The reluctant crusader

PHIL TAYLOR reports on a widow's dedicated attempt to discover the truth about how her husband died in hospital after what was expected to be a routine operation


This is the story Shirley Crowley never wanted written. To be in the public spotlight is anathema to this capable, determined woman who describes herself as just an ordinary person.

This was not part of the retirement she imagined. That dream was about her and husband Lionel enjoying their six grandchildren, perhaps travelling, taking leisurely strolls along Tauranga's beaches.

Crowley is a regular on the foreshore but her walking companion is not Lionel, it's Candy, her poodle. Candy is a comfort, as pets often are, but much more than that, she is a reminder.

Candy, the runt of the litter, was born on December 21, 2000. "That was the first anniversary of Lionel's death and that is why I got her," says Crowley.

Extraordinary circumstances had intervened to blight Shirley Crowley's dream. Lionel Crowley died because of a series of mistakes which has resulted in Tauranga surgeon Ian Breeze being found guilty of professional misconduct and ordered to pay costs and a $50,000 fine.

The death, nearly four years ago, has led to revelations of earlier concerns about the surgeon and that Breeze had been required to undergo retraining in the mid-90s. The adequacy of that retraining and the way information is passed - or isn't passed - between hospitals and public and private spheres of the health system has been called into question because of Crowley's determination to get answers for the sake of her late husband.

The Health and Disability Commissioner is re-examining two cases in which Breeze's patients died after operations and is likely to be inundated with new complaints, judging by the incessant ringing of Crowley's phone since the professional misconduct finding became public.

She never saw herself as a crusader and doesn't believe she is, but reluctantly accepts she may be a catalyst for others about to embark along the road she has travelled.

Her drive was her determination to get "fairness" for her husband. "He was a very fair person and, well, it didn't need to happen."

Lionel Crowley was 65 when he went into hospital a week before Christmas 1999 for what should have been a routine operation to remove a small cancerous growth from his bowel.

There was no reason to suspect he wouldn't be home to enjoy a family Christmas with their son, who was visiting from Scotland, and daughter, home on holiday from Australia. Their father was home for Christmas, in a coffin. His funeral was held between Christmas and New Year.

By then there was enough concern that something had gone seriously amiss for Crowley's son to tell his mother: "Take notes".

That was before a sympathy card arrived from the surgeon saying the autopsy indicated death was the result of coronary artery disease rather than septicaemia. That was plain wrong, to put it politely, says Crowley.

In fact, the autopsy report said death was the result of the rampant spread of toxins which caused multiple organ failure. The source of the toxins was from faeces which leaked from an 18mm hole in the bowel, which Breeze failed to seal, spreading infection through his patient's body.

Crowley knew none of this as her husband slipped towards death. She has since learned that Breeze didn't read the nurse's notes before operating and didn't visit his patient during a crucial 30-hour period, despite several calls from colleagues warning his patient's condition was serious and deteriorating.

She received the autopsy report six weeks after his death. "After reading that I decided there was certainly something dramatically wrong."

Next, she got the hospital records - "a horror story on their own".

"He [Breeze] didn't come near him from 7am the morning after the operation until at least 30 hours later, when it was too late."

By then Lionel had been resuscitated after lapsing into a coma but was in such bad shape it was decided he was beyond saving.

This was 2.45am on the second day after the operation. He had been transferred to Tauranga Hospital's intensive care unit the previous afternoon from the private hospital where the operation was done.

Breeze came to see his patient later that day but, as the tribunal notes, "by this time the patient's fate was sealed".

Reading through the hospital records, Crowley discovered just how crucial time was. Re-operating was an option as long as it was done before infection became too widespread. As time ticked by that window of opportunity narrowed, then closed. Although there was an option to operate again, Breeze chose instead a conservative approach of fighting the infection with antibiotics and drainage, which didn't require him to attend the patient.

Crowley recalls her husband telling her, on regaining consciousness the night after the operation, that he felt lousy. She put that down to the stress of the operation, but when she returned the next morning he was shaking. "It was really scary," she recalls.

She was told there had been problems with his epidural anaesthetic but believes in hindsight it was rigor caused by the spread of poison through his body.

During that day Breeze was telephoned three times. A nurse rang in the morning to tell him blood tests showed what the tribunal later called "a very toxic picture". He was rung again about 1.30pm by a doctor who suspected faecal material may be poisoning him. That doctor decided to transfer the patient to Tauranga Hospital's intensive care unit and stressed to Breeze that his patient was very sick.

Breeze preferred to continue the conservative approach rather than to operate.

In the afternoon, a Tauranga Hospital doctor rang Breeze and outlined a dire situation: faecal material was being drained, low white cell count, profound septic shock and the likelihood of imminent respiratory failure.

The doctor told the tribunal Breeze ruled out his suggestion of an operation and said he would contact the on-call acute surgical registrar and visit his patient the next morning. Breeze told the tribunal he believed he had called but the registrar was emphatic he hadn't.

The tribunal report notes Breeze was 10 minutes away from Tauranga Hospital when notified of the seriousness of his patient's condition late that afternoon. Breeze went home soon after 5pm and went to an end-of-year function that evening, the report says.

Lionel Crowley's condition deteriorated during the night. Shortly before 3am he stopped breathing but was resuscitated. His condition was so bad it was decided no further resuscitation would be attempted.

By the time Breeze visited, later on December 18, there were no options left. Lionel Crowley died on December 21, 1999.

On the strength of the autopsy report and hospital notes, Crowley requested a coroner's inquiry into her husband's death.

"Then I went down the long trail to the Commissioner of Health and Disability [Ron Paterson] and it took 3 1/2 years."

She drove to Auckland and spent most of a day with Paterson. At the end of the session she was asked "which complaint do you want to follow through?"

Five specific complaints were put to the tribunal, which has found three amount to professional misconduct. It allowed Breeze to continue to practise because, as far as the tribunal was aware, these were a one-off set of facts.

Crowley, whose brown hair turned grey during her pursuit of these facts, wonders about that.

Lynda Scott, a geriatrician and the National Party's health spokeswoman, told Parliament this week there had been "13 cases of documented 'serious complications', five accident compensation medical mishaps, two medical errors and six complaints to the Health and Disability Commissioner".

As a result of Lionel Crowley's death, Breeze was stopped from doing bowel surgery by Southern Cross and by Tauranga Hospital but the private Norfolk Community Hospital claims it wasn't told about this until it merged with Southern Cross. About a year after Crowley's death, and a year before the merger, Breeze operated on Barry Baker, 69, to remove a small cancerous growth from his bowel.

Baker died 25 days later after two more operations. ACC accepted a claim for medical mishap and his is one of two cases the Health and Disability Commissioner is considering reopening.

Just when Crowley thought this episode of her life was at an end, she is being sought out as a mentor. It's not a role she wants but she feels an obligation.

"I am absolutely shattered about the fact that there are so many people who have come out of the woodwork." She's been told about 20 stories, each complaining that the same doctor made mistakes. Some patients had died, others were "suffering horribly. Their quality of life has deteriorated to such an extent they find it difficult to carry on living, a couple of them.

"I think there should be an inquiry right now and I also think there should be a helpline for some of these people, because I'm not a counsellor. They've come to me because I'm an individual who has done the long walk."

Her advice? Keep going until you are satisfied you have the answers.

"Don't ever accept someone telling you, 'Oh, he died of so and so'. I'm not vindictive. All I ever wanted to know was the truth. If he [Breeze] had said to me, 'Look, I stuffed up, I'm really sorry', I would probably have walked away."

But for the sake of others now coming forward, she's thankful to have seen the journey through. Satisfaction came with the Medical Practitioners Disciplinary Tribunal's decision, "because I had been vindicated in that I wasn't a stupid female. I was right".

She wasn't specifically accused of such a thing but she did discern an attitude. At the one meeting she had with Breeze after her husband's death she was told to go home and finish grieving.

"I never set out to create a witchhunt and I don't think it's developed into that. I set out to find out the reasons why he died and how he died. I just wanted it clarified."

She didn't go to the media with her story and is reluctant to be in the spotlight now. She recalls the case of Northland gynaecologist Graham Parry who was accused of disgraceful conduct.

"Really, he was crucified by the media first before the tribunal hearing and I didn't think that was fair. That's why I shut up, because I didn't want people to say to me afterwards, 'Oh yes, but you sounded off to the media and the poor guy didn't have a chance'.

"I went through the proper process."