Carmen Walker with her husband Bob Walker. Photo / Supplied
Carmen Walker with her husband Bob Walker. Photo / Supplied
A woman suffering from terminal cancer bled to death after treatment supposed to prolong the length and quality of her life.
An investigation by the Health and Disability Commission found aspects of the care given to Carmen Walker were "suboptimal" and the Waikato District Health Board was criticised for lacking several safeguards.
The Health and Disability Commissioner decided to take no further action and the DHB no longer performs the complex procedure.
The family of Walker, who was a fit 77-year-old other than the melanoma, says the questions raised by her death in 2010 have not been answered.
"It was unbelievable to be perfectly honest," her son Craig Walker says.
A malignant melanoma on Walker's right ankle had spread up her leg, despite radiotherapy and surgery to remove the cancerous nodes.
Amputation was suggested but in an attempt to improve the quality of life for her remaining years, Walker decided to undergo palliative treatment called isolated limb infusion (ILI).
Walker with sons Craig and Lane Walker. Photo / Supplied
The palliative treatment is uncommon in New Zealand and not without risk, like any complex procedure.
Normal chemotherapy treatment attacks healthy and sick cells throughout the body.
But with ILI, doctors cut off the circulation to a limb with two tourniquets and infuse a highly concentrated chemotherapy agents to "bathe" the cancerous cells.
The stronger dose would be toxic if given like regular chemotherapy.
But with the tourniquets in place, the concentrated chemotherapy can be given directly to the affected limb with only a small amount escaping into the patient's circulation system.
The tourniquets also stop oxygenated blood flowing from the heart into the limb, so a bypass machine is used to maintain circulation.
At the end of the treatment, tainted blood is drained into a waste bucket and the limb "washed out" with solution before the tourniquets are released.
It was at this point Walker's blood pressure dropped and her heart stopped.
Despite being resuscitated, she died in Waikato Hospital later that night.
Coroner Gordon Matenga ruled the cause of death was "cardiogenic shock" - extreme low blood pressure - as a direct result of the procedure.
However, the Coroner and an internal Waikato DHB investigation did not reach a definitive conclusion as to why Walker suffered such severe loss of blood pressure.
Several contributing factors were raised including the possibility the tourniquets had not completely isolated Walker's leg, as her arteries were hardened from calcification.
This would mean blood from Walker's body seeped under the tourniquet, into her leg, then drained into the waste bucket during the "washout phase".
Dr Adam Greenbaum, who observed the procedure and attempted to later resuscitate Walker, was concerned at not being interviewed as part of the internal DHB investigation.
He laid a complaint with the Health and Disability Commissioner Anthony Hill about the care given of Walker.
In a letter to Hill about the complaint, DHB chief executive Craig Climo described Greenbaum as "vexatious" after an employment dispute settled out of court.
However, Associate Professor Susan Neuhaus, the independent expert engaged by the HDC, found a number of problems after Greenbaum's complaint.
No one measured the washout fluid - which was not part of the DHB protocol for the procedure - or checked whether the tourniquets were leaking.
While she did not question the "competence or intent" of members of the team, Neuhaus said these issues "did not provide an environment" where problems could be identified at an early stage.
In her opinion, Walker most likely died from undetected blood loss during the "washout" phase.
This was disputed by the lead surgeon who said it was "impossible" - based on maximum flow rates - for Walker to have suffered the massive blood loss during the washout phase.
In his opinion, the surgeon said undetected internal bleeding - not the washout phase - was the likely source of the blood loss.
As the washout fluid was not measured - ironically, one of the identified failings - Health and Disability Commissioner Anthony Hill said he was unable to determine the cause of the blood loss.
But he found aspects of the care of Walker were "suboptimal".
"A procedure of this kind must have adequate systems in place to ensure the early detection of serious complications," Hill wrote in his 2013 findings.
"It is my view that where a vascular procedure involves the removal of a significant volume of blood from a patient, there should be systems in place to alert the surgical team."
The Waikato DHB and the doctor wrote letters of apology to the Walker family as a result of the HDC report.
"We were all absolutely devastated and are very very sorry about how it turned out," the surgeon wrote.
In a statement to the Weekend Herald, the Waikato DHB said it always intends to deliver the best possible care to patients.
"It is regrettable that on this occasion, eight years ago, we did not live up to our own expectations and we continue to express our apologies to the family. We engaged fully in the Health and Disability Commissioner's Investigation at that time and accept the associated findings."
Hill took no further action in the case as the DHB no longer performed isolated limb infusion, so there was no ongoing risk to the public.
It's a decision which continues to frustrate the family of Walker.
They say the Coroner ruled on the cause of her death without knowing all the facts about her care, while the HDC ruled on her care without determining the cause of death.
"It's hard to believe someone could die in circumstances like this and nothing happens," says her son Craig Walker.
