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Speaker 1: My name is Hedley Thomas.

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Speaker 2: Sick to Death is based on my book of the

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Speaker 2: same name, and it's the true story of doctor Jan

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Speaker 2: Patel's lies and manipulation and the herculean effort it took

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Speaker 2: to finally stop him. We've used voice actors throughout this series,

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Speaker 2: and on occasion the real people from the story have

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Speaker 2: read their words for us.

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Speaker 1: It is brought to you by Me and the Australian.

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Speaker 2: Chapter nineteen The Messenger, eighteen March two thousand and four.

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Speaker 2: Rob Messenger wanted to start with a few home truths.

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Speaker 2: He looked up and smiled at his supporters in the

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Speaker 2: public Gallery of State Parliament in George Street, Brisbane. It

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Speaker 2: had been a hard slog to arrive in this place.

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Speaker 1: He hoped it would be worth it.

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Speaker 2: Nobody had ever accused Messenger of being born with a

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Speaker 2: silver spoon in his mouth. At four thirty pm on

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Speaker 2: eighteen March two thousand and four, as the National Party's

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Speaker 2: new member for Burnett prepared to deliver his first speech,

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Speaker 2: he felt unbeatable.

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Speaker 3: I have to confess my journey to this historic chamber

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Speaker 3: was not planned. As a child and teenager playing in

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Speaker 3: the red did cane fields of South Clan. I never

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Speaker 3: harbored dreams of becoming a politician, and I'll be the

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Speaker 3: first to admit that I'm only standing here before you

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Speaker 3: because of God's grace.

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Speaker 2: With a nod to the gallery, Messenger explained how he

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Speaker 2: drew inspiration from his father Dez when self doubt and

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Speaker 2: fatigue set in. Des had been a cane cutter in Bunderberg.

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Speaker 2: Like the Kannakas a century ago. He had the backbreaking

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Speaker 2: job of cutting and loading tons of caine a day

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Speaker 2: for a meager one dollar sixty a ton. Rob Messenger

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Speaker 2: still marveled at how his father Deares managed to feed, clothe,

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Speaker 2: and shelter him and his two brothers.

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Speaker 1: Greg and Danny.

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Speaker 2: When Messenger was a teenager, he danced and sang to

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Speaker 2: the evocative lyrics of Australian band Ganga Jang's anthem sounds

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Speaker 2: of them about growing up in Bunderberg. Out on the

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Speaker 2: patio we'd sit and the humidity we'd breathe, We'd watch

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Speaker 2: the lightning crackover cane fields, laugh and think this is Australia.

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Speaker 2: He remembered his mother Irene, laughing and joking with the

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Speaker 2: other women of the district while they picked tomatoes in

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Speaker 2: thirty five degree tropical heat. Irene lived for Rob's regular

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Speaker 2: visits to her bedside at Bunderberg Hospital in the weeks

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Speaker 2: before she finally succumbed to a particularly aggressive bow cancer.

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Speaker 2: In September two thousand and two. Messenger watched his well

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Speaker 2: known mother die at the hospital after an eighteen month battle.

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Speaker 2: He came to know the doctors and nurses. Some of

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Speaker 2: them began confiding a few secrets and worries. The hospital

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Speaker 2: was running on empty. It had been managed to a

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Speaker 2: standstill and starved of funds as the district manager, Peter Leck,

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Speaker 2: enforced rigid budgetary controls. Specialists and the best doctors were

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Speaker 2: leaving disillusioned and distressed at the deteriorating levels of care.

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Speaker 2: All the while, public announcements and press releases from Queensland

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Speaker 2: Health's Brisbane headquarters spewed positive but wholly misleading guff about

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Speaker 2: the hospital in which Messenger had been born. Messenger used

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Speaker 2: his first speech to underline what he knew from his

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Speaker 2: months on the campaign trail. The hospital was sick. It

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Speaker 2: was a diseased limb of a very sick body, whose

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Speaker 2: staff had been cowed into silence.

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Speaker 3: These dedicated professionals must be allowed to tell the truth

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Speaker 3: while avoiding any possibility of placing their careers with Queensland

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Speaker 3: Health in jeopardy. These workers' stories must be heard and

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Speaker 3: acted on if the people of the Bernet are ever

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Speaker 3: to enjoy the level of health care that they richly deserve.

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Speaker 2: The parless condition of the health system was a major

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Speaker 2: feature of the state election campaign in early two thousand

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Speaker 2: and four. The opposition coalition, of which Rob Messenger was

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Speaker 2: a member, had paid for hard hitting advertisements depicting people

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Speaker 2: who had waited years for straightforward surgery, while the Australian

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Speaker 2: Medical Association ran a highly effective campaign to highlight secrecy

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Speaker 2: and underfunding in the health system. Stung by the constant

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Speaker 2: stories and revelations from clinicians about how patients were so

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Speaker 2: offfering because the hospitals could not cope with demand, Premier

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Speaker 2: Peter Beatty threw money at the problems. The waiting lists

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Speaker 2: for surgery were a significant part of Beattie's electoral strategy.

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Speaker 2: He pledged a one hundred and ten million dollar injection

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Speaker 2: of extra funds to pay for thousands of extra operations.

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Speaker 4: This new initiative will be the biggest effort to reduce

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Speaker 4: elective waiting lists that Queensland has ever seen. People have

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Speaker 4: made it clear to me over a period of time

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Speaker 4: they want these lists tackled. We have done well, but

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Speaker 4: clearly we can do better. We will be making health

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Speaker 4: our number one priority.

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Speaker 2: The Health Minister Wendy Edmund had retired from politics. By then,

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Speaker 2: Beatty had kept a straight face while commending her as

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Speaker 2: the country's best health minister. The new Health Minister, Gordon Nuttle,

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Speaker 2: was telling his executive team to put every public hospital

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Speaker 2: on notice the waiting lists were critical. In the internal

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Speaker 2: confidential briefing paper he received after being sworn in, Nuttle

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Speaker 2: was worn that Queensland Health had become extremely reliant on

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Speaker 2: overseas trained doctors, who comprised thirty percent of the medical workforce.

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Speaker 5: Employment of overseas trained doctors provides a short term solution

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Speaker 5: to doctor shortages. However, this approach brings with it a

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Speaker 5: range of skill and competence issues.

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Speaker 2: Messenger hammered health issues as stubbornly and relentlessly as he

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Speaker 2: had during his electoral campaign. He repeatedly called for an

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Speaker 2: independent investigation into Bunderberg Hospital, its procedures and practices. The

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Speaker 2: attempts by the Beatty government to silence him became farcical.

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Speaker 2: At one point, Messenger had said.

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Speaker 3: Rather than pulling back from this issue, I intend to

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Speaker 3: turn up the blow torch.

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Speaker 2: The metaphor was too much for Nuttle, who called for

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Speaker 2: a formal investigation into whether Rob Messenger planned to commit

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Speaker 2: arson or burn alive any bureaucrats. Messenger was industrious and

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Speaker 2: highly effective. He uncovered figures showing the hospital had just

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Speaker 2: one hundred and thirty six beds, eighty one fewer than

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Speaker 2: in nineteen eighty nine, despite the region's steady growth. The

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Speaker 2: door of his electorate office at Bagara, near Jayant Patel's

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Speaker 2: home apartment, was always open to hospital staff with stories

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Speaker 2: of crises. Doctors came to tell him how they had

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Speaker 2: been forced to work twenty four hour shifts, compromising patient

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Speaker 2: care through sheer exhaustion. The regular outpourings were embarrassing for Nuttle,

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Speaker 2: and they were infuriating the new Director General of Health,

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Speaker 2: doctor Steve Bucklin, who had angrily banged the desk and

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Speaker 2: abused Messenger in one memorable meeting. During a short stint

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Speaker 2: as acting Director of Nursing, Tony Hoffman was surprised to

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Speaker 2: see Peter Leck, who read the speeches on the parliamentary

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Speaker 2: website as soon as they had been posted, furiously denouncing

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Speaker 2: something Messenger had said. Peter Leck and Darren Keating stood

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Speaker 2: at the computer screen and ridiculed the politician. An unprecedented

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Speaker 2: meeting of the executive staff was called by Lek to

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Speaker 2: discuss what effect having a National Party member would have

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Speaker 2: on the hospital. Lek expected Rob Messenger to create trouble.

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Speaker 2: Lek wondered if the parliamentarian was upset about the hospital's

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Speaker 2: treatment of his mother. Hoffman realized that Messenger had become

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Speaker 2: a major thorn in their side. She liked his courage

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Speaker 2: and stamina. He was like a dog with a bone

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Speaker 2: in relentlessly exposing the hospital's ills. He spoke of patients

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Speaker 2: dying unnecessarily due to a dangerous culture, borrowing from one

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Speaker 2: of the maxims of Anglo Irish statesman, politician and philosopher

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Speaker 2: Edmund Burke, a leading light in the House of Commons

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Speaker 2: more than two hundred years ago. Messengers spoke of evil

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Speaker 2: prospering while good men remained silent. Hoffman wondered if she

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Speaker 2: might one day pluck up the courage to go to

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Speaker 2: Messenger about Jayant Patel good.

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Speaker 1: Men had done nothing. It might be left to a

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Speaker 1: good woman.

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Speaker 2: Chapter twenty The Catalyst, July two thousand and four. Dares

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Speaker 2: Bramich liked to stay busy. If a job was worth doing,

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Speaker 2: he wrecked it was worth doing straight away. A little

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Speaker 2: after four point thirty pm on Sunday, twenty five July,

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Speaker 2: Des Bramage, age fifty six, was doing one of those

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Speaker 2: good deeds. It had been a glorious day in Agnus Water,

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Speaker 2: a sleepy seafront community about.

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Speaker 1: An hour and a half's drive from Bunderberg.

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Speaker 2: Grammage, who ran an earth moving business with his son Mark,

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Speaker 2: was beneath a caravan. He was helping to remove one

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Speaker 2: of its tires for his youngest son Luke, before the

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Speaker 2: sun disappeared. On one of the shortest days of the year.

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Speaker 1: Mark was walking back to.

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Speaker 2: The land rover to get some tools when the caravan

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Speaker 2: fell from its supports. The muffled thud as the weight

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Speaker 2: came down onto his father's chest sounded ominous. Mark looked

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Speaker 2: back and saw his father conscious but gasping.

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Speaker 1: He was clearly having trouble breathing.

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Speaker 2: Unknown at the time, two of his ribs were badly fractured.

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Speaker 2: A plural membrane lining the inside of the chest wall

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Speaker 2: was torn on the right side. The upper part of

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Speaker 2: his sternum was also fractured, probably damaging arteries running down

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Speaker 2: either side of his breastbone. Mark rushed to get a

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Speaker 2: jack from the car to try to lift the caravan

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Speaker 2: off his dad's crushed chest.

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Speaker 1: In the panic and fading light.

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Speaker 2: On an afternoon that had become suddenly bleak and foreboding,

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Speaker 2: he fumbled to grip and lift the heavy steel contraption.

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Speaker 1: Thankfully, help arrived quickly.

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Speaker 2: A local medic, doctor, Salassa Vouti, one of the town's

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Speaker 2: overseas trained doctors, inserted a tube to help Bramwich breathe.

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Speaker 2: The ambulance rushed to the accident site to provide emergency

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Speaker 2: backup and transport. A rescue helicopter arrived to airlift him

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Speaker 2: to Bunderberg Hospital. Quickly to his father's wife, pack.

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Speaker 6: Your bags and go to the hospital.

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Speaker 7: Tests dad's had an accident.

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Speaker 2: Test trembled with worry as her friend, Agnes Smythe gunned

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Speaker 2: the white commodore, beating the helicopter by fifteen minutes. Tess

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Speaker 2: was told her husband had suffered severe internal injuries, but

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Speaker 2: that the prognosis was good. Once he had been stabilized

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Speaker 2: in the trauma room, there were tests and scans of

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Speaker 2: his chest. Des was thirsty, and, with a nurse's approval,

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Speaker 2: test gave him an ice cube to wet his mouth.

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Speaker 2: One of the doctors told Tess there was no reason

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Speaker 2: why a fit, middle aged man, a non smoker and

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Speaker 2: non drinker would not make it. She was greatly comforted

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Speaker 2: by the reassuring words. Even as they transferred her husband

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Speaker 2: to the intensive care unit, she watched the nurses there

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Speaker 2: hooking him up to machines to monitor and assist his.

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Speaker 1: Heart and breathing.

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Speaker 2: They gave him morphine intravenously and an oxygen mask. Tess,

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Speaker 2: who was born in the Philippines, and Des had wed

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Speaker 2: a decade earlier. Tess was DES's third wife. They often

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Speaker 2: joked about how, at age thirty three, she was younger

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Speaker 2: than Mark, even though she was step grandmother to Mark's kids.

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Speaker 2: Des and Tess had not looked back. The Bramich father

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Speaker 2: and son business was doing well. The couple had great

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Speaker 2: friends in the town where everybody knew each other. Their

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Speaker 2: young daughter, Maria acquiet beauty with Tess's brown skin and

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Speaker 2: smoldering dark eyes was a family treasure. Now At one am,

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Speaker 2: Tess kept a vigil in the hospital. When Dez suggested

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Speaker 2: that she should leave to get some sleep, the staff agreed,

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Speaker 2: although they were more concerned about his rest. When Tess

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Speaker 2: returned at six a m. And saw him smiling in

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Speaker 2: bed with most of the color returned to his face,

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Speaker 2: her spirits rose.

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Speaker 1: By nine a m.

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Speaker 2: Some of his extended family were perched around his bed

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Speaker 2: in the ICU, Des spoke to Mark's visibly distressed wife, Fatima.

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Speaker 8: Don't cry, I'm all right.

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Speaker 1: He was making jokes at his own expense and wise

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Speaker 1: cracking about being far too young to die.

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Speaker 8: I'm like a cat, I have nine lives.

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Speaker 2: After X rays and a cup of tea, he spoke

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Speaker 2: about the accident. His son beamed when Des said that

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Speaker 2: had it not been for Mark, the crush from the

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Speaker 2: caravan would have put him in a coffin. Tony Hoffman

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Speaker 2: was touched by the natural affection and love enveloping her patient,

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Speaker 2: who exerted a cheerfulness she put down to genuine family contentment.

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Speaker 2: She chatted freely to DEAs and Tess, their daughter, ten

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Speaker 2: year old Maria, gazing at her Dad with those liquid

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Speaker 2: eyes was gorgeous. Hoffman gave her a soft white toy,

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Speaker 2: the seal that she kept in the bottom of the

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00:15:12,320 --> 00:15:15,600
Speaker 2: filing cabinet for young children who came into the unit.

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Speaker 2: At times like this, Tony Hoffman regretted some of the

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00:15:20,480 --> 00:15:24,440
Speaker 2: choices she had made. Hoffman wished things had turned out

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Speaker 2: differently with some of the men she had loved. Her

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00:15:27,880 --> 00:15:31,880
Speaker 2: career had been fulfilling, but at home after the shift ended,

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00:15:32,240 --> 00:15:37,160
Speaker 2: she sometimes felt desperately lonely. By the time Tess returned

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00:15:37,200 --> 00:15:41,600
Speaker 2: from lunch, the bed in the ICUU was empty. She

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00:15:41,680 --> 00:15:44,240
Speaker 2: was immediately worried, but Des was fine.

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Speaker 1: He was doing so.

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Speaker 2: Well that he had been wheeled into the surgical ward

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00:15:50,000 --> 00:15:53,360
Speaker 2: that afternoon. After he had been helped into the chair

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Speaker 2: beside his bed, test stayed and chatted with him until evening.

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Speaker 2: When she returned early the next morning, twenty seven July,

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Speaker 2: Des was in a bad way.

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Speaker 8: Dahl, I really didn't have a good sleep last night

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Speaker 8: because I was in pain all night.

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00:16:12,600 --> 00:16:17,040
Speaker 2: Tess was confused. She had been assured that the morphine

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Speaker 2: trickling into his veins would deaden the pain. She examined

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00:16:21,920 --> 00:16:25,440
Speaker 2: the intravenous connection and saw that it had become loose

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00:16:25,680 --> 00:16:26,720
Speaker 2: and it was dripping.

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Speaker 9: Could you just please fix that properly?

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00:16:31,040 --> 00:16:34,440
Speaker 2: They waited impatiently for a junior doctor to come by

243
00:16:34,760 --> 00:16:37,000
Speaker 2: and Reattach the line.

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00:16:37,240 --> 00:16:39,080
Speaker 1: Des was encouraged.

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00:16:38,560 --> 00:16:42,200
Speaker 2: To walk around the hospital corridors with a physiotherapist and

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00:16:42,320 --> 00:16:45,800
Speaker 2: an assistant. He hobbled in pain as they supported him

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00:16:45,840 --> 00:16:49,360
Speaker 2: under his armpits, then returned to bed and spoke by

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00:16:49,400 --> 00:16:54,000
Speaker 2: telephone to his worried mother and sister. When the Bunderberg

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00:16:54,120 --> 00:16:57,720
Speaker 2: News Males reporter arrived, Des recounted the accident.

250
00:16:58,720 --> 00:16:59,560
Speaker 8: Mike is my hero.

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00:17:01,440 --> 00:17:04,880
Speaker 2: Tess returned from lunch to discover that he had suddenly

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00:17:04,960 --> 00:17:09,880
Speaker 2: collapsed and been rushed back to the intensive care unit. Hoffmann,

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00:17:10,400 --> 00:17:15,320
Speaker 2: shocked at how rapidly he had deteriorated, calmly organized her staff.

254
00:17:16,280 --> 00:17:19,479
Speaker 2: The nurses rushed to save his life. Des could not

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00:17:19,600 --> 00:17:23,959
Speaker 2: breathe and his blood pressure had plummeted. His heart was racing,

256
00:17:24,040 --> 00:17:27,840
Speaker 2: and the pain in his chest had become unbearable. He

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00:17:27,920 --> 00:17:32,520
Speaker 2: was slipping in and out of consciousness. Doctor if Ta

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00:17:32,520 --> 00:17:37,119
Speaker 2: Carr Eunus, one of the anesthetists, was attempting to resuscitate

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00:17:37,200 --> 00:17:41,000
Speaker 2: him with the help of three nurses. Doctor Martin Carter,

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00:17:41,359 --> 00:17:45,440
Speaker 2: the anesthetist in charge of the ICU, was clear.

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00:17:46,080 --> 00:17:48,640
Speaker 7: If the patient is going to need blood products, he'll

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00:17:48,680 --> 00:17:49,840
Speaker 7: need to be flown out.

263
00:17:51,160 --> 00:17:55,640
Speaker 2: Carter decided that as Bramwich might need thoracic surgery, long

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00:17:55,720 --> 00:17:59,439
Speaker 2: term ventilatory support and access to a blood bank, he

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00:17:59,520 --> 00:18:04,120
Speaker 2: should be rush to one of the larger hospitals in Brisbane.

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00:18:04,320 --> 00:18:07,160
Speaker 2: There were urgent efforts to find a bed in Brisbane.

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00:18:07,480 --> 00:18:10,639
Speaker 2: Prince Charles Hospital was full that a bed might be

268
00:18:10,680 --> 00:18:16,080
Speaker 2: available at Princess Alexandra Hospital. The Royal Flying Doctor Servis

269
00:18:16,280 --> 00:18:21,200
Speaker 2: was ready for the mercy mission. Hoffman relayed the message

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Speaker 2: from the bed coordinators in Brisbane to doctor Carter, doctor

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00:18:25,600 --> 00:18:30,120
Speaker 2: Jim Gaffield and doctor James Boyd, a principal house officer

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00:18:30,200 --> 00:18:37,600
Speaker 2: working under doctor Jayant Patel's supervision. Hoffman was ecstatically.

273
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Speaker 10: Relieved They've got a bed.

274
00:18:40,600 --> 00:18:43,359
Speaker 2: She could see that des Bramwich needed to be in

275
00:18:43,400 --> 00:18:48,440
Speaker 2: a hospital which practiced thoracic surgery. Under no circumstances did

276
00:18:48,480 --> 00:18:51,119
Speaker 2: she want to see Bramwich fall into the hands of

277
00:18:51,240 --> 00:18:57,040
Speaker 2: Jayant Patel, the director of surgery, had been absent from

278
00:18:57,040 --> 00:18:58,400
Speaker 2: the hospital for all of.

279
00:18:58,400 --> 00:18:59,280
Speaker 1: May and June.

280
00:18:59,680 --> 00:19:02,800
Speaker 2: He had had taken study leave and holidays to return

281
00:19:02,840 --> 00:19:06,520
Speaker 2: to Jamnagar in India to see his mother, and then

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00:19:06,600 --> 00:19:09,639
Speaker 2: to Portland in the United States to spend time with

283
00:19:09,760 --> 00:19:15,480
Speaker 2: his family. The run of complications, the conflict in the wards,

284
00:19:15,560 --> 00:19:20,040
Speaker 2: and the fears of the staff had disappeared. Doctor Patel's

285
00:19:20,119 --> 00:19:24,639
Speaker 2: holiday was a blessing for all. Tony Hoffman recalled the

286
00:19:24,680 --> 00:19:29,240
Speaker 2: plight of Una Conners, whom Patel operated on for cancer

287
00:19:29,320 --> 00:19:33,080
Speaker 2: of the sigmoid colon in April. The woman had to

288
00:19:33,080 --> 00:19:37,199
Speaker 2: be rushed back by ambulance after a complete evisceration of

289
00:19:37,240 --> 00:19:42,560
Speaker 2: the wound and her intestines being almost fully exposed. Hoffman

290
00:19:42,640 --> 00:19:46,800
Speaker 2: had grown unusually fond of Desbramach and his family in

291
00:19:46,840 --> 00:19:49,640
Speaker 2: the few hours she had spent with them in the ICU.

292
00:19:50,520 --> 00:19:55,080
Speaker 2: But his perilous condition was worsening. As doctor Eunice tried

293
00:19:55,119 --> 00:19:58,160
Speaker 2: to put in a central line to convey drugs, the

294
00:19:58,160 --> 00:20:03,959
Speaker 2: gravely ill man experienced ventricular standstill. His heart was refusing

295
00:20:04,000 --> 00:20:09,520
Speaker 2: to pump blood. Doctor Gaffield asked Patel to look at

296
00:20:09,520 --> 00:20:13,280
Speaker 2: the X rays of his chest. Patel seized the offer

297
00:20:13,440 --> 00:20:16,800
Speaker 2: and in his booming voice, started undoing the plans to

298
00:20:16,920 --> 00:20:18,919
Speaker 2: transfer Brammage from Bunderberg.

299
00:20:19,960 --> 00:20:22,000
Speaker 11: The patient doesn't need to go to Brisbane. He isn't

300
00:20:22,000 --> 00:20:24,640
Speaker 11: sick enough. If we can't care for such simple things

301
00:20:24,680 --> 00:20:27,280
Speaker 11: as fractured ribs, there is no point in doing any

302
00:20:27,280 --> 00:20:28,840
Speaker 11: sort of drama surgery at the hospital.

303
00:20:30,400 --> 00:20:33,720
Speaker 1: Hoffman, stricken with fear, waited.

304
00:20:33,359 --> 00:20:38,040
Speaker 2: For Gaffield to take charge. Brammage was doctor Gaffield's patient.

305
00:20:38,680 --> 00:20:41,359
Speaker 2: Doctor Carter had already come to the view that the

306
00:20:41,400 --> 00:20:47,560
Speaker 2: best course was urgent transfer. Doctor Eunice agreed arrangements had

307
00:20:47,600 --> 00:20:52,680
Speaker 2: been made, but Patel's dominant personality was assuming control.

308
00:20:54,040 --> 00:20:57,080
Speaker 11: He doesn't need to be transferred. I've been a cardiothoracic

309
00:20:57,119 --> 00:21:00,320
Speaker 11: surgeon for twenty years. If he needs anything, can do

310
00:21:00,359 --> 00:21:00,880
Speaker 11: it here.

311
00:21:01,720 --> 00:21:05,800
Speaker 2: He repeated the confident boasts to members of Bramich's family,

312
00:21:05,880 --> 00:21:09,600
Speaker 2: as Hoffmann quietly pleaded for the transfer to go ahead.

313
00:21:10,280 --> 00:21:14,760
Speaker 10: Please Dr Gaffield fin this man through to Brisbane, even

314
00:21:14,840 --> 00:21:18,200
Speaker 10: if you think he doesn't need a cardiothoracic surgeon. I'm

315
00:21:18,240 --> 00:21:21,600
Speaker 10: really afraid that he's going to die.

316
00:21:21,760 --> 00:21:26,720
Speaker 1: Dr Gaffield replied, No, that won't happen. He won't die.

317
00:21:28,160 --> 00:21:31,199
Speaker 2: He said he wanted to do a CT scan to

318
00:21:31,240 --> 00:21:35,480
Speaker 2: provide definitive information for the handover to the surgeons in Brisbane,

319
00:21:36,680 --> 00:21:40,600
Speaker 2: Patel disappeared back into the operating theater to perform a

320
00:21:40,680 --> 00:21:43,639
Speaker 2: colonoscopy on a patient, but in the course of that

321
00:21:43,800 --> 00:21:48,760
Speaker 2: procedure he perforated the bow. He insisted his injured patient

322
00:21:48,800 --> 00:21:51,879
Speaker 2: should have a CT scan of the bowl before the

323
00:21:51,960 --> 00:21:53,240
Speaker 2: gravely ill Brammage.

324
00:21:54,000 --> 00:21:58,520
Speaker 11: Patel yelled a perforated both takes precedence over a non

325
00:21:58,640 --> 00:22:00,640
Speaker 11: urgency scan at all times.

326
00:22:01,400 --> 00:22:04,720
Speaker 2: The latest botch up a rarity for most doctors, but

327
00:22:04,840 --> 00:22:08,679
Speaker 2: a common occurrence for Petel, meant that another doctor was

328
00:22:08,800 --> 00:22:12,800
Speaker 2: needed to help him repair the bow. Tony Hoffman asked

329
00:22:12,840 --> 00:22:15,720
Speaker 2: doctor Martin Carter, who was due to leave, to give

330
00:22:15,760 --> 00:22:18,880
Speaker 2: a lecture to accompany Bramwich for the CT scan.

331
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Speaker 1: He agreed.

332
00:22:21,000 --> 00:22:24,119
Speaker 2: By the time they returned to the intensive care unit,

333
00:22:24,440 --> 00:22:29,120
Speaker 2: the scan showed three liters of blood pooling in Bramich's chest.

334
00:22:30,040 --> 00:22:33,240
Speaker 2: As Hoffman left the intensive care unit at seven point

335
00:22:33,240 --> 00:22:36,719
Speaker 2: thirty pm to go home, the Royal Flying Doctor aircraft

336
00:22:36,840 --> 00:22:40,840
Speaker 2: was being ready for the trip to Bunderberg. Hoffman had

337
00:22:40,840 --> 00:22:44,000
Speaker 2: stayed back for three hours to ensure des Bramwich would

338
00:22:44,000 --> 00:22:47,359
Speaker 2: get away for the help he so desperately needed. She

339
00:22:47,520 --> 00:22:50,720
Speaker 2: walked to the hospital car park. Confident that Bramwich would

340
00:22:50,800 --> 00:22:55,920
Speaker 2: survive in Brisbane despite his problems, Hoffman felt sure he

341
00:22:55,960 --> 00:22:58,879
Speaker 2: would wake up in the morning. Three hundred and seventy

342
00:22:58,960 --> 00:23:13,320
Speaker 2: kilometers from tell chapter twenty one, the stabbing, late July

343
00:23:13,680 --> 00:23:14,639
Speaker 2: two thousand and.

344
00:23:14,520 --> 00:23:20,600
Speaker 10: Four, Oh did mister Brammage get off all right?

345
00:23:22,240 --> 00:23:25,320
Speaker 2: Outside the hospital elevator At the start of her shift

346
00:23:25,359 --> 00:23:28,359
Speaker 2: the morning after the frantic efforts to save his life

347
00:23:28,520 --> 00:23:31,880
Speaker 2: and move him to Brisbane, Tony Hoffman had bumped into

348
00:23:31,920 --> 00:23:36,240
Speaker 2: doctor Martin Carter. She popped the question. After a quick

349
00:23:36,280 --> 00:23:37,680
Speaker 2: exchange of pleasantries.

350
00:23:38,720 --> 00:23:40,520
Speaker 1: No, he died.

351
00:23:42,040 --> 00:23:45,720
Speaker 2: When the Flying Doctor had finally arrived after ten pm

352
00:23:45,880 --> 00:23:49,760
Speaker 2: with flight nurse Anita Carr and doctor Jackie Butler. Their

353
00:23:49,840 --> 00:23:52,600
Speaker 2: patient was closer to death than he had ever been.

354
00:23:53,960 --> 00:23:57,280
Speaker 2: Patel had remained in control and declared him to be

355
00:23:57,400 --> 00:24:01,600
Speaker 2: too sick to be transferred. As Bramich died a little

356
00:24:01,600 --> 00:24:05,800
Speaker 2: after midnight, despite frantic resuscitation efforts by doctor if T

357
00:24:05,920 --> 00:24:11,240
Speaker 2: Carr Eunice, the nurses were in tears. The Flying Doctor

358
00:24:11,240 --> 00:24:16,920
Speaker 2: staff wept. Tess, Maria and Mark huddled together, shocked, crying

359
00:24:17,280 --> 00:24:22,800
Speaker 2: and wondering what had gone wrong. Hoffman was devastated, she

360
00:24:23,040 --> 00:24:25,800
Speaker 2: thought of the beautiful little girl who no longer had

361
00:24:25,800 --> 00:24:30,480
Speaker 2: a father. She guessed immediately that Patel's decision to halt

362
00:24:30,520 --> 00:24:34,359
Speaker 2: the transfer was all about Patel and his determination to

363
00:24:34,480 --> 00:24:38,480
Speaker 2: flaunt himself. It had little to do with the welfare

364
00:24:38,560 --> 00:24:48,119
Speaker 2: of patients. Despite mounting evidence of needless deaths and injuries,

365
00:24:48,400 --> 00:24:52,159
Speaker 2: the director of surgery remained delusional about his own abilities.

366
00:24:53,280 --> 00:24:57,639
Speaker 2: The death of Bramich was the turning point. Hoffman decided

367
00:24:57,720 --> 00:25:00,879
Speaker 2: from that moment to do everything in her power to

368
00:25:01,000 --> 00:25:05,480
Speaker 2: highlight Petel's lethal menace. She told Martin Carter.

369
00:25:06,040 --> 00:25:08,760
Speaker 10: We have to do something about this, so we cannot

370
00:25:08,840 --> 00:25:10,439
Speaker 10: let this happen any longer.

371
00:25:11,520 --> 00:25:14,240
Speaker 2: She went to her office and broke down in tears.

372
00:25:14,760 --> 00:25:18,480
Speaker 2: The Bunderberg newsmail that day had a bright picture story

373
00:25:18,520 --> 00:25:22,959
Speaker 2: about des Bramich's near death experience. He was sitting up

374
00:25:23,000 --> 00:25:27,160
Speaker 2: in the photograph, looking larger than life. In the article,

375
00:25:27,280 --> 00:25:28,320
Speaker 2: Bramwich says.

376
00:25:28,880 --> 00:25:30,879
Speaker 8: I thought I was going to die because I couldn't

377
00:25:30,880 --> 00:25:33,960
Speaker 8: get any air. It never hit me until the next morning,

378
00:25:34,119 --> 00:25:36,040
Speaker 8: the reality of it that I was in the hands

379
00:25:36,040 --> 00:25:38,400
Speaker 8: of the gods.

380
00:25:38,400 --> 00:25:42,920
Speaker 2: Doctor Martin Strawn, a general physician in private practice who

381
00:25:43,040 --> 00:25:46,240
Speaker 2: worked part time as a visiting medical officer at the

382
00:25:46,280 --> 00:25:50,240
Speaker 2: hospital saw Hoffman sobbing and gently asked what was wrong.

383
00:25:51,600 --> 00:25:54,720
Speaker 2: She told him about the Bramwich case and the circumstances

384
00:25:54,720 --> 00:25:58,439
Speaker 2: of several other deaths, and she recounted the startling rates

385
00:25:58,480 --> 00:26:03,840
Speaker 2: of wound breakdowns and complications. She told him how doctor

386
00:26:03,920 --> 00:26:07,720
Speaker 2: Carter referred to Patel behind his back as doctor Death,

387
00:26:08,840 --> 00:26:12,480
Speaker 2: how the nurses were distraught with worry for the patients,

388
00:26:12,880 --> 00:26:16,359
Speaker 2: how in the renal unit he had flouted basic anti

389
00:26:16,400 --> 00:26:21,639
Speaker 2: contamination standards, and how the director of medicine, doctor Peter Meak,

390
00:26:21,920 --> 00:26:26,959
Speaker 2: refused to let Patel anywhere near his patients. Doctor Strawn

391
00:26:27,080 --> 00:26:29,359
Speaker 2: promised to go away and talk to some of his

392
00:26:29,440 --> 00:26:31,919
Speaker 2: colleagues about Patel and his competence.

393
00:26:33,119 --> 00:26:35,360
Speaker 1: Two days later, he told her.

394
00:26:36,280 --> 00:26:39,640
Speaker 8: There's widespread concern, but nobody is willing to stick their

395
00:26:39,680 --> 00:26:40,400
Speaker 8: neck out yet.

396
00:26:41,960 --> 00:26:46,720
Speaker 2: The untimely death of des Bramitch galvanized the nurses. Several

397
00:26:46,720 --> 00:26:50,560
Speaker 2: of those nurses who had witnessed the last agonizing hours

398
00:26:50,600 --> 00:26:56,040
Speaker 2: of his life, Karen Fox, Vivian Tapiolis, Daniel Aitken and

399
00:26:56,240 --> 00:27:00,639
Speaker 2: Sandra Sharp, were appalled at the turn of events. The

400
00:27:00,920 --> 00:27:03,919
Speaker 2: ICU staff mourned in the beginning and then they became

401
00:27:04,000 --> 00:27:07,320
Speaker 2: angry as they reflected on all the patients Patel had

402
00:27:07,400 --> 00:27:11,040
Speaker 2: harmed since he came to the hospital. They did not

403
00:27:11,280 --> 00:27:15,840
Speaker 2: know the extent of des Bramitch's internal injuries. It was

404
00:27:16,040 --> 00:27:19,320
Speaker 2: probable that these injuries were so severe he may have

405
00:27:19,480 --> 00:27:23,919
Speaker 2: died even if he had been transferred. But they understood

406
00:27:23,920 --> 00:27:26,240
Speaker 2: that he had been robbed of at least a fighting

407
00:27:26,359 --> 00:27:30,400
Speaker 2: chance by a bombastic surgeon who threw his weight around

408
00:27:30,480 --> 00:27:35,640
Speaker 2: to prevent a transfer. First, Patel had insisted that Desbramitch

409
00:27:35,760 --> 00:27:38,960
Speaker 2: was not sick enough to go, and then he was

410
00:27:39,000 --> 00:27:43,600
Speaker 2: too sick. They understood that Patel had spoken callously to

411
00:27:43,640 --> 00:27:47,640
Speaker 2: the family, telling Tess that she should start praying because

412
00:27:47,840 --> 00:27:52,320
Speaker 2: her husband would surely die, telling Tess and her daughter

413
00:27:52,480 --> 00:27:56,160
Speaker 2: to stop crying at the bedside, telling anyone who cared

414
00:27:56,160 --> 00:28:00,000
Speaker 2: to listen how his experience in trauma surgery made him

415
00:28:00,160 --> 00:28:03,640
Speaker 2: better qualified than anyone in Brisbane to manage the care.

416
00:28:05,000 --> 00:28:08,720
Speaker 2: At one point, another nurse, Sharon Cree, had to move

417
00:28:08,760 --> 00:28:12,440
Speaker 2: away from Patel because he was talking so obnoxiously about

418
00:28:12,440 --> 00:28:18,840
Speaker 2: his wealth of experience and expertise. Karen Fox was tormented

419
00:28:18,880 --> 00:28:22,119
Speaker 2: by the death she could not erase from her mind.

420
00:28:22,240 --> 00:28:25,560
Speaker 2: An image of Patel's stabbing Brammage with a large needle.

421
00:28:26,600 --> 00:28:31,440
Speaker 2: For some unexplained reason, Patel had decided that Bramach's critical

422
00:28:31,480 --> 00:28:34,800
Speaker 2: condition might be due to blood between the two layers

423
00:28:34,960 --> 00:28:38,760
Speaker 2: of the peri cardium, a protective sack around the heart.

424
00:28:40,000 --> 00:28:44,320
Speaker 2: Although an ultrasound had already proved there was no fluid there,

425
00:28:44,600 --> 00:28:49,880
Speaker 2: Patel had diagnosed a cardiac tamponade. He decided to perform

426
00:28:50,040 --> 00:28:55,680
Speaker 2: a peri cardio sentisis using a wide born needle. He

427
00:28:55,840 --> 00:29:00,520
Speaker 2: wanted to puncture the sack to drain nonexistent blood. The

428
00:29:00,560 --> 00:29:06,600
Speaker 2: invasive procedure requires skill and strength. Patel botched it. The

429
00:29:06,600 --> 00:29:09,280
Speaker 2: needle is supposed to go in within a few attempts.

430
00:29:10,080 --> 00:29:14,280
Speaker 2: Patel stabbed the needle violently and repeatedly into the semi

431
00:29:14,320 --> 00:29:20,000
Speaker 2: conscious Brammage's chest. After flailing away in a frenzy, Patel

432
00:29:20,120 --> 00:29:25,880
Speaker 2: finally extracted a minuscule few milli liters of blood. Nurse

433
00:29:26,000 --> 00:29:30,280
Speaker 2: Fox had never seen anything like it. Doctor Carter and

434
00:29:30,360 --> 00:29:35,360
Speaker 2: doctor iftekar Unus were also confused. They knew the ultrasound

435
00:29:35,400 --> 00:29:38,120
Speaker 2: results gave no indication of blood.

436
00:29:37,920 --> 00:29:38,520
Speaker 1: In the sack.

437
00:29:39,880 --> 00:29:42,560
Speaker 2: There appeared to be no good reason to be adding

438
00:29:42,600 --> 00:29:46,800
Speaker 2: to des brahmages to stress and pain. Eunus was angry

439
00:29:46,800 --> 00:29:51,040
Speaker 2: about it. He suspected Patel might have punctured a coronary

440
00:29:51,160 --> 00:29:55,920
Speaker 2: vessel with his repeated stabbing motions. Nurse Fox told Hoffman.

441
00:29:56,960 --> 00:30:00,280
Speaker 12: During this procedure, doctor Pateel was loudly making comment that

442
00:30:00,320 --> 00:30:02,400
Speaker 12: the patient will die and does not need to go

443
00:30:02,400 --> 00:30:05,160
Speaker 12: to Brisbane. I asked doctor Peateell to mind what he

444
00:30:05,280 --> 00:30:07,120
Speaker 12: was saying as the family were in the hallway.

445
00:30:08,240 --> 00:30:11,840
Speaker 2: Patel had told Fox that the family members needed to

446
00:30:11,920 --> 00:30:16,440
Speaker 2: know the seriousness of the situation, but Fox replied.

447
00:30:16,640 --> 00:30:19,480
Speaker 12: They need to be told face to face, not overhearing

448
00:30:19,480 --> 00:30:21,160
Speaker 12: what's being said behind the curtains.

449
00:30:22,240 --> 00:30:26,640
Speaker 1: Fox told Hoffman all the distressing details, including how Patel

450
00:30:26,760 --> 00:30:28,960
Speaker 1: had inserted a chestrain and.

451
00:30:29,280 --> 00:30:33,160
Speaker 12: Poked and prodded using his fingers through the incision.

452
00:30:34,280 --> 00:30:38,280
Speaker 2: Tony Hoffman was so frustrated and worried about the situation

453
00:30:38,520 --> 00:30:43,120
Speaker 2: she telephoned the acting coroner, Neil Lavering and explained the

454
00:30:43,200 --> 00:30:48,360
Speaker 2: concerns over Patel's competence. She described the brammished death and

455
00:30:48,400 --> 00:30:55,080
Speaker 2: the interference by Patel. Lavering replied, well, that confirms some

456
00:30:55,160 --> 00:30:58,080
Speaker 2: of the things I've been thinking about what has been

457
00:30:58,160 --> 00:31:01,880
Speaker 2: going on at the hospital. He said he would await

458
00:31:01,920 --> 00:31:07,800
Speaker 2: the documentation. Hoffman also telephoned the Bunderberg police station and

459
00:31:08,160 --> 00:31:11,600
Speaker 2: was put through to a senior officer. He asked if

460
00:31:11,640 --> 00:31:16,120
Speaker 2: the hospital held morbidity and mortality meetings or had any

461
00:31:16,160 --> 00:31:21,320
Speaker 2: other mechanisms that would identify negligence causing deaths, but neither

462
00:31:21,520 --> 00:31:26,200
Speaker 2: the coroner's office nor the police followed up. Hoffman next

463
00:31:26,280 --> 00:31:30,800
Speaker 2: prepared a sentinel event report. This was a major step.

464
00:31:31,400 --> 00:31:36,000
Speaker 2: According to the protocol, a sentinel event is rare, serious

465
00:31:36,320 --> 00:31:42,560
Speaker 2: and requires prompt and in depth investigation. Hoffman's accompanying memo

466
00:31:42,760 --> 00:31:47,640
Speaker 2: to management described how Patel bullied staff, misused the intensive

467
00:31:47,680 --> 00:31:52,959
Speaker 2: care unit, compromised care, and constantly threatened to quit because

468
00:31:52,960 --> 00:31:57,880
Speaker 2: he did not want his patients transferred. Tony Hoffman wrote this.

469
00:31:58,960 --> 00:32:02,600
Speaker 10: The director of the union, Dr Carter, is usually supportive

470
00:32:02,640 --> 00:32:07,680
Speaker 10: and proactive about transferring patients, except when doctor Petel's patients

471
00:32:07,680 --> 00:32:12,480
Speaker 10: are concerned. Dr Patel creates such an atmosphere of fear

472
00:32:12,520 --> 00:32:16,600
Speaker 10: and intimidation in the unit that his behavior is rarely challenged.

473
00:32:17,520 --> 00:32:21,000
Speaker 10: On several occasions, when doctor Petel's patients have been in

474
00:32:21,040 --> 00:32:25,120
Speaker 10: the ICU, he has refused to transfer his patient to Brisbane,

475
00:32:25,720 --> 00:32:28,880
Speaker 10: even when the patients have deteriorated and have been in

476
00:32:29,280 --> 00:32:32,880
Speaker 10: ICU for much longer than twenty four to forty eight hours.

477
00:32:33,840 --> 00:32:36,920
Speaker 10: He has done this when a bed has already been obtained.

478
00:32:37,720 --> 00:32:41,840
Speaker 10: This has on several occasions placed the patient in jeopardy

479
00:32:41,960 --> 00:32:43,720
Speaker 10: as they have further deteriorated.

480
00:32:47,480 --> 00:32:50,640
Speaker 2: Hoffman repeated the concerns that she had expressed more than

481
00:32:50,680 --> 00:32:54,720
Speaker 2: twelve months earlier to Darren Keating about the dangers inherent

482
00:32:54,880 --> 00:32:59,560
Speaker 2: in the esophagectomy procedures that Patel had been determined to perform.

483
00:33:00,400 --> 00:33:04,080
Speaker 2: She said Patel's interference in the care of des Brammage

484
00:33:04,160 --> 00:33:07,320
Speaker 2: may have led to his death. She ended the two

485
00:33:07,360 --> 00:33:09,680
Speaker 2: page document by saying Patel.

486
00:33:10,040 --> 00:33:12,920
Speaker 10: Actually endangers the lives of the patients.

487
00:33:14,640 --> 00:33:19,040
Speaker 2: The acting Director of Nursing, Patrick Martin, who perused the document,

488
00:33:19,240 --> 00:33:21,200
Speaker 2: gave Tony Hoffman some feedback.

489
00:33:22,520 --> 00:33:26,080
Speaker 1: Wow. Love, that's all pretty heavy. It's very good, though.

490
00:33:26,680 --> 00:33:29,520
Speaker 6: My experience with Darren is to stick to facts and

491
00:33:29,560 --> 00:33:31,400
Speaker 6: figures and not be a motive.

492
00:33:31,720 --> 00:33:33,400
Speaker 13: He absolutely turns off a motive.

493
00:33:33,440 --> 00:33:37,880
Speaker 6: Approaches quote, percentages and figures to him, and he responds

494
00:33:38,160 --> 00:33:39,200
Speaker 6: much more favorably.

495
00:33:40,960 --> 00:33:44,760
Speaker 2: Hoffman had lost confidence in her own line manager the

496
00:33:44,840 --> 00:33:49,040
Speaker 2: new director of Nursing, Linda Mulligan. She was a stickler

497
00:33:49,080 --> 00:33:52,920
Speaker 2: for the memo and formal appointments for meetings, but when

498
00:33:53,000 --> 00:33:56,200
Speaker 2: it came to ward rounds, Mulligan was rarely seen by

499
00:33:56,240 --> 00:34:01,440
Speaker 2: the nurses. She operated very differently to Glennis Goodman, who

500
00:34:01,480 --> 00:34:02,720
Speaker 2: had retired.

501
00:34:03,880 --> 00:34:04,920
Speaker 1: A few weeks earlier.

502
00:34:04,960 --> 00:34:08,400
Speaker 2: When Hoffman went to Mulligan to voice concerns about Patel,

503
00:34:08,960 --> 00:34:12,680
Speaker 2: she left the executive office feeling more powerless than ever.

504
00:34:14,160 --> 00:34:18,000
Speaker 2: Mulligan had given her a book called Coping with Difficult

505
00:34:18,040 --> 00:34:21,600
Speaker 2: People by doctor Robert Ranson to take home to read.

506
00:34:23,080 --> 00:34:26,799
Speaker 2: She had suggested that Hoffman should consult a psychologist and

507
00:34:26,960 --> 00:34:29,440
Speaker 2: undergo training in conflict resolution.

508
00:34:39,360 --> 00:34:42,400
Speaker 1: Chapter twenty two, Justice for Elise.

509
00:34:42,840 --> 00:34:49,439
Speaker 2: Late July two thousand and four, the files describing ten

510
00:34:49,520 --> 00:34:53,040
Speaker 2: year old Elise Neville's final few hours moved me to

511
00:34:53,120 --> 00:34:56,239
Speaker 2: tears in the public area of the District Court Registry

512
00:34:56,400 --> 00:35:00,600
Speaker 2: in George Street, Brisbane, as Tony Hoffman and the other

513
00:35:00,719 --> 00:35:04,879
Speaker 2: nurses at Bunderberg Hospital seethed and grieved over the death

514
00:35:04,920 --> 00:35:08,279
Speaker 2: of Desbramitch. I became absorbed in the story of a

515
00:35:08,280 --> 00:35:10,719
Speaker 2: little girl who had rolled the wrong way in her

516
00:35:10,760 --> 00:35:13,560
Speaker 2: sleep and fallen out of a bunk bed during a

517
00:35:13,640 --> 00:35:18,320
Speaker 2: holiday with her family on the Sunshine Coast. Leaning over

518
00:35:18,440 --> 00:35:21,719
Speaker 2: a large folder laid out on a chipped counter, I

519
00:35:21,760 --> 00:35:25,960
Speaker 2: read hundreds of pages of witness statements and medical reports

520
00:35:25,960 --> 00:35:30,279
Speaker 2: that helped reconstruct seven January two thousand and two and

521
00:35:30,320 --> 00:35:35,240
Speaker 2: the ensuing forty eight hours. Although some of the accounts differed,

522
00:35:35,440 --> 00:35:39,160
Speaker 2: they documented the seriousness of Elisa's head injury when she

523
00:35:39,239 --> 00:35:43,640
Speaker 2: was rushed to Caloundra Hospital shortly after three am, the

524
00:35:43,760 --> 00:35:48,160
Speaker 2: deficiencies of the examination by doctor Andrew Donovan and Nurse

525
00:35:48,239 --> 00:35:54,400
Speaker 2: Beverly Duncan's examination in the emergency department, the inevitable brain injury,

526
00:35:54,680 --> 00:35:58,080
Speaker 2: and the agony of Elisa's parents, gered and the rain.

527
00:35:59,640 --> 00:36:03,880
Speaker 2: There was something primal about Jered's pain on raw display,

528
00:36:04,000 --> 00:36:06,920
Speaker 2: as graphically as if he had spilled his own blood

529
00:36:07,040 --> 00:36:08,000
Speaker 2: throughout the folder.

530
00:36:09,120 --> 00:36:10,440
Speaker 1: This is what he wrote.

531
00:36:11,320 --> 00:36:13,600
Speaker 14: We will pursue this while there is still breath in

532
00:36:13,640 --> 00:36:17,120
Speaker 14: our bodies and blood flowing in our hearts. The whole

533
00:36:17,160 --> 00:36:20,280
Speaker 14: episode is an absolute scandal, and there is no way

534
00:36:20,320 --> 00:36:22,040
Speaker 14: that we will ever let them get away with it.

535
00:36:25,400 --> 00:36:28,239
Speaker 2: Jered believed he had failed in his duty as a

536
00:36:28,320 --> 00:36:31,800
Speaker 2: father and as a doctor, to protect his daughter from palm,

537
00:36:32,760 --> 00:36:37,480
Speaker 2: and he blamed himself, the fatigued doctor Donovan, the nurses,

538
00:36:37,840 --> 00:36:41,680
Speaker 2: the system, and the hospital. Jered further wrote.

539
00:36:43,000 --> 00:36:46,000
Speaker 14: The doctor came probably about fifteen minutes after we first

540
00:36:46,080 --> 00:36:49,480
Speaker 14: arrived at the hospital. His name was Andrew, as we recall,

541
00:36:50,120 --> 00:36:53,640
Speaker 14: we didn't catch his surname. He took a very brief history.

542
00:36:54,000 --> 00:36:56,120
Speaker 14: I told him that I was medically trained, but that

543
00:36:56,160 --> 00:37:00,239
Speaker 14: I had not done clinical work for many years. Soon

544
00:37:00,239 --> 00:37:03,520
Speaker 14: began a discussion about the need for a CT computerized

545
00:37:03,520 --> 00:37:08,040
Speaker 14: tomography scan. He said, you can't see tee everyone who

546
00:37:08,120 --> 00:37:11,560
Speaker 14: hits their head. We return to a discussion about going

547
00:37:11,560 --> 00:37:14,840
Speaker 14: to Nambole hospital. We ask how far it is and

548
00:37:14,880 --> 00:37:17,080
Speaker 14: how long it will take to get there. He still

549
00:37:17,120 --> 00:37:20,560
Speaker 14: hasn't really examined Lease, and he says something like lots

550
00:37:20,600 --> 00:37:23,400
Speaker 14: of kids hit their head. Namble will probably send you

551
00:37:23,440 --> 00:37:27,560
Speaker 14: home too. We say that Elise has vomited, and he says,

552
00:37:27,800 --> 00:37:30,760
Speaker 14: lots of kids vomit at night. We say that Elise

553
00:37:30,880 --> 00:37:35,279
Speaker 14: rarely vomits. He keeps reassuring, We keep sending signals of

554
00:37:35,320 --> 00:37:38,719
Speaker 14: worry and concern. The discussions have gone on for some

555
00:37:38,880 --> 00:37:42,200
Speaker 14: time and we are at an impasse. He then says

556
00:37:42,239 --> 00:37:44,840
Speaker 14: something along the lines of look, I will do a

557
00:37:44,880 --> 00:37:48,680
Speaker 14: neurological examination if that would make you feel better. He

558
00:37:48,760 --> 00:37:51,760
Speaker 14: gets a tendon hammer to go with his torch. Elise

559
00:37:51,840 --> 00:37:55,080
Speaker 14: has her eyes closed and won't cooperate with him. She

560
00:37:55,200 --> 00:37:57,920
Speaker 14: is in pain and acting nothing like her normal self.

561
00:37:58,560 --> 00:38:00,640
Speaker 14: We tell him that she is not normal like this.

562
00:38:01,480 --> 00:38:04,160
Speaker 14: He then says coldly in front of a lisea as well,

563
00:38:04,840 --> 00:38:07,480
Speaker 14: she's a ten year old girl. It's late, she has

564
00:38:07,520 --> 00:38:09,919
Speaker 14: had a disturbed night, and she is pulling the wool

565
00:38:09,920 --> 00:38:13,279
Speaker 14: over her parents' eyes. By this stage, we have a

566
00:38:13,360 --> 00:38:16,440
Speaker 14: child with a head injury, a large contusion over her

567
00:38:16,520 --> 00:38:21,799
Speaker 14: left temple, a history of vomiting, and developing uncoperation. He

568
00:38:21,840 --> 00:38:24,120
Speaker 14: finishes with something like, I don't think there will be

569
00:38:24,200 --> 00:38:27,919
Speaker 14: any problems in your case. You're a sensible father. Take

570
00:38:27,960 --> 00:38:30,759
Speaker 14: her home and watch her. Even if she starts to

571
00:38:30,800 --> 00:38:32,920
Speaker 14: have problems, there will be plenty of time to do

572
00:38:32,960 --> 00:38:36,359
Speaker 14: what needs to be done. We didn't want to go home,

573
00:38:36,400 --> 00:38:38,759
Speaker 14: but we had nowhere else to go, as he and

574
00:38:38,840 --> 00:38:45,040
Speaker 14: the hospital had totally rejected us. I kept checking Lisa's pulse, eyes, breathing,

575
00:38:45,160 --> 00:38:47,560
Speaker 14: and movement as she lay next to me on our bed.

576
00:38:48,160 --> 00:38:51,960
Speaker 14: She was restless and kept moaning, crying, and complaining about

577
00:38:51,960 --> 00:38:55,279
Speaker 14: her sore head. I kept trying to diagnose what might

578
00:38:55,360 --> 00:38:57,319
Speaker 14: be going on, but it was all a blur and

579
00:38:57,360 --> 00:39:01,320
Speaker 14: nothing made any sense to me. Convinced myself that Elise

580
00:39:01,520 --> 00:39:04,280
Speaker 14: must just have a minor concussion at the very worst,

581
00:39:04,520 --> 00:39:06,440
Speaker 14: and we would see how she was a bit later

582
00:39:06,719 --> 00:39:11,239
Speaker 14: and probably get some more medical attention in the morning. Eventually,

583
00:39:11,280 --> 00:39:14,480
Speaker 14: it was now some time after six am, Alise seemed

584
00:39:14,520 --> 00:39:18,480
Speaker 14: to finally settle. Thinking that Elise was finally sleeping, I

585
00:39:18,520 --> 00:39:20,600
Speaker 14: started a doze on and off as I lay next

586
00:39:20,600 --> 00:39:23,879
Speaker 14: to her. I was never actually asleep, more just lying

587
00:39:23,920 --> 00:39:26,000
Speaker 14: next to her with my eyes closed and trying to

588
00:39:26,040 --> 00:39:30,200
Speaker 14: calm down. It had been a harrowing night. I suddenly

589
00:39:30,239 --> 00:39:32,520
Speaker 14: jolted up from my dozing when I felt something was

590
00:39:32,640 --> 00:39:35,560
Speaker 14: very wrong with Leise. So did Lorraine at the very

591
00:39:35,600 --> 00:39:38,799
Speaker 14: same time. I looked at Elise and screamed, oh my god,

592
00:39:38,840 --> 00:39:41,160
Speaker 14: Oh my god. It looked like she had a rash

593
00:39:41,160 --> 00:39:43,239
Speaker 14: down the left side of her body. I rolled a

594
00:39:43,320 --> 00:39:46,759
Speaker 14: lease on her back and saw it there too. Elisa's

595
00:39:46,800 --> 00:39:49,720
Speaker 14: eyes looked like they were popping out. Her jowel looked

596
00:39:49,719 --> 00:39:53,360
Speaker 14: like it was rigid. I thought Elise was dead. I

597
00:39:53,480 --> 00:39:57,080
Speaker 14: yelled to Lorraine get an ambulance. I was absolutely distraught

598
00:39:57,160 --> 00:40:01,200
Speaker 14: from that moment. Lorraine couldn't turn on her mobile phone,

599
00:40:01,239 --> 00:40:03,240
Speaker 14: so she ran to the next door unit for help.

600
00:40:04,040 --> 00:40:06,440
Speaker 14: I carried Lease from our room to the living room

601
00:40:06,520 --> 00:40:08,719
Speaker 14: and then back to our bedroom. I didn't know what

602
00:40:08,840 --> 00:40:12,440
Speaker 14: to do. At about seven thirty am, the ambulance took

603
00:40:12,480 --> 00:40:16,160
Speaker 14: a Lease, Lorraine and me. The first face I saw

604
00:40:16,280 --> 00:40:18,759
Speaker 14: was the same doctor from earlier in the night. He

605
00:40:18,840 --> 00:40:22,640
Speaker 14: saw me and said what happened? He was visibly shocked

606
00:40:22,800 --> 00:40:26,759
Speaker 14: and became very pale. I frantically said something like she's

607
00:40:26,760 --> 00:40:30,400
Speaker 14: gone right off. She needs a neurosurgeon. At one stage

608
00:40:30,440 --> 00:40:33,440
Speaker 14: she said was it to himself or to us? Something

609
00:40:33,560 --> 00:40:36,360
Speaker 14: like I'm so sorry, It's all my fault. What have

610
00:40:36,440 --> 00:40:36,839
Speaker 14: I done?

611
00:40:36,920 --> 00:40:37,080
Speaker 15: Oh?

612
00:40:37,239 --> 00:40:37,520
Speaker 1: Fuck?

613
00:40:42,360 --> 00:40:46,360
Speaker 2: Anette Thompson, one of the nurses who helped with the resuscitation,

614
00:40:46,719 --> 00:40:49,600
Speaker 2: saw Lorrain Neville lying on a bed in a waiting

615
00:40:49,680 --> 00:40:50,960
Speaker 2: area for relatives.

616
00:40:51,719 --> 00:40:55,160
Speaker 16: The nurse recalled she was in a fetal position and

617
00:40:55,360 --> 00:40:57,760
Speaker 16: was cuddling a stuffed toy, which I assumed.

618
00:40:57,360 --> 00:40:58,080
Speaker 17: To be Elise's.

619
00:40:58,760 --> 00:41:01,360
Speaker 16: Her eyes were shut in her fis appearance suggested that

620
00:41:01,440 --> 00:41:05,800
Speaker 16: she'd totally withdrawn into herself. Missus Nevill was making no sound,

621
00:41:06,120 --> 00:41:09,200
Speaker 16: but responded to my questions in a quiet voice. She

622
00:41:09,280 --> 00:41:11,840
Speaker 16: told me that Elise was a lovely girl and things

623
00:41:11,920 --> 00:41:15,520
Speaker 16: like this shouldn't happen to someone like her. She approached

624
00:41:15,640 --> 00:41:18,759
Speaker 16: Lisa's bed and spoke in whispers to her. Doctor Nevill

625
00:41:18,880 --> 00:41:22,040
Speaker 16: was very upset and cried loudly as the helicopter departed,

626
00:41:22,600 --> 00:41:27,239
Speaker 16: missus Neville began crying as well.

627
00:41:27,400 --> 00:41:31,600
Speaker 2: From doctor Donovan's account of events, starting with Elisa's first

628
00:41:31,680 --> 00:41:35,600
Speaker 2: presentation at three twenty five am, she had been lying

629
00:41:35,640 --> 00:41:38,880
Speaker 2: on her side, facing away from him when he started

630
00:41:38,880 --> 00:41:40,080
Speaker 2: a physical examination.

631
00:41:41,560 --> 00:41:44,160
Speaker 7: I coaxed her two to three times to turn and

632
00:41:44,239 --> 00:41:46,800
Speaker 7: face me so that I could look into her eyes.

633
00:41:47,400 --> 00:41:51,160
Speaker 7: Alise then rolled over and opened her eyes freely. I

634
00:41:51,200 --> 00:41:54,440
Speaker 7: examined Elsa's pupils and noted that they were equal and

635
00:41:54,640 --> 00:41:58,960
Speaker 7: reactive to light. I noticed some swelling and bruising lateral

636
00:41:59,000 --> 00:42:02,080
Speaker 7: to her left eye. I felt the area of swelling

637
00:42:02,120 --> 00:42:05,560
Speaker 7: and did not palpate a skull fracture. Alise then said

638
00:42:05,600 --> 00:42:08,399
Speaker 7: words to the effect, I want some sleep, and pulled

639
00:42:08,400 --> 00:42:10,960
Speaker 7: her sheet up and rolled back onto her left hand side.

640
00:42:11,960 --> 00:42:14,040
Speaker 7: I did not consider the swelling to the side of

641
00:42:14,040 --> 00:42:16,640
Speaker 7: the head to be unusual, as in my experience it

642
00:42:16,680 --> 00:42:19,160
Speaker 7: is not uncommon for children to suffer bruising to the

643
00:42:19,200 --> 00:42:22,120
Speaker 7: head even after a short fall onto a soft surface.

644
00:42:23,320 --> 00:42:26,719
Speaker 7: Mister Neville and I had a conversation regarding the indications

645
00:42:26,719 --> 00:42:30,080
Speaker 7: for performing a CT scan and whether a lease required

646
00:42:30,120 --> 00:42:32,800
Speaker 7: a CT scan. I had treated a few children with

647
00:42:32,880 --> 00:42:36,160
Speaker 7: vomiting and diarrhea at Caloundra Hospital and had been told

648
00:42:36,160 --> 00:42:39,680
Speaker 7: that the hospital did not admit children for observation. Therefore,

649
00:42:39,880 --> 00:42:41,759
Speaker 7: I was of the impression that Elise could not be

650
00:42:41,880 --> 00:42:45,800
Speaker 7: admitted for observations, and I explained this to mister Neville.

651
00:42:46,080 --> 00:42:48,200
Speaker 7: I told mister Neville to keep an eye on Elise

652
00:42:48,280 --> 00:42:50,799
Speaker 7: for the next day or so. The Nevills left the

653
00:42:50,800 --> 00:42:56,000
Speaker 7: hospital amicably. Mister Neville carried a lease from hospital. After

654
00:42:56,040 --> 00:42:58,760
Speaker 7: the Nevills left the hospital, there were no further patients,

655
00:42:58,800 --> 00:43:02,080
Speaker 7: so I went to sleep. At about seven hundred hours,

656
00:43:02,239 --> 00:43:04,879
Speaker 7: I rose and got dressed, and literally as I walked

657
00:43:04,920 --> 00:43:07,920
Speaker 7: out of the room, mister Neville arrived in the emergency

658
00:43:07,920 --> 00:43:11,600
Speaker 7: department in a very distressed state. He was followed by

659
00:43:11,600 --> 00:43:14,600
Speaker 7: the ambulance officers with Elise on a trolley. I was

660
00:43:14,680 --> 00:43:19,560
Speaker 7: shocked that Elise's condition had so radically deteriorated. Mister Neville

661
00:43:19,600 --> 00:43:24,319
Speaker 7: was extremely distraught. While resuscitation procedures were taking place, he

662
00:43:24,400 --> 00:43:27,040
Speaker 7: said words to the effect of it's my fault. It's

663
00:43:27,080 --> 00:43:29,920
Speaker 7: a curse being a doctor, and I fell asleep on

664
00:43:29,920 --> 00:43:33,239
Speaker 7: two or three occasions. I assured mister Neville that it

665
00:43:33,280 --> 00:43:36,880
Speaker 7: was not his fault, but my fault. In saying this,

666
00:43:37,120 --> 00:43:39,280
Speaker 7: I did not intend it as an admission of fault,

667
00:43:39,760 --> 00:43:42,880
Speaker 7: but as a feeling of personal responsibility as the last

668
00:43:42,920 --> 00:43:44,440
Speaker 7: doctor to have attended Elise.

669
00:43:49,280 --> 00:43:52,400
Speaker 2: I had first read something about Elise in the Courier

670
00:43:52,440 --> 00:43:56,440
Speaker 2: Mail in late two thousand and three. The description of

671
00:43:56,480 --> 00:44:01,120
Speaker 2: her parents' relentless efforts to force Queensland Health, the Medical Board,

672
00:44:01,360 --> 00:44:05,160
Speaker 2: the Nursing Council and the Health Rights Commission into rigorous

673
00:44:05,160 --> 00:44:09,600
Speaker 2: self examination was a small part of a much larger story.

674
00:44:10,800 --> 00:44:14,080
Speaker 2: I spoke about the case to doctor David mcloy, who

675
00:44:14,160 --> 00:44:17,320
Speaker 2: had taken over from doctor Ingrid Tall as head of

676
00:44:17,360 --> 00:44:22,279
Speaker 2: the Australian Medical Association in Queensland. Dr mcloy told me.

677
00:44:23,400 --> 00:44:25,760
Speaker 17: It is one of those tragic issues that brings everything

678
00:44:25,760 --> 00:44:26,360
Speaker 17: to account.

679
00:44:26,680 --> 00:44:27,440
Speaker 1: The system.

680
00:44:27,520 --> 00:44:29,279
Speaker 17: The junior doctor at the end of a very long

681
00:44:29,320 --> 00:44:32,440
Speaker 17: shift in a small hospital, the lack of supervision and

682
00:44:32,480 --> 00:44:36,800
Speaker 17: the protocols. There is significant concern that in any hearing

683
00:44:36,840 --> 00:44:39,640
Speaker 17: of this case, the system itself will be under scrutiny,

684
00:44:39,680 --> 00:44:42,640
Speaker 17: and if so, Queensland Health will have to take a

685
00:44:42,640 --> 00:44:44,120
Speaker 17: good hard look at its systems.

686
00:44:46,080 --> 00:44:50,360
Speaker 2: My earlier investigations into Queensland Health had made me deeply

687
00:44:50,400 --> 00:44:55,120
Speaker 2: suspicious of its management and culture. In November two thousand

688
00:44:55,200 --> 00:44:58,719
Speaker 2: and three, after my stories were published on the concerns

689
00:44:58,760 --> 00:45:02,400
Speaker 2: over the standards of overt trained doctors in Queensland and

690
00:45:02,440 --> 00:45:06,440
Speaker 2: the lack of checking of their credentials and skills, Jered

691
00:45:06,560 --> 00:45:07,719
Speaker 2: Neville emailed me.

692
00:45:08,760 --> 00:45:11,360
Speaker 14: I am not seeking anything from you, but I certainly

693
00:45:11,520 --> 00:45:14,239
Speaker 14: encourage you and the Courier Mail to keep the heat

694
00:45:14,320 --> 00:45:18,319
Speaker 14: up in regards to professional health standards. I have absolutely

695
00:45:18,400 --> 00:45:20,600
Speaker 14: no doubt there are real issues in regard to the

696
00:45:20,640 --> 00:45:25,120
Speaker 14: competence of some health professionals. These issues are not being

697
00:45:25,160 --> 00:45:29,239
Speaker 14: given the attention required to protect the community. It's just

698
00:45:29,360 --> 00:45:32,279
Speaker 14: part of the bigger picture about the effectiveness of the

699
00:45:32,320 --> 00:45:37,360
Speaker 14: system of ensuring that health professionals, whether trained overseas or locally,

700
00:45:37,760 --> 00:45:41,160
Speaker 14: are competent and not putting their patients' lives at risk.

701
00:45:42,840 --> 00:45:45,759
Speaker 2: Now we were in July two thousand and four and

702
00:45:45,840 --> 00:45:49,880
Speaker 2: the Medical Board of Queensland had decided that doctor Andrew Donovan,

703
00:45:50,160 --> 00:45:53,919
Speaker 2: who had treated a least Neville at Caloundra Hospital, would

704
00:45:53,960 --> 00:45:58,640
Speaker 2: be prosecuted for unprofessional conduct in the Health Practitioners Tribunal,

705
00:45:59,000 --> 00:46:04,839
Speaker 2: a part of the District Court. Queensland Health's dangerous policies

706
00:46:04,920 --> 00:46:08,320
Speaker 2: had forced Donovan to work a twenty four hour shift

707
00:46:08,360 --> 00:46:11,160
Speaker 2: on the day Elease was brought into the hospital by

708
00:46:11,200 --> 00:46:16,080
Speaker 2: her worried parents, Yet the same organization was now hanging

709
00:46:16,160 --> 00:46:20,320
Speaker 2: him out to dry, having refused to fund his legal defense.

710
00:46:21,640 --> 00:46:25,440
Speaker 2: The Director General, doctor Steve Buckland, was silent on the

711
00:46:25,600 --> 00:46:29,440
Speaker 2: stupidity of the twenty four hour shifts and the hospital's

712
00:46:29,480 --> 00:46:30,239
Speaker 2: policy not.

713
00:46:30,239 --> 00:46:31,600
Speaker 1: To admit children.

714
00:46:32,840 --> 00:46:36,160
Speaker 2: Nowhere in the file, a public document at the Court's

715
00:46:36,200 --> 00:46:40,600
Speaker 2: registry was the confidential and damning Queensland Health Report by

716
00:46:40,680 --> 00:46:45,240
Speaker 2: doctor William Rodgers about the need for several experienced doctors

717
00:46:45,280 --> 00:46:51,120
Speaker 2: to staff the emergency department at Caloundra Hospital. By late

718
00:46:51,200 --> 00:46:54,600
Speaker 2: July two thousand and four, there was enough material on

719
00:46:54,640 --> 00:46:58,719
Speaker 2: the public record to write several balanced and detailed stories

720
00:46:58,760 --> 00:47:03,319
Speaker 2: about the haphazard culture in Queensland. Health and its devastating

721
00:47:03,360 --> 00:47:08,479
Speaker 2: effect on at least one family. An emergency helicopter had

722
00:47:08,520 --> 00:47:12,560
Speaker 2: taken a lease from Calandra Hospital to the pediatric intensive

723
00:47:12,600 --> 00:47:16,080
Speaker 2: care unit at the Royal Children's Hospital in Brisbane, but

724
00:47:16,200 --> 00:47:19,959
Speaker 2: even the transfer was bungled. It took twice as long

725
00:47:20,040 --> 00:47:23,800
Speaker 2: as a road trip. In alease Neville's chart at the

726
00:47:23,880 --> 00:47:30,840
Speaker 2: Royal Children's, doctor David Coman noted unstable day irretrievable brain injury,

727
00:47:30,920 --> 00:47:35,040
Speaker 2: with brain death the most likely outcome. Not responding to

728
00:47:35,360 --> 00:47:42,680
Speaker 2: voice or head and neck stimuli. Jennifer Rich, a social

729
00:47:42,760 --> 00:47:46,319
Speaker 2: worker who had been counseling Elisa's parents as well as

730
00:47:46,360 --> 00:47:50,759
Speaker 2: her older sister Laura and younger brother Michael, wrote.

731
00:47:50,400 --> 00:47:54,319
Speaker 10: This father is experiencing a lot of guilt associated with

732
00:47:54,360 --> 00:47:55,920
Speaker 10: the accident given his profession.

733
00:47:57,239 --> 00:48:01,600
Speaker 2: Jennifer Rich's last entry in the hospital's electronic diary reported

734
00:48:01,640 --> 00:48:03,280
Speaker 2: the family's request.

735
00:48:02,920 --> 00:48:05,600
Speaker 17: That foot and hand prints, as well as a lock

736
00:48:05,640 --> 00:48:07,200
Speaker 17: of hair, be taken for themselves.

737
00:48:09,000 --> 00:48:11,879
Speaker 2: One of the treating doctors would later break down over

738
00:48:11,920 --> 00:48:12,880
Speaker 2: the waste.

739
00:48:12,480 --> 00:48:14,200
Speaker 1: Of young life.

740
00:48:14,320 --> 00:48:17,600
Speaker 2: A police officer wrote out a receipt for Elisa's property,

741
00:48:18,520 --> 00:48:22,759
Speaker 2: a blue hat, white sox statue of Mary A.

742
00:48:22,840 --> 00:48:23,200
Speaker 1: Winnie.

743
00:48:23,200 --> 00:48:26,200
Speaker 2: The Pooh Teddy Bear, blue and white shorts, pink top,

744
00:48:26,640 --> 00:48:30,240
Speaker 2: hair clips, hair bands, and a white ribbon.

745
00:48:31,560 --> 00:48:32,640
Speaker 1: Jerry wrote this.

746
00:48:34,080 --> 00:48:36,839
Speaker 14: Later that day, Lorraine and I decided to turn off

747
00:48:36,840 --> 00:48:40,279
Speaker 14: for Lisa's life support. At Least died at five point

748
00:48:40,600 --> 00:48:44,279
Speaker 14: five pm on the ninth of January two thousand and two.

749
00:48:46,000 --> 00:48:49,680
Speaker 14: As she died, peace came to her tormented face, and

750
00:48:49,719 --> 00:48:50,839
Speaker 14: her spirit and.

751
00:48:50,760 --> 00:48:52,200
Speaker 1: Beauty reigned over us.

752
00:48:52,200 --> 00:48:52,480
Speaker 4: All.

753
00:48:54,040 --> 00:48:56,840
Speaker 14: She showed us she had gone to somewhere nice and safe,

754
00:48:56,880 --> 00:48:58,480
Speaker 14: where people care for each other.

755
00:49:00,280 --> 00:49:00,640
Speaker 1: Might be.

756
00:49:01,239 --> 00:49:05,040
Speaker 14: I know it is certainly not in Caloundra Hospital, a

757
00:49:05,160 --> 00:49:07,680
Speaker 14: dangerous place that should be closed.

758
00:49:10,920 --> 00:49:13,680
Speaker 1: And the Lisa's mother, Lorraine added.

759
00:49:14,320 --> 00:49:17,279
Speaker 9: She shone with happiness and a beauty of nature and

760
00:49:17,320 --> 00:49:21,120
Speaker 9: soul that are irreplaceable and which will continue to be

761
00:49:21,160 --> 00:49:23,040
Speaker 9: our inspiration and guiding light.

762
00:49:24,440 --> 00:49:28,080
Speaker 2: There was a report by doctor Michael Redmond, a neurosurgeon,

763
00:49:28,160 --> 00:49:29,839
Speaker 2: who wrote, it.

764
00:49:29,840 --> 00:49:34,040
Speaker 13: Is considered unacceptable for a patient following head injury to

765
00:49:34,280 --> 00:49:38,680
Speaker 13: talk and die. At least Neville is one who talked

766
00:49:39,040 --> 00:49:43,960
Speaker 13: and died in a responsible medical system such as we enjoy,

767
00:49:44,440 --> 00:49:48,160
Speaker 13: with such access to hospitals of ascending levels of sophistication,

768
00:49:48,800 --> 00:49:52,160
Speaker 13: it is tragic and unacceptable that an event such as

769
00:49:52,200 --> 00:49:53,200
Speaker 13: this should occur.

770
00:49:54,280 --> 00:50:00,239
Speaker 2: And doctor Johannes Wenzel, a specialist in emergency medicine, wrote, I.

771
00:50:00,239 --> 00:50:03,640
Speaker 15: See it as a system problem that our public hospitals

772
00:50:03,680 --> 00:50:06,399
Speaker 15: put junior doctors into positions where they have to deal

773
00:50:06,480 --> 00:50:10,799
Speaker 15: with presentations beyond their expertise, combined with the fact that

774
00:50:10,880 --> 00:50:14,719
Speaker 15: working long shifts reduces the decision making ability to a

775
00:50:14,760 --> 00:50:17,960
Speaker 15: similar level as a person with point zero five percent

776
00:50:18,000 --> 00:50:19,280
Speaker 15: alcohol blood content.

777
00:50:20,440 --> 00:50:24,319
Speaker 2: According to two independent medical experts who studied all the

778
00:50:24,440 --> 00:50:29,080
Speaker 2: case notes and statements, doctor Donovan had made a tragic

779
00:50:29,400 --> 00:50:34,080
Speaker 2: wrong call. He had done an incomplete examination of Elise,

780
00:50:34,520 --> 00:50:38,360
Speaker 2: although he must have been fatigued after working nineteen hours

781
00:50:38,560 --> 00:50:42,520
Speaker 2: of a twenty four hour shift. If he had thoroughly

782
00:50:42,640 --> 00:50:46,040
Speaker 2: questioned and examined a lease or urged her parents to

783
00:50:46,120 --> 00:50:49,520
Speaker 2: go to another hospital for a CT scan of her skull,

784
00:50:50,160 --> 00:50:53,560
Speaker 2: its fracture and the hemorrhage would have been obvious.

785
00:50:54,520 --> 00:50:55,520
Speaker 1: There still would have.

786
00:50:55,440 --> 00:50:58,719
Speaker 2: Been time to relieve the pressure building from the accumulation

787
00:50:58,880 --> 00:51:03,799
Speaker 2: of blood before her rain soft tissue was crushed. In

788
00:51:03,920 --> 00:51:08,560
Speaker 2: his defense, doctor Andrew Donnoman wrote.

789
00:51:07,840 --> 00:51:11,000
Speaker 7: I would sincerely hope that doctors are not rusted on

790
00:51:11,040 --> 00:51:14,919
Speaker 7: for any longer than a twelve hour shift. Twenty four

791
00:51:14,920 --> 00:51:18,279
Speaker 7: hour shifts without a break are excessive and dangerous, and

792
00:51:18,320 --> 00:51:21,080
Speaker 7: no patient or doctor should ever be put through the

793
00:51:21,120 --> 00:51:24,520
Speaker 7: devastation that both the Nevills and my family have had

794
00:51:24,560 --> 00:51:25,160
Speaker 7: to endure.

795
00:51:26,800 --> 00:51:29,400
Speaker 2: When I called Jared Neville to tell him that I

796
00:51:29,480 --> 00:51:33,200
Speaker 2: planned to write several lengthy stories about the case, he

797
00:51:33,320 --> 00:51:36,960
Speaker 2: agreed to a meeting. I went to the suburb of

798
00:51:37,080 --> 00:51:40,360
Speaker 2: Tuwong and the rain served tea and biscuits as we

799
00:51:40,480 --> 00:51:43,799
Speaker 2: talked about Elise in the family home, filled with her

800
00:51:43,880 --> 00:51:47,520
Speaker 2: image and memory, but cloaked in quiet sadness.

801
00:51:48,440 --> 00:51:52,719
Speaker 9: We live with the ongoing trauma. We ask ourselves what

802
00:51:52,800 --> 00:51:55,919
Speaker 9: could we have done, What did we miss? How could

803
00:51:56,000 --> 00:51:59,680
Speaker 9: we let this happen? It is so cruel for Jared.

804
00:52:00,400 --> 00:52:04,520
Speaker 9: He had the very best of intentions. Fate had something

805
00:52:04,560 --> 00:52:07,440
Speaker 9: else in mind. We do not want to be seen

806
00:52:07,480 --> 00:52:11,560
Speaker 9: to be vindictive and nasty to certain individuals in this

807
00:52:12,480 --> 00:52:14,960
Speaker 9: It's more about the bigger picture and how it can

808
00:52:15,000 --> 00:52:19,359
Speaker 9: be improved. Elise was just as perfect a child as

809
00:52:19,400 --> 00:52:22,719
Speaker 9: you could ever have. The last thing she would have

810
00:52:22,760 --> 00:52:25,759
Speaker 9: remembered was putting her head on Daddy's shoulder as he

811
00:52:25,800 --> 00:52:27,000
Speaker 9: carried her in from the car.

812
00:52:27,040 --> 00:52:27,640
Speaker 1: To the unit.

813
00:52:29,320 --> 00:52:32,959
Speaker 2: Jered's grief was still angry. He looked like a man

814
00:52:33,040 --> 00:52:35,200
Speaker 2: who had lost much of his will to live.

815
00:52:36,520 --> 00:52:38,359
Speaker 14: I know people look at me and say, how did

816
00:52:38,400 --> 00:52:40,840
Speaker 14: this happen? How did you let this happen? Of course

817
00:52:41,000 --> 00:52:44,200
Speaker 14: I have blamed myself. I'm a doctor and I'm a father.

818
00:52:45,200 --> 00:52:48,960
Speaker 14: It's tragic. It's a cancer. It eats away at you.

819
00:52:49,719 --> 00:52:53,280
Speaker 14: I don't trust health at all. I don't respect health

820
00:52:53,400 --> 00:52:57,600
Speaker 14: and I work there. It's a terrible dilemma. Now I

821
00:52:57,640 --> 00:53:00,799
Speaker 14: have a more important job to do, trying to bring

822
00:53:00,840 --> 00:53:04,839
Speaker 14: the Queensland health system into the twenty first century. I

823
00:53:04,880 --> 00:53:08,080
Speaker 14: want to see some honesty in the health system. If

824
00:53:08,080 --> 00:53:10,960
Speaker 14: this can put pressure on the system to respond in

825
00:53:11,000 --> 00:53:14,560
Speaker 14: a learning way, then it is worth it. Maybe I

826
00:53:14,600 --> 00:53:17,200
Speaker 14: have been relentless, but I'm going to stay that way

827
00:53:17,239 --> 00:53:20,000
Speaker 14: because the truth leads to findings and they will lead

828
00:53:20,000 --> 00:53:24,640
Speaker 14: to recommendations that can improve things. We will get comfort

829
00:53:24,760 --> 00:53:27,719
Speaker 14: knowing that something good will come out of this. I

830
00:53:27,800 --> 00:53:30,520
Speaker 14: know for a fact that if we did nothing, nothing

831
00:53:30,520 --> 00:53:34,680
Speaker 14: would change. Elise and I have made up, we have

832
00:53:34,760 --> 00:53:38,720
Speaker 14: worked it out. She's forgiven me. I know this sounds nuts,

833
00:53:38,760 --> 00:53:41,320
Speaker 14: but one day, when I sat next to her grave,

834
00:53:41,600 --> 00:53:45,000
Speaker 14: I saw her, and she was deliriously happy, but I

835
00:53:45,040 --> 00:53:49,279
Speaker 14: still want her back. It shouldn't have happened. She wasn't

836
00:53:49,400 --> 00:53:50,320
Speaker 14: given a chance.

837
00:53:52,000 --> 00:53:55,160
Speaker 2: The unfairness and emotion of it all made the stories

838
00:53:55,200 --> 00:53:59,000
Speaker 2: difficult to write. I knew that doctor Donovan, a father

839
00:53:59,120 --> 00:54:02,239
Speaker 2: of young children himself, was in agony and had been

840
00:54:02,320 --> 00:54:07,680
Speaker 2: punishing himself over Elisa's death. I knew his sister, Paula,

841
00:54:07,960 --> 00:54:10,800
Speaker 2: a colleague at the Courier Mail, was not in favor

842
00:54:10,840 --> 00:54:14,480
Speaker 2: of me exposing her brother to public scrutiny. But as

843
00:54:14,520 --> 00:54:18,320
Speaker 2: a fellow reporter, I hoped she understood it was unavoidable.

844
00:54:19,440 --> 00:54:22,880
Speaker 2: I talked over the angles with my wife Ruth. We

845
00:54:23,080 --> 00:54:26,239
Speaker 2: pledged never to let our children, who yearned to know

846
00:54:26,360 --> 00:54:29,960
Speaker 2: the story of the little girl, sleep in bunk beds.

847
00:54:30,719 --> 00:54:34,239
Speaker 2: My daughter, Sarah, aged three, came home from kindergarten with

848
00:54:34,320 --> 00:54:38,239
Speaker 2: a drawing of Elise. She had been asking me to

849
00:54:38,280 --> 00:54:43,840
Speaker 2: tell her bedtime stories about Elise for a week. Sarah

850
00:54:43,840 --> 00:54:48,800
Speaker 2: told her teacher the story of the tragic accident. Before

851
00:54:48,840 --> 00:54:52,000
Speaker 2: anything was published. I spoke to doctor Steve Buckland, the

852
00:54:52,080 --> 00:54:55,400
Speaker 2: Director General of Queensland Health, in his office with his

853
00:54:55,560 --> 00:55:01,160
Speaker 2: media manager, Lisa Schultz. Buckland did not appear concerned at

854
00:55:01,160 --> 00:55:05,319
Speaker 2: the major systemic issues, the twenty four hour shifts, the

855
00:55:05,480 --> 00:55:10,520
Speaker 2: rostering of inexperienced doctors to take charge of emergency departments.

856
00:55:11,360 --> 00:55:13,920
Speaker 2: It occurred to me that it was easier for doctor

857
00:55:13,960 --> 00:55:17,680
Speaker 2: Buckland and the regulatory system to punish Donovan than to

858
00:55:17,760 --> 00:55:21,480
Speaker 2: look at glaring and fundamental flaws that would take courage

859
00:55:21,640 --> 00:55:26,360
Speaker 2: and money to remedy. Before I went to see doctor Buckland,

860
00:55:26,719 --> 00:55:30,799
Speaker 2: he had a meeting with Jared Neville. Jered wrote this

861
00:55:30,920 --> 00:55:32,280
Speaker 2: in his diary that day.

862
00:55:33,320 --> 00:55:36,200
Speaker 14: He clearly does not have a positive outlook on Headley

863
00:55:36,280 --> 00:55:40,160
Speaker 14: Thomas or what his motives might be. Says he is

864
00:55:40,560 --> 00:55:41,120
Speaker 14: a grub.

865
00:55:42,560 --> 00:55:46,000
Speaker 2: After seeing the photographs of Elise at her parents' home,

866
00:55:46,520 --> 00:55:50,680
Speaker 2: I asked Jered and Lorraine for permission to publish one.

867
00:55:50,760 --> 00:55:54,200
Speaker 2: They considered the request overnight, and Jered called me the

868
00:55:54,239 --> 00:55:56,160
Speaker 2: next day to agree.

869
00:55:56,480 --> 00:56:00,160
Speaker 14: I want every health professional in Queensland to stare into her.

870
00:56:01,160 --> 00:56:04,279
Speaker 14: Maybe it will cause them to search their conscience and

871
00:56:04,320 --> 00:56:06,200
Speaker 14: appreciate what we are trying to do.

872
00:56:10,719 --> 00:56:14,480
Speaker 2: When the main feature and several accompanying stories were published

873
00:56:14,520 --> 00:56:18,799
Speaker 2: prominently on Saturday thirty one July, the reaction was immediate

874
00:56:18,920 --> 00:56:24,200
Speaker 2: and overwhelming. Many doctors were furious at the punishment of Donovan.

875
00:56:25,239 --> 00:56:28,680
Speaker 2: Staff and users of the health system were furious at

876
00:56:28,680 --> 00:56:33,680
Speaker 2: its obvious shortcomings. A number of readers called me to

877
00:56:33,760 --> 00:56:36,800
Speaker 2: say that they had wept for Elise and her parents.

878
00:56:37,440 --> 00:56:41,720
Speaker 2: The Australian Medical Association demanded action by the Beatty government

879
00:56:41,800 --> 00:56:46,680
Speaker 2: to stop unsafe practices in the health system. Tony Hoffman

880
00:56:46,840 --> 00:56:51,400
Speaker 2: had never contacted a journalist before. She cried when she

881
00:56:51,520 --> 00:56:55,240
Speaker 2: stared into the eyes of Elise Neville on the newspapers page,

882
00:56:55,320 --> 00:56:57,680
Speaker 2: and then she sat down to write an email.

883
00:56:58,719 --> 00:57:02,240
Speaker 10: Dear Headley, I read your article in this morning's Career

884
00:57:02,280 --> 00:57:05,640
Speaker 10: Mail with dismay. I am one of the nurses who

885
00:57:05,719 --> 00:57:09,600
Speaker 10: continues to work in the environment you describe. This week,

886
00:57:09,680 --> 00:57:12,960
Speaker 10: I stayed three hours after my shift finished to try

887
00:57:13,000 --> 00:57:16,560
Speaker 10: and ensure a patient was transferred to Brisbane from the

888
00:57:16,600 --> 00:57:20,960
Speaker 10: provincial hospital where I work. One of the surgeons involved

889
00:57:21,000 --> 00:57:24,400
Speaker 10: in the case insisted the patient did not need transferred,

890
00:57:24,480 --> 00:57:27,760
Speaker 10: despite the fact our hospital does not have the facilities

891
00:57:27,800 --> 00:57:31,760
Speaker 10: to care for such a patient. Finally, the retrieval team

892
00:57:31,840 --> 00:57:34,640
Speaker 10: was on its way and I left. When I returned

893
00:57:34,640 --> 00:57:37,200
Speaker 10: in the morning, I expected that the patient would have

894
00:57:37,240 --> 00:57:40,720
Speaker 10: been transferred, only to find he had died two hours

895
00:57:40,760 --> 00:57:46,000
Speaker 10: after the team arrived. The intimidating, bullying surgeon, of course,

896
00:57:46,200 --> 00:57:49,880
Speaker 10: was not wrong. He had delayed a transfer for several hours,

897
00:57:49,920 --> 00:57:53,000
Speaker 10: despite the pleas of the nursing staff. There is no

898
00:57:53,040 --> 00:57:57,280
Speaker 10: one we can complain to the hospital hierarchy. Believe this

899
00:57:57,360 --> 00:58:00,320
Speaker 10: surgeon is doing a great job because his making the

900
00:58:00,360 --> 00:58:04,560
Speaker 10: hospital money and keeping the waiting this down. If we complain,

901
00:58:04,880 --> 00:58:08,480
Speaker 10: we're in danger of losing our jobs. No one will

902
00:58:08,520 --> 00:58:13,760
Speaker 10: notice in the patient's notes the delay. It's not obvious

903
00:58:13,920 --> 00:58:17,200
Speaker 10: except to those of us who were there. The nursing

904
00:58:17,320 --> 00:58:20,800
Speaker 10: staff was so distraught the next day we are told

905
00:58:20,920 --> 00:58:24,160
Speaker 10: to follow the proper protocol to deal with such issues,

906
00:58:24,920 --> 00:58:26,080
Speaker 10: only to find no.

907
00:58:26,000 --> 00:58:27,240
Speaker 18: One supporting us.

908
00:58:28,000 --> 00:58:31,560
Speaker 10: The poor family of the patient will believe all was

909
00:58:31,680 --> 00:58:35,000
Speaker 10: done for this patient when we know this is not

910
00:58:35,120 --> 00:58:38,520
Speaker 10: the case. Keep up the good work at examining what's

911
00:58:38,600 --> 00:58:42,000
Speaker 10: going on in our hospital. How dare Queen's that Health

912
00:58:42,040 --> 00:58:45,959
Speaker 10: make Dr Donovan the escapegoat for a system which does

913
00:58:46,000 --> 00:58:46,600
Speaker 10: not work.

914
00:58:47,560 --> 00:58:48,200
Speaker 1: There are so.

915
00:58:48,280 --> 00:58:51,800
Speaker 10: Many good, kind and caring people out there trying to

916
00:58:51,840 --> 00:58:54,760
Speaker 10: do the best they can, but it is not working.

917
00:58:56,200 --> 00:59:07,000
Speaker 18: Tony Hoffman, Chapter twenty three, Suspicious Minds, Late July to

918
00:59:07,040 --> 00:59:13,760
Speaker 18: October two thousand and four, Nurse Michelle Hunter was seeing

919
00:59:13,800 --> 00:59:16,920
Speaker 18: too many surgical disasters with a common feature.

920
00:59:17,760 --> 00:59:19,240
Speaker 1: There were more wound.

921
00:59:18,960 --> 00:59:23,960
Speaker 2: Breakdowns, infections, and complications connected to the surgery of J. M.

922
00:59:24,080 --> 00:59:27,000
Speaker 1: Patel than all the other doctors in the hospital.

923
00:59:28,040 --> 00:59:31,600
Speaker 2: She asked died Jenkin, the manager of the surgical unit.

924
00:59:31,360 --> 00:59:34,720
Speaker 5: About it is anyone looking at what's going on here?

925
00:59:36,200 --> 00:59:39,320
Speaker 2: Nurse Hunter, back in Bunderberg after a stint in the

926
00:59:39,400 --> 00:59:42,960
Speaker 2: vascular surgical ward of a large hospital in Bath in

927
00:59:43,000 --> 00:59:47,360
Speaker 2: the United Kingdom, was stunned by some of Patel's decisions,

928
00:59:47,400 --> 00:59:49,760
Speaker 2: such as when he ordered that a plaster be put

929
00:59:49,840 --> 00:59:54,400
Speaker 2: on a man's amputated leg stump. After several days, she

930
00:59:54,560 --> 00:59:57,640
Speaker 2: asked Patel to look at the wound. It had completely

931
00:59:57,680 --> 01:00:01,400
Speaker 2: fallen apart. He casually told her to take out the

932
01:00:01,440 --> 01:00:05,920
Speaker 2: stitches and remove the necrotic tissue, as there was little

933
01:00:05,960 --> 01:00:09,480
Speaker 2: he could do. The man died a few weeks later.

934
01:00:11,040 --> 01:00:13,800
Speaker 2: Patel's lack of hygiene appalled the nurse.

935
01:00:14,480 --> 01:00:17,320
Speaker 16: She told him, I want you to go and wash

936
01:00:17,360 --> 01:00:19,400
Speaker 16: your hands before you go to the next patient.

937
01:00:20,360 --> 01:00:23,520
Speaker 2: But when Hunter was not around, Patel went back to

938
01:00:23,680 --> 01:00:26,440
Speaker 2: his old habit of moving from bed to bed and

939
01:00:26,520 --> 01:00:31,920
Speaker 2: touching wounds without once washing his hands. Hunter, who was

940
01:00:32,000 --> 01:00:36,440
Speaker 2: harboring serious doubts about Patel's competence, wondered if the surgeon

941
01:00:36,480 --> 01:00:40,240
Speaker 2: had been involved in any negligence cases in Oregon, where

942
01:00:40,640 --> 01:00:45,520
Speaker 2: he often boasted he had extensive experience. After a Google

943
01:00:45,600 --> 01:00:48,680
Speaker 2: search linked her to the website for the Oregon Board

944
01:00:48,760 --> 01:00:52,240
Speaker 2: of Medical Examiners, she put his name in the search field.

945
01:00:53,240 --> 01:00:58,040
Speaker 2: The information that appeared was amazing. Doctor j. I. Patel

946
01:00:58,160 --> 01:01:02,960
Speaker 2: had been subjected to recent serious discipline reaction. He had

947
01:01:03,000 --> 01:01:06,400
Speaker 2: been barred from performing a wide range of surgery because

948
01:01:06,440 --> 01:01:12,280
Speaker 2: of his proven incompetence. Although shocked, Hunter decided that information

949
01:01:12,600 --> 01:01:15,760
Speaker 2: so easily discovered had to be known to the Medical

950
01:01:15,800 --> 01:01:19,520
Speaker 2: Board of Queensland and the hospital's managers if indeed it

951
01:01:19,640 --> 01:01:25,680
Speaker 2: related to the same Jayant Patel. One evening, Karen Stumer,

952
01:01:25,880 --> 01:01:29,520
Speaker 2: a nurse in the intensive care unit, received an unusual

953
01:01:29,600 --> 01:01:32,920
Speaker 2: request from a theater wardsman. He had rushed out of

954
01:01:32,960 --> 01:01:35,600
Speaker 2: surgery and was in a state of mild panic.

955
01:01:36,160 --> 01:01:37,440
Speaker 13: Can we have some mouth swabs?

956
01:01:37,600 --> 01:01:38,200
Speaker 1: It's urgent.

957
01:01:39,240 --> 01:01:43,400
Speaker 2: Stumer wondered why they were needed in surgery. She went

958
01:01:43,440 --> 01:01:46,040
Speaker 2: to the stockroom and removed a handful of the swabs,

959
01:01:46,080 --> 01:01:50,080
Speaker 2: which were used in the ICU to clean patient's mouths.

960
01:01:50,880 --> 01:01:51,720
Speaker 1: What's the problem.

961
01:01:52,600 --> 01:01:55,840
Speaker 13: We need them because doctor Patel has flushed the bow backwards.

962
01:01:56,000 --> 01:01:58,680
Speaker 13: We have to clean out the patient's mouth before he wakes.

963
01:01:58,480 --> 01:02:01,200
Speaker 1: Up physically sick.

964
01:02:01,680 --> 01:02:06,200
Speaker 2: Betel's bungled flushing technique meant the patient's fecal matter had

965
01:02:06,240 --> 01:02:08,600
Speaker 2: gone the wrong way instead of being.

966
01:02:08,560 --> 01:02:10,080
Speaker 1: Washed out at the lower end.

967
01:02:11,600 --> 01:02:15,520
Speaker 2: By the end of July, amid serious disquiet among nurses

968
01:02:15,600 --> 01:02:19,000
Speaker 2: and some of the doctors over dez Bramach's death, Patel

969
01:02:19,120 --> 01:02:23,280
Speaker 2: had been the director of Surgery for sixteen months, yet

970
01:02:23,280 --> 01:02:27,120
Speaker 2: he had steadfastly refused to seek fellowship of the College

971
01:02:27,120 --> 01:02:30,160
Speaker 2: of Surgeons, even though it would have given him formal

972
01:02:30,240 --> 01:02:36,600
Speaker 2: specialist status, a hefty rays, and more boasting rights. Patel

973
01:02:36,760 --> 01:02:41,080
Speaker 2: kept making excuses. In truth, he must have known that

974
01:02:41,200 --> 01:02:45,040
Speaker 2: fellowship would be granted only after a careful vetting and

975
01:02:45,120 --> 01:02:52,960
Speaker 2: accreditation exercise. His United States bands would be discovered. His managers,

976
01:02:53,040 --> 01:02:57,320
Speaker 2: doctor Darren Keating and Peter Leck, did not twig. They

977
01:02:57,320 --> 01:03:00,560
Speaker 2: were delighted that Patel had made such a sky significant

978
01:03:00,680 --> 01:03:04,800
Speaker 2: dent in the waiting lists, but as both Tony Hoffman

979
01:03:04,920 --> 01:03:09,240
Speaker 2: and doctor Martin Carter had made known their worries about

980
01:03:09,280 --> 01:03:12,800
Speaker 2: the Bramwich case. Doctor Keating decided to look into it.

981
01:03:13,720 --> 01:03:18,480
Speaker 2: He asked Patel, Carter, doctor Jim Gaffield, and doctor if

982
01:03:18,520 --> 01:03:22,760
Speaker 2: Deca Eunice to supply reports on the care of Brammage.

983
01:03:22,920 --> 01:03:28,160
Speaker 2: Their accounts were in conflict. When Patel saw the Sentinel

984
01:03:28,200 --> 01:03:32,400
Speaker 2: event report by Tony Hoffman, he denounced it as based

985
01:03:32,400 --> 01:03:40,400
Speaker 2: on misinformation, misrepresentation and personal bias. The email Hoffman had

986
01:03:40,440 --> 01:03:43,680
Speaker 2: sent to me after reading the thirty one July story

987
01:03:43,760 --> 01:03:47,560
Speaker 2: about Elise Neville remained unopened until my return from a

988
01:03:47,640 --> 01:03:52,840
Speaker 2: family holiday. The cabin we had booked into near adam Innabee,

989
01:03:53,000 --> 01:03:55,720
Speaker 2: a forty five minute drive from the ski fields at

990
01:03:55,800 --> 01:03:59,760
Speaker 2: Mount Selwyn in New South Wales's Cosiosco National Park, was

991
01:04:01,040 --> 01:04:03,520
Speaker 2: but when we saw the bunk beds for the children,

992
01:04:03,880 --> 01:04:07,680
Speaker 2: we again thought of Alice. We covered the top bunk

993
01:04:07,720 --> 01:04:11,480
Speaker 2: with suitcases and organized the betting to ensure Sarah and

994
01:04:11,600 --> 01:04:16,040
Speaker 2: Alexander would sleep together on the bottom bunk. On my

995
01:04:16,160 --> 01:04:20,720
Speaker 2: return to work in mid August, I emailed Hoffman. I wrote,

996
01:04:21,040 --> 01:04:24,800
Speaker 2: I'm very concerned by the situation you've described. How do

997
01:04:24,840 --> 01:04:27,160
Speaker 2: you feel about me investigating it?

998
01:04:27,240 --> 01:04:27,800
Speaker 1: In a way?

999
01:04:28,040 --> 01:04:32,480
Speaker 2: Of course, that does not affect you, Tony replied.

1000
01:04:32,920 --> 01:04:35,840
Speaker 10: I would be very grateful on behalf of Queensland Health

1001
01:04:35,880 --> 01:04:39,760
Speaker 10: patients if you would investigate the situation that currently exists

1002
01:04:39,760 --> 01:04:43,800
Speaker 10: in Queensland Health, especially in the provincial areas, where we

1003
01:04:44,000 --> 01:04:46,800
Speaker 10: are very much at the mercy of third world doctors

1004
01:04:46,840 --> 01:04:50,640
Speaker 10: and management who do not support the grassroots and who

1005
01:04:50,720 --> 01:04:53,960
Speaker 10: consistently lie to cover up what is really going on.

1006
01:04:55,000 --> 01:04:57,880
Speaker 10: I have invested a lot of time, money and study

1007
01:04:57,960 --> 01:05:01,440
Speaker 10: in my career, but I am suddenly concerned about the

1008
01:05:01,480 --> 01:05:05,360
Speaker 10: state of affairs and just wish management would be accountable.

1009
01:05:06,640 --> 01:05:11,080
Speaker 2: Hoffman had deliberately not disclosed the hospital or town in

1010
01:05:11,120 --> 01:05:15,240
Speaker 2: which she worked. She wanted to continue pressing her concerns

1011
01:05:15,320 --> 01:05:20,320
Speaker 2: about Patel through official channels. In relation to a patient's death,

1012
01:05:20,360 --> 01:05:22,360
Speaker 2: which she described, she said.

1013
01:05:22,800 --> 01:05:27,000
Speaker 10: The surgeon continues to operate even though queens and Health

1014
01:05:27,040 --> 01:05:32,160
Speaker 10: are doing a preliminary investigation. The coroner is investigating. I

1015
01:05:32,240 --> 01:05:35,080
Speaker 10: really feel queens and Health is out of control with

1016
01:05:35,240 --> 01:05:37,280
Speaker 10: protecting incompetent doctors.

1017
01:05:37,360 --> 01:05:42,480
Speaker 2: Regardless, the lack of feedback from management to Hoffman gave

1018
01:05:42,560 --> 01:05:46,560
Speaker 2: her little confidence. At the urging of other nurses, she

1019
01:05:46,640 --> 01:05:49,880
Speaker 2: pleaded for advice from Vicky smy and Kim Barry of

1020
01:05:49,920 --> 01:05:54,280
Speaker 2: the Queensland Nurses Union. Hoffman had been going back over

1021
01:05:54,320 --> 01:05:58,720
Speaker 2: the records looking at deaths and complications in the ICU

1022
01:05:58,880 --> 01:06:04,000
Speaker 2: in the previous sixty months. She revealed how concerned she

1023
01:06:04,160 --> 01:06:08,720
Speaker 2: had become. Kim Barry told Tony, you can't collect that

1024
01:06:08,960 --> 01:06:16,240
Speaker 2: sort of information and not act on it. Antoine Gortray

1025
01:06:16,400 --> 01:06:19,520
Speaker 2: asked his friends and family to wish him well before

1026
01:06:19,560 --> 01:06:23,440
Speaker 2: going into the hospital in early September for a Whipple's procedure,

1027
01:06:23,960 --> 01:06:27,720
Speaker 2: an extremely complex operation to remove a tumor in the

1028
01:06:27,760 --> 01:06:32,160
Speaker 2: head of his pancreas. Although it was a procedure Petel

1029
01:06:32,320 --> 01:06:37,320
Speaker 2: had bungled in Portland, Oregon, with fatal consequences resulting in

1030
01:06:37,440 --> 01:06:42,000
Speaker 2: him being specifically restricted from attempting it again, he decided

1031
01:06:42,000 --> 01:06:45,240
Speaker 2: to use Gortray as his guinea pig in a hospital

1032
01:06:45,320 --> 01:06:48,320
Speaker 2: ill equipped for the post operative care that would be needed.

1033
01:06:49,240 --> 01:06:53,480
Speaker 2: Gortray was a seriously unwell man when he came out

1034
01:06:53,480 --> 01:06:56,800
Speaker 2: of theater. The extent of his cancer was such that

1035
01:06:56,840 --> 01:07:00,600
Speaker 2: the operation would almost certainly kill him. Before the disease

1036
01:07:00,720 --> 01:07:05,400
Speaker 2: took his life, Few, if any, surgeons would have operated

1037
01:07:05,520 --> 01:07:10,080
Speaker 2: on Gortray in his perilous condition but in his trademark

1038
01:07:10,240 --> 01:07:15,400
Speaker 2: cockshaw manner, Patel forged a head. Gortray died in late

1039
01:07:15,440 --> 01:07:19,240
Speaker 2: September after a stormy and prolonged stay in the intensive

1040
01:07:19,280 --> 01:07:25,919
Speaker 2: care unit. His death certificate stated clebsiella. Towards the end,

1041
01:07:26,360 --> 01:07:29,960
Speaker 2: a dark brown and sticky sputum that Gortray had been

1042
01:07:30,040 --> 01:07:33,520
Speaker 2: coughing up caused pneumonia and pockets of pass in.

1043
01:07:33,480 --> 01:07:35,000
Speaker 1: The lining of his lungs.

1044
01:07:37,240 --> 01:07:41,720
Speaker 2: The week after Gortray's death, Patel operated on In Vowels,

1045
01:07:41,960 --> 01:07:44,680
Speaker 2: a cabinet maker who had a polyop in the lining

1046
01:07:44,720 --> 01:07:49,560
Speaker 2: of his bowl. Instead of simply removing the fleshy growth,

1047
01:07:49,720 --> 01:07:54,520
Speaker 2: Patel opted for drastic action, removal of the entire bowel.

1048
01:07:55,680 --> 01:07:57,960
Speaker 2: Patel told him.

1049
01:07:57,600 --> 01:07:59,920
Speaker 11: Well, the sisters attached to the wall of your bower,

1050
01:08:00,080 --> 01:08:03,080
Speaker 11: and I cannot see what's in behind it. Jo Bowel

1051
01:08:03,160 --> 01:08:04,200
Speaker 11: does not like your body.

1052
01:08:04,600 --> 01:08:05,400
Speaker 1: We were work it out.

1053
01:08:06,240 --> 01:08:09,480
Speaker 11: I've done a lot of these operations before. People After

1054
01:08:09,520 --> 01:08:13,160
Speaker 11: they get welligan, they go skiing. You'll have no worries whatsoever.

1055
01:08:15,120 --> 01:08:21,160
Speaker 2: The operation was entirely unnecessary. The polyp was benign at

1056
01:08:21,200 --> 01:08:24,439
Speaker 2: the time Patel did the operation. There was nothing to

1057
01:08:24,479 --> 01:08:29,639
Speaker 2: suggest it might develop into cancer. At fifty seven Fowls

1058
01:08:29,720 --> 01:08:34,080
Speaker 2: was fitted with an illiostomy bag. There were serious post

1059
01:08:34,120 --> 01:08:38,840
Speaker 2: operative complications. His quality of life was never the same again.

1060
01:08:42,360 --> 01:08:46,000
Speaker 2: Glenn Tatham usually tried to inject humor into his deadly

1061
01:08:46,080 --> 01:08:48,160
Speaker 2: serious talks for Queensland Health.

1062
01:08:49,080 --> 01:08:51,120
Speaker 1: A few jokes sprinkled.

1063
01:08:50,600 --> 01:08:55,280
Speaker 2: Here and there made the subject ethical awareness less, foreboding

1064
01:08:55,400 --> 01:09:01,640
Speaker 2: for hospital staff. As a misconduct invests based in Brisbane,

1065
01:09:02,120 --> 01:09:05,680
Speaker 2: Tatham went to Bunderberg Hospital to remind the staff of

1066
01:09:05,720 --> 01:09:10,479
Speaker 2: their obligations under the Code of Conduct. Some people think

1067
01:09:10,560 --> 01:09:12,599
Speaker 2: that people who complain are dobbers.

1068
01:09:12,920 --> 01:09:14,679
Speaker 18: Do you agree?

1069
01:09:14,720 --> 01:09:18,559
Speaker 2: Tony Hoffman and the other nurses were increasingly alarmed as

1070
01:09:18,600 --> 01:09:23,599
Speaker 2: they watched one part of Tatham's PowerPoint presentation headed breach

1071
01:09:23,680 --> 01:09:30,600
Speaker 2: of confidentiality the small Town Scandal. Another part related to

1072
01:09:30,800 --> 01:09:36,800
Speaker 2: whistleblowing about serious threats to safety. Tatham and the explanatory

1073
01:09:36,800 --> 01:09:40,640
Speaker 2: material warned that a whistleblower who disclosed information to a

1074
01:09:40,800 --> 01:09:44,760
Speaker 2: union representative, the media or a member of parliament could

1075
01:09:44,800 --> 01:09:48,400
Speaker 2: be sacked and even imprisoned for committing a criminal offense.

1076
01:09:49,640 --> 01:09:51,760
Speaker 2: Dahela Alma said to Hoffman.

1077
01:09:52,200 --> 01:09:54,000
Speaker 12: I'm so glad you didn't do what you were going

1078
01:09:54,040 --> 01:09:54,320
Speaker 12: to do.

1079
01:09:55,720 --> 01:09:59,000
Speaker 2: The nurses were alarmed at the timing of the presentation

1080
01:09:59,240 --> 01:10:03,040
Speaker 2: and the con Quince's for staff who spoke outside the system,

1081
01:10:03,240 --> 01:10:06,840
Speaker 2: even though the system was not properly responding to complaints

1082
01:10:06,920 --> 01:10:13,320
Speaker 2: made internally. Until Tatham's sobering warning, Tony Hoffman had been

1083
01:10:13,360 --> 01:10:16,080
Speaker 2: ready to go to Brisbane with a Union official to

1084
01:10:16,120 --> 01:10:20,120
Speaker 2: bring jay N Pateel to the Health Rights Commission's notice.

1085
01:10:20,360 --> 01:10:24,000
Speaker 2: But now she was scared. She wondered if the timing

1086
01:10:24,040 --> 01:10:27,280
Speaker 2: of the talk was more than a coincidence, and whether

1087
01:10:27,360 --> 01:10:30,960
Speaker 2: she might already be in trouble for confiding information to

1088
01:10:31,120 --> 01:10:44,519
Speaker 2: me and the union. Sick to Death is written and

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Speaker 2: presented by me Hedley Thomas, the Australian's National Chief correspondent.

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Speaker 2: Claire Harvey is The Australian's editorial director. Audio editing, production

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Speaker 2: and music have been done by Jasperlik with assistance from

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Speaker 2: Leah Sammaglu and Neil Sutherland. Our producer is Christen Amias.

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Speaker 2: Production management by Stephanie Coombs. Artwork by Sean Callanan. Thanks

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Speaker 2: to Ryan Osland, Matthew Condon, Karina Berger, Ellie Dudley, David Murray,

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Speaker 2: Dominique McDermott, Zach Sculander and all our family friends and

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Speaker 2: colleagues who helped in this series and contributed voice acting

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Speaker 2: and special thanks to Tony Hoffman and Rob Messenger. Subscribers

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Speaker 2: to The Australian Here new episodes of Sick to Death

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Speaker 2: first at Sick to deathpodcast dot com and on Apple Podcasts.

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Speaker 2: You can get exclusive access to photographs, videos, timelines and

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Speaker 2: more at the website