories about the rapid blood loss that caused Walker's death.
One was an unrecognised tourniquet leak, as maintained by an Australian expert used in the HDC investigation who said this was a "severe departure from the expected standards for ILI".
The other theory was an unidentified internal lesion, as later suggested by the lead surgeon, which was not found during an autopsy.
Hardy said these facts would have been admissible had they been available to the coroner in 2011.
However, she said the new information was unlikely to lead to any recommendations to reduce the risk of deaths in similar circumstances.
Dr Adam Greenbaum, a consultant plastic surgeon, has urged the Deputy Solicitor-General to reconsider her decision not to order a second inquest in Carmen Walker's death. Photo / Alan Gibson
She said there was no proof of Greenbaum's allegations the DHB deliberately delayed its investigation until after the coroner's inquiry or acted improperly by not consulting him for the review and redacting the clinical notes.
"The threshold for making fraud allegations is high, and there is no evidence in the documents we have reviewed which substantiates your concerns.
"The Commissioner has investigated the role of the DHB and the medical team who performed the procedure and found no evidence of fraud."
She pointed out the coroner was aware that Greenbaum was an observer.
Hardy acknowledged the new facts may lead to a coroner giving a fuller description of the cause of Walker's death to include hypovolaemic shock, but noted a coroner could still find it difficult determining the cause of the blood loss because the waste bucket was not measured.
"Even where there are new facts, the overriding consideration is whether it would be in the interests of justice to reorder a second inquiry.
"I acknowledge the wishes of Mrs Walker's children in favour of a second coronial inquiry, but on balance, I have concluded that it is not necessary in the interests of justice to open a further inquiry into Mrs Walker's death."
But Greenbaum said it was imperative the case be heard in court because so much of it was never investigated, including why the Medical Council did not investigate his complaint, and why the surgeon who usually carried out the complicated procedure was not available that day.
Greenbaum said he and was "bitterly disappointed" by the decision and believed Walker's death was avoidable, that those responsible had not been sufficiently held accountable, and steps to prevent similar patient deaths had not been attempted.
Hill said the complaints to the HDC and Medical Council were separately assessed and resolved, and he was confident that proper processes were followed in relation to both.
