CLOT DEATH: MUM SEEKS TRUTH

Cot death: mum seeks truth

Louise Hall, Sun Herald

March 30, 2008

A MAJOR hospital has admitted that it failed to properly treat a disabled woman who died while in its care.

Karen Stone, 41, was admitted to Sydney's St George Hospital in October 2004, with acute leg pain.

She died a few days later from pulmonary thromboembolism after an undiagnosed clot in her leg travelled to her lung, the State Coroner found the following year.

Now her mother wants to know why doctors at the hospital failed to give her routine preventative treatment.

Lynette Stone said both she and her daughter repeatedly asked hospital staff to investigate if the pain was caused by deep vein thrombosis. Their concerns were dismissed, even though Ms Stone was a high-risk patient.

Mrs Stone questions if her daughter's disability meant she received less care and attention from staff.

Ms Stone had a rare medical condition called Prader-Willi Syndrome that causes an obsession with food and eating, poor muscle tone and learning difficulties.

Debora Picone, who was in charge of the hospital at the time and is now the Director-General of NSW Health, said in a letter to the Health Care Complaints Commission soon after the autopsy that there was no excuse for the failure.

"A satisfactory explanation was not documented in the clinical record nor was the caring medical team able to provide one when questioned," she wrote. She admitted the hospital should have provided anticoagulant therapy.

The simple, but life-saving, injection was finally ordered by a professor who was taking a group of medical students on tour of the ward two days later, but the treatment was still not administered for another 24 hours. Ms Stone died the next day.

"It cannot be ascertained why the omission of treatment occurred," Professor Picone wrote.

The Health Care Complaints Commission did not investigate the death, instead offering conciliation - an informal discussion with no power to make any decisions. Lorraine Long from Medical Error Action Group said government departments set up to deal with complaints had proved to be "ineffective" and a "waste of time" for bereaved families.

"I have not encountered a person to be satisfied with a health-care complaints commission anywhere in the country," she said. "They want you to conciliate a death - it's obscene."

Mrs Stone said her daughter was a "wonderful soul" who brought endless joy to her family and friends.

"In my heart I feel she should still be with us. If only they had taken more care, questioned more about why the pain wouldn't go away, she would not have died," she said.

"If she'd been 'normal' would they have taken more notice of her?"

Venous thromboembolism, which refers to deep vein thrombosis and pulmonary embolism, causes 10,000 deaths each year in hospitals - more than lung and breast cancer combined.

Professor Beng Chong, a hematologist at St George Hospital and head of the Department of Medicine at the University of NSW, said many hospitals did not assign the task of venous thromboembolism risk assessment to particular doctors or nurses, while many simply forgot.

lhall@sunherald.com.au

Source: The Sun-Herald