NEW SOUTH WALES MID-NORTH COAST —

A coronial inquest has found the death of a 19-month-old girl at Port Macquarie Base Hospital after an incident during surgery in February 2019 could have been prevented.

The Coroner Derek Lee said anaesthetic team missed a “constellation of signs” that the intubation was incorrectly placed in the oesophagus.

Coroner Lee said there were a number of signs indicating the ETT had been place incorrectly, but staff failed to recognise them.  The oesophageal intubation [incorrectly placed ETT] resulted in sudden deterioration of the girl’s condition,” he said.

“Her heart rate and oxygen saturations decreased to precariously low levels and she went into cardiac arrest.  Despite resuscitation efforts, she could not be revived and was tragically pronounced deceased, only 10 hours after arriving at the wildlife park.”

Port Macquarie Base Hospital is part of the Mid North Coast Local Health District which has apologised to the victim’s family.

Mid North Coast Local Health District Chief Executive Stewart Dowrick said since the incident, appropriate measures have been put in place at Port Macquarie Base Hospital to help prevent another tragedy of this kind.

SYDNEY —

Vale Eddie Jaku OAM.  At 101½ years he has sadly passed away.

We honour you Eddie.  Great friend of MEAG … a wonderful person to know.

Cherished friend of Lorraine Long for some 36 years.  Thank you for your kindness, joy, generosity, spirit and wisdom.

Eddie Jaku, Medal of the Order of Australia, 2013 Australia Day Honours.

You’ve got to read his book “The Happiest Man on Earth”.  Eddie was a best selling author at 100 years of age!

South Korea is forcing surgeons to film their operations to prevent the sexual abuse of patients under anaesthetic and procedures being carried out by unqualified “ghost doctors”.

It follows cases in which patients suffered injury or died in some of the country’s numerous and poorly regulated cosmetic clinics when surgeons allowed inexperienced or unqualified colleagues to perform operations in their place.  South Korea is the first developed country to impose a legal requirement on doctors to film procedures after parliament passed a law this week.

“It is a medical crime when someone else — ‘a ghost’ — performs the surgery, and not the surgeon hired, without [the] patient’s consent,” Lee Na-geum, whose son died in 2016, said.  “There are so many unfortunate bereaved families who cannot expose the truth because they don’t have physical evidence when a healthy person dies in an operating room.”  Her son, Kwon Dae-hee, a 24-year-old student, died after seven weeks in a coma following botched cosmetic surgery on his jaw at a clinic in Seoul.

CCTV obtained by Lee showed that although the doctor for whom he was paying began the operation, it was completed by a non-specialist who had only recently left medical school.

Her son began to haemorrhage as indifferent nurses applied make-up and looked at their phones.  The head surgeon at the clinic, which has since closed, was convicted of involuntary manslaughter and jailed for three years.

Kwon’s family were awarded damages of 430 million Korean won (£270,000) in 2019.  Lee said: “I think many youngsters are still victimised by ghost surgeries at factory-like plastic surgery hospitals.”

The law was opposed by some doctors who feared it would compromise privacy and discourage specialists from making decisions in the interests of their patients.  Others believe cameras will prevent abuse, including sexual assault.

SOURCE:  Richard Lloyd Parry, Asia Editor, The Times London

CCTV in operating theatres aims to foil rogue surgeons

MEAG COMMENT:  We have pushed for this for many years — written about it, spoken about it.  

Today we honour June Long and remember her iatrogenic death for it is the reason The June Long Foundation for Patient Safety and the fearless         Medical Error Action Group were founded on 16 August 1996.

June Long, sportswoman, medical, veterinary and vaccine researcher, loving mother, we honour and remember you.

LONDON — Lord Kenneth CLARKE, who was a Thatcher Government Conservative Minister of State for Health (1982-85), Secretary of State for Health (1988-90), was in the witness box at the Infected Blood Inquiry yesterday.

Ken CLARKE has been criticised by families affected by the infected blood inquiry for displaying “contempt” in his evidence after he showed a reluctance to answer questions.

Lord Clarke appeared to become irritated with the level of detail being examined by the lead counsel, Jenni Richards QC.

At one point, he asked: “Why do we have to go through such meticulous detail through who said what when, when did he change his mind?”  He added that it was “interesting” but “pretty pointless”.

Earlier he said he was not responsible for blood products during the early days of the infected blood scandal despite being a health minister at the time.  He said he was dealing with policies such as closing “old Victorian asylums” or getting rid of “old geriatric hospitals”.

“I didn’t call meetings on it.  I was never the minister directly responsible for blood products. I was never asked to take a decision on blood products.  I never intervened to take a decision on blood products.  I did intervene or get involved in discussions a bit when I wanted to be reassured.”

Judge Sir Brian Langstaff is running this inquiry and determines the questioning, not Lord Clarke!

Read more of Sarah Marsh’s story in The Guardian:

Ken Clarke criticised for showing ‘contempt’ at infected blood inquiry

Let all politicians’ heads roll for their dereliction of duty.

Australia’s politicians?  You’re next.

LONDON — CONTAMINATED BLOOD INQUIRY UK — Not a day goes by without the horrors of contaminated blood being revealed.

Treloar College, Hampshire, school for children with a disability, were caught up in what has been called the worst treatment disaster in NHS history.

From 1974 to 1987, young boys with haemophilia were given Factor VIII contaminated with HIV and viral HEPATITIS C – and a death sentence with it.

At least 72 died after being given a drug contaminated with it.

The “official cover-up” by the British Government!  It is the “unofficial cover-up” in Australia.

30,000 British received contaminated blood, 3,000 died.  These are the figures being revealed now.

Politicians involved in the cover-up are unfolding.  Australia’s turn is coming.

In Australia MEAG knows of 20,000 patients who were contaminated and about the same number died.  But our government could not care less.

Read more from the BBC News Jim Reed’s story:

Contaminated blood inquiry: The school where dozens of pupils died.

Read more from The Sunday Times Caroline Wheeler’s story:

‘We told them the truth: the boys were infected, some would die early’

LISMORE, NORTHERN NSW — The NSW Parliament Legislative Council’s Rural Regional Remote Health inquiry is hearing evidence in country New South Wales.

During evidence at the inquiry yesterday the Northern NSW Local Health District CEO Wayne JONES denied doctors were under pressure to discharge patients to free up beds or meet key performance indicators.  Mr JONES instead blamed a lack of preparation for the “rare” instances.

Wayne JONES, who are you kidding?  We didn’t come down in the last shower. The general public doesn’t have to run local health districts to see glaring omissions and failures happening on your watch.  These LHD CEOs are the people in charge!  For God’s sake, spare us, please.

Wait till you’re in hospital Wayne JONES and get a taste of your own medicine.

NSW Ministry of Health can’t work out what is wrong?  Stupidity rules.

Read the story in full in today’s Sydney Morning Herald by Carrie Fellner:

Lismore Base Hospital ‘booted out’ patients in the middle of the night in their pyjamas

NEW SOUTH WALES, MID NORTH COAST — Today’s hearings into Rural Regional Remote Health inquiry raised another criminal doctor Emil GAYED that our regulators deliberately omitted to oust and failed his patients who were injured by his medical methods.

Now we have another Local Health District CEO saying “sorry”.  Well, Hunter New England Health CEO Michael DiRIENZO, your sorry doesn’t cut it.  MEAG wrote to you repeatedly about this criminal practising as a doctor, you deemed fit to allow the public to be damaged, and did nothing.  You’ve still got your job?  How is this?  Shall we list all the other stuff-ups you have covered up?

Reminder to read the ABC News Mid North Coast Kerrin Thomas’ story:

Disgraced gynaecologist Emil Gayed continued to operate due to inadequate oversight, regional health inquiry hears

Europe —  German firm TUV Rheinland was negligent in awarding safety certificates to a French company which made faulty breast implants, a Paris court ruled, a decision advocacy groups said paved the way for thousands of women worldwide to seek damages.

More than 300,000 women received implants that were made in the 10 years up to 2010 by PIP (Poly Implant Prothèse) and filled with cheap, industrial-grade silicone not cleared for human use.

Aumaitre said the court’s ruling meant that TUV’s negligence left it solely responsible for paying damages.

“After 10 years of waiting and fierce combat, the German certifier will have to fully compensate the victims,” said Aumaitre.

Read the full story by Matthieu Protard and Richard Lough of Reuters:

French court orders damages for victims of PIP breast implant scandal

Read more of MEAG’s work on this:  PIP breast implants: A ruptured disaster