Record of investigation into death: Piyanat Siriwan - Maurice ...

.. .... .I
STATE
CORONER
VICTORIA
CORONERS REGULATIONS 1996
Form 1
RECORD OF INSTIGATION INTO DEATH
I, PARSA ANTONIADIS SPANOS, Coroner,
State Coroners Offce
57~83 Kavanagh Street
Southban 3006
Telephone: (03) 9684 4380
(All Hour)
Toll Fre: 1300 309 519
(Only COWltr Victoria)
Fax: (03) 96821206
Case No: 1137/04
having investigated the death of PIY ANA T ANNA SIR AN
with Inquest held at the CoroniaI Services Centre, Southban on the 28th, 29th, 30th, 31st
March, 10th and 12th October 2006,
rind that the identity of the deceased was PLY ANA T ANNA SIRiw AN and that
death occurred on I st April, 2004 at Monash Medical Centre from -
I (a) POST PARTUM HAEMORRHAGE COMPLICATING AMNIOTIC FLUID
EMBOLISM
in the following circumstaces:
1. BACKGROUN
Mrs Piyanat Anna Sirwan was a thy-thee year old maried woman who resided with her
husband Mr Hainat Sirwan at 2 Hayden Road, Clayton. Mrs Sirwan was employed by
\,Thai Airays as a flght attendant, when at thy-two weeks gestation in her first pregnancy
she attended Dr Maurce Lichter, an Obstetrcian and Gynaecologist with rooms at 331
Princes Highway, Noble Park. Mrs Sirwan's early pregnancy had been managed
elsewhere, and apar from the relatively late change of doctors, her antenatal course had
been uneventfl.
On 3 i . March 2004 at South Eastern Private Hospital, Mrs Sirwan was induced at her
request at fort-one weeks gestation, and a healthy baby daughter was born by normal
vaginal delivery at 8.0Sam on i April 2004. Dr Lichter was in attendance until 8.ISam
when he made clincal notes before leaving the labour ward. i Despite being cared for by an
experienced obstetrician. and an experienced anaesthetist, in a private hospital with carng
and experienced nursing staf and an on-site pathology laboratory, despite access to an
experienced haematologist, urgent transfer by ambulance to Monash Medical Centre and
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¡ , , . /
intensive efforts there to save her life, Mrs Siriwan died at 2.15pm on the same afternoon
that she gave bir.
The consequences for her husband, daughter and other family members are obvious enough
and undoubtedly life-alterig. The emotional cost to them, but also to many others who
came into contact with Mrs Siriwan in their varous professional capacities on that fateful
day, was apparent even as they attended the inquest and testified some two years after her
death. I wish to acknowledge that emotional cost at the outset.
2. SECTION 19(1) OF THE CORONERS ACT 1985
As a coroner I am required to find, if possible, the identity of the deceased person, how the
death occured, the cause of death, and the date and place of death.2 In order to distinguish
'how death occured' froIl the 'cause of death', the practice is to refer to the latter as the
medical cause of death, and the former as the context within which the death occured, or
the 'backgrouru aru surrouruing circumstances'. As a coroner I am also able to comment
on any matter connected with the death including public health of safety3, to report to the
Attorney-General on the death, and to make recommendations to any Minster or public
statutory authority on any matter connected with the death, including public health or safety
or the admistration of justice.4
In relation to Mrs Siriwan's death, her identity and the date and place of death were clear
enough and required no coronial investigation. As a matter of formality, I find that Mrs
Piyanat Anna Sirwan died at the Monash Medial Centre, Clayton, Victoria, at 2.15pm on 1
April 2004.
3. THE CAUSE OF DEATH. THE PATHOLOGIST'S REPORT
Ultimately, the medical cause of Mrs Sirwan's death, was also uncontentious. Dr Matthew
J. Lynch, Forensic Pathologist5, performed an autopsy on 6 April 2004 and provided a
written report in which he summarised his autopsy findings as 'Amnotic fluid embolism
with numerous foetal squames noted within maternal lungs; evidence of peripar
hysterectomy; conspicuous petechial haemorrhages epicardium, subendocardium and renal
pelvic mucosa; posterior vaginal laceration; and, intensely haemorrhagic vaginal mucosa. "6
Dr Lynch attributed the cause of death to "l(a) Post partum haemorrhage complicating
amniotic fluid embolism", and commented that-
"The cause of death ... may be attibuted to complications of post par haemorrhage
which has occured as a result of amotic fluid embolism. As Attwood notes "amotic
fluid embolism is recognsed as a cause of maternal death durng labour and shortly after
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"
delivery. Shock with cyanosis or bleeding with incoagulable blood are the mai clincal
syndromes". . The diagnosis rests on a demonstration of foetal material withn maternal
pulmonar vessels in the context of an appropriate clincal history and mode of death. The
components of amiotic fluid which may be identified include epithelium squames, laguo
hairs, fat derived from vernix caseosa and mucin and bile derived from meconium. In this
instance the most conspicuous element (as is usually the case) was foetal squames. ...
A review of the medical deposition would tend to suggest that some form of genital tract
trauma was suspected as having contributed to the post par haemorrhage. Review of
the operative notes reveals that the surgeon noted a right sided broad ligament haematoma, a
contracted uterus and "probably lower uterine segment ruptue". There does not appear to
have been free blood noted within the peritoneal cavity. The hysterectomy specimen was
submitted for pathological examination. The macroscopic description describes the inerior
margin as ragged. It is unclear whether ths represents a surgical resection margin or the site
of possible rupture. The microscopic description includes ..."The disrupted margin is
iregular, fragmented and diffsely haemorrhagic in keeping with ruptured uterus (my
emphasis)". The autopsy findings are in keeping with coagulopathy complicating amotic
fluid embolism. The issue as to whether the uterus was in fact ruptued is one I suspect is
beyond resolution."?
Based on Dr Lynch's unchallenged autopsy report I find that the medical cause of Mrs
Siriwan's death was postpartum haemorrhage complicating amniotic fluid embolism.
4. 'HOW DEATH OCCURED' - TH SUROUNING CIRCUMSTANCES
The only remaining matter to be ascertained, the main focus of the coronial investigation of
Mrs Siriwan's death including the inquest, was 'how death occured'. Given the
circumstances already mentioned in sumar above, the inquest focussed mainly on the
events occurg with the five hour or so period, commencing immediately after the
birth of Mrs Siriwan's daughter, and ending shortly after 1.00pm with her arval at the
Emergency Department of the Monash Medical Centre. More specifically, the focus was on
the extent of Mrs Sirwan's post parm haemorrhage, and the clincal managment of her
post partum haemorrhage.
In writing this finding about events occurng within that five hour period, I have considered
all the material the product of the coronial investigation and inquest, namely the statements
of those involved in providing care to Mrs Sirwan, the evidence of those amongst them who
testified at the inquest, the medical records and other documents tendered at the inquest, the
reports of expert witnesses and their testimony, and the submissions of counseL. I do not
propose to sumarise all that material, but wil refer to it in such detail as appears to me to
be waranted on the basis of forensic signficance, and in the interests of narative clarty.
It wil be convenient to consider the events occuring within ths period in five shorter
periods, framed by key events -
(a) Immediately following delivery to the callng of a Code "Blue" (8.06am-8.59am)
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"
At 8.06am 1M Syntometrine Iml was admistered to Mrs Sirwan, ,and at 8.07am the thd
stage of labour was completed with the delivery of the placenta. Imediately post delivery
400mls of blood loss was noted.
At 8.15am Dr Lichter left for his rooms and the second midwife also left. Ms Christine
Margaret Hayes, a Registered Division 1 Nurse and Midwife remained with Mrs Siriwan. In
her first post delivery observations at 8.20am she noted the uterie fudus was lacking tone
and was therefore "rubbed up", blood pressure was 100/70, hear rate 100bpm and there was
a 200-300mIs bright red gush of blood per vagina.
At 8.23am Ms Hayes pressed the call bell for assistance. A third midwife Ms Helen Brewin
answered the call, and telephoned Dr Lichter to tell hi of the fuer blood loss and
observations. He gave a phone order and 1M Syntocinon 10 units was administered by Ms
Brewin.
When the next observations were taken at 8.30am blood pressure was 80/60, hear rate was
90bpm, and the uterus was stil lacking in tone and needing to be "rubbed up", Ms Hayes
telephoned Dr Lichter who ordered Misoprostal 2x200mg, and said he would attend to site
an intravenous line for fluids.
The Misoprostal was administered at 8.35am, at which time the uterus was still lacking in
tone and require frequent "rubbing up", blood pressure was 90/? and very difficult to hear,
and hear rate was 100bpm. When Dr Lichter attended at 8.40am he established an IV line
and Mrs Siriwan was commenced on Haran's IL. Bleeding appeared to have settled
at this time. When Ms Hayes queried the need for Haemacell in light of Mrs Sirwan's low
blood pressure and blood loss, Dr Lichter declined. He ordered Syntocinon 40 unts in
Haran's lL to ru at 250mls per hour over four hours and left.8 At inquest Dr Lichter
explained that he felt he could leave at this time as he thought the situation had resolved,
that although Mrs Siriwan's blood pressure and hear rate suggested she may have been low
in blood volume, her vital signs were agreeable, and the bleeding had settled. He was
adamant that he would not have left if he thought the bleeding was continuing.9
The Syntocinon insion was commenced at 8.45am. Observations at this time were blood
pressure 90/70, heart rate 90bpm and as the fudus was continuing to be rubbed up heavy
blood loss (estimated at llOOmls) including clots, was expelled. Mrs Sirwan's bed was
adjusted to help maintain her blood pressure, and when she complained of shortess of
breath, Ms Hayes commenced oxygen via a face mask.
There was little comfort from the next two sets of observations. At 8.50am blood pressure
was 80, hear rate was 100bpm, the uterus was stil lackig in tone and required rubbing up,
blood loss continued and Mrs Siriwan vomited a small amount of clear fluid. At 8.55am as
blood pressure was stil low at 85/70, hear rate was 90bpm and blood loss continuing, a
second line was commenced for delviery of Haran's 1L. At 8.57am Ms Hayes notified
her Associate Unit Manager Ms Robyn Blyth as she 'felt the patient's condition was
deteriorating and she needed extra back up, due to the level and continuity of blood loss and
the apparent inefficacy of the measures ordered by Dr Lichter'.10 At 8.58am when Ms
Blyth attended it was becoming difficult to take Mrs Siriwan's blood pressure.
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In light of the overall clinical pictue at 8.59am - blood pressure, was approximately 65
systolic - Ms Blyth called a Code Blue, and Dr Lichter was notified to attend imediately.
The Code Blue team arived at 9.00am, commenced Haemacell and ECG monitorig, and
discontinued the second line of Haran's. Dr Lichter arved after the Code Blue team,
and according to the medical records at 9.03am. He ordered the Syntocinon infsion to
increase to 900mls per hour. '
Following the Code Blue Mrs Sirwan's obervations were blood pressure 90 systolic, hear
rate was 121bpm, blood loss was settlng, oxygen satuation was 99% and the uterus
continued to need rubbing up.!!
(b) The decision to proceed with an examination under anaesthetic, and the
procedure proper (9.15am-10.25am)
At 9.15am Mrs Sirwan's observations were blood pressure 90 systolic, and hear rate 109.
A second bag of Haemacell was given, and Dr Lichter made the decision to perform an
examination under anaesthetic. At 9.20am Mrs Siriwan was transferred from the biring
suite to the operating theatre.
Ms Maureen An Nacey, a Registered Division One Nurse and the Manager Theatre
Operations, made arangements for the theatre to be prepared, and for nursing support. Dr
Emlyn Wiliams, Anaesthetist, had just completed his mornng list and was stil in the
operating suite. He was requested to provide anaesthetics for Mrs Siriwan, and was assisted
by Ms Sandra Southern, a Registered Division One Nurse, as anaesthetics nurse.
The procedure proper commenced at 9.30am, and was completed at 10.15am, according
to the medical records and other unèhallenged evidence. In his statement Dr Wiliams
explained that after pre-oxygenation and intubation, he performed a rapid sequence
induction, inserted a l6g IV line into a vein in the right ar and took a blood sample
for
cross-matching four unts of blood before an insion was stared into that line.I2 At inquest
Dr Wiliams testified that this was undertaken at the commencement of the procedure, near
enough to 9.30am.13
Ongoing bleeding and concerns about coagulopathy
Ms Barbara McManus, a Registered Division One Nurse and Midwife, was the Assistat
Unit Manger in the Theatre on the day. According to her statement when Mrs Sirwan was
anaesthetised and her legs put into stirps, a large amount of blood including clots, was
expelled from her vagina. Ms McManus estimated ths loss at one litre, stated that blood
continued to trickle throughout the procedure, and that at the conclusion of the
procedure, with the vaginal packs acting as a wick, there was stil a small slow trckle of
blood.!4 At inquest, in response to questions from Mr Saccardo SC, Ms McManus agreed
that the blood had been collecting in the uterus and was expelled in response to a change of
position. is She also added the following description of the expelled blood, consistent with
coagulopathy -
"she was passing big clots plus sort of - how can I put it - as well as just normal flow of
blood that you would get post delivery that yo/, could see but that was in the very beginning,
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as the time was progressing it was getting - it was what you call thinner... it wasn't as
blooded as it should have been so... (it looked a bit likej Strawberry topping. "16
Dr Lichter performed the procedure which he later sumarsed in the operating theatre
notes!?' in the following terms - "Empty uterus. Treat Ergometrine, Syntometrine.
Misoprostal by two. Failure to stop uterine relaxtion. Treat via vaginal packs into uterus.
For transfusion. Opinion Haematologist...Routin. post-anaesthetic observations aru
intensive nursing.'" Durng cross-examation by Mr F. D. Saccardo SC, Counsel
representing the Sirwan famly, Dr Lichter expanded on this summar and explained the
rationale for this treatment. He explained that he did not anticipate a ruptue in the
uterus but was lookig for retained products of conception, as their presence would impede
contraction of the uterus, and in tu cause post par haemorrhage. Dr Lichter said that
retained products were the most usual cause of post par haemorrhage, but having found
none and no other apparent cause for the failure of the uterus to contract, he decided to pack
the uterus. He inserted five gauze vaginal packs into the uterus in order to compress the
, blood vessels and stem the bleeding. ! 8
According to Dr Wiliams, Mrs Siriwan remained relatively stable thoughout the procedure
with a systolic blood pressure at or above 100 at all times.1~ However durng the procedure,
both Dr Lichter and Dr Wiliams became concerned about Mrs Siriwan's blood clotting
capacity, and a second sample of blood was taen for clotting studies. At inquest, Dr
Wiliams explained the sequence of events leading to the takg of two separate samples of
blood (the first for cross-matchig already mentioned above, and the second for coagulation
studies) as follows - "While she was in theatre blood was taken for clotting studies ... I
believe the concern for clotting occurred during the procedure in theatre, otherwise the
blood would have been taken at the same time as blood for cross-matching. "20
Consistent with ths concern, Dr Lichter sought advice from Dr Mark David Levi, Head
of ihe Deparent of Haematology, Dorevitch Pathology, Heidelberg. Ths was faciliated
by Ms Nacey, and as best I can ascertain, occured by telephone call either towards the end
or immediately after the procedure. Dr Lichter recalled he was still scrubbed and in
theatre,2! and Dr Levin put the tie of the call "shorty afer morng tea, about
io.15am".22 It is not so much the precise timig of that phone call but the content of the
conversation which is significant. In his statement Dr Lichter stated briefly that a
'Haematologist was called to ascertain if D.I.C. & assist with treatment' 23. In answers to
questions from Mr Saccardo SC, Dr Lichter explained that he didn't remember the exact
words he used, but he thought that Dr Levin would have understood the critica nature
of Mrs Sirwan's condition.24
Later, in answerS to (admittedly leading questions) from Mr J. G. Olle, Counsel for
Dorevitch Pathology, Dr Lichter agreed that he 'conveyed to Dr Levin that the patient is
delivered, he was having difficulties stopping the bleeding and was seeking assistance to
investigate a possible haematological cause'. Although he could not recall the words used
he conveyed that 'she was bleeding a lot, he was having difficulty controlling the bleeding,
and that he considered it uulikely that Dr Levin could have been unaware that there had
been a massive recent bleed' .25
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In response to questions from his own Counsel, Mr N. G. Ross, D,r Lichter adopted26 the
version of what Dr Lichter had conveyed to Dr Levin, in the latter's statement - "He
explained that a patient was bleeding from the uterus, suffering a post-par haemorrhage.
He stated that the uterus was atonic and he said he was having difficulty stopping the
bleeding. He asked if I could investigate a possible haematological cause contrbuting to the
bleeding."2? Dr Lichter also expressed his opinon that in order to provide haematological
advice Dr Levin did not need to know anything further.28 Regrettably, Dr Lichter was
wrong about this, and Dr Levin's answers to a number of questions highlighted how a fuller
history from Dr Lichter might have reduced the delay in defintively diagnosing
coagulopathy, and hastened appropriate treatment for Mrs Sirwan's post par
haemòrrhage.29
At lO.l2am, about the same time that this discussion between Dr Lichter and Dr Levin was
taking place, the Dorevitch Pathology Laboratory at SEPH printed interi results of a 'full
blood examnation' of what must have been the first sample taen by Dr Wiliams shortly
after the commencement of the procedure, and report a 'marked neutrophilia' with a
haemoglobin of 7.9 (well below the reference range of 11.5-16.5) and Neutrophils 15.2
(well above the reference range of 2.0-S.0),30 In cross-examination by Mr Saccardo Dr
Lichter agreed that the results would have been available to him at about that time and that
they were concernng, paricularly the low haemoglobin and platelet count3! and would
indicate the need for blood transfusion as quickly as possible.32 However he did not recall
seeing the results before Mrs Sirwan left the operating theatre,33 nor could he say when he
did see them and/or factored the results into his clincal management of Mrs Sirwan.
(c) Mrs Siriwan leaves theatre for the Recovery Room and the decision to transfer
her to another hospital for a hysterectomy (10.25am-ll.45arn12.00pm)
Mrs Siriwan left theatre for the Post Anaesthetic Care Unit or 'Recovery Room' at about
'lO.22am, but in any event shorty before lO.30am, accompaned by Dr Wiliams and Ms
Southern. In the Recovery Room she was attended to by Ms Vivienne Barallon, a
Registered Division i Nurse, who wrote the notes on the Post Anaesthetic Record34 between
lOAOam-I1.50am, Ms Fran Catacouzinos, also a Registered Division i Nurse, who was
providing jaw support thoughout the tie Mrs Siriwan remained in the Recovery Room,
and Ms Southern. Each of these nurses provided statements in which they describe Mrs
Sirwan's concerng and deteriorating condition at ths time.3S
According to Ms Southern's statement, she felt Mrs Sirwan needed extra care and so she
stayed in the Recovery Room to be 'another set of hands to help pump fluids, check drgs
and assist where I could'. Ms Southern's statement contaed the following salient comment
- "It was obvious to me when the patient arrived in recovery that she was not well. It was
obvious by just looking at the patient". At the Inquest Ms Southern explained that the nurse
to patient ratio in the Recovery Room is 1:1 where the patient is unconscious, and that noone
made a decision as such to provide 3:1 nursing care. It just seemed to her that she
should stay to help her two colleagues.36
In her statement Ms Barallon described Mrs Siriwan as requirng jaw support thoughout
her time in the Recovery Room, and at lOA5am requirg warng to help with her
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circulation. At the Inquest Ms Barallon agreed that Mrs Siriwan was a very sick patient
from the time she was admtted to the Recovery RoomY
The statement of Ms Catacouzinos was comprehensive, in keeping with her role as Mrs
Siriwan's primar care nurse. She described Mrs Sirwan in the following terms - she
required jaw support immediately upon admission to maintain her airay, intially it was
difficult to obtain monitorig readings but these became obtainable by lOAOam, oxygen
satuations were low and oxygen was being administered at full capacity via a size 3 guedels
to obtain a good reading, she was pale unconscious and unesponsive, her temperatue was
35.7 and she require warg, she had two large iv lines (one in each ar) and was
receiving Haran's solution and saline.38 At paragraph 14 of her statement Ms
Catacouzinos stated that "I recall during the course of the morning having never seen before
such an unwell patient. Her colour, her vital signs aru her blood loss all led to her being
very unwell."
I should note that the accuracy of the Post Anaesthetic Record (Exhibit "E") as a record of
observations taen ofMrs Sirwan by the nurses carng for her at ths time, was attested to a
number of witnesses.39 i accept that it is not only an accurate record of Mrs Sirwan's
clincal state, but a record entirely consistent with a patient in a critical and deterioratig
condition. Mrs Sirwan's concerng clincal presentation should have been obvious to
anyone perusing ths record. No less obvious was her actual clinical presentation to anyone
who was there to see it.40
The presence or absence of Dr Lichter and/or Dr Wiliams from the Recovery Room
during this period occupied a lot of time at Inquest. Dr Lichter's statement was laconic,
even cryptic on this issue - "Bleeding settled with packing. 4 U blood transfused 1105. BP
- I 20/Piyanat extubated & observed in theatre recovery -I 140. 1145 Piyanat reviewed. . BP
difcult to control. HR difcult to palpate... "41 At inquest Dr Lichter explaied that afer
writing his notes about the procedure, at about lOAOam he left the Recovery Room and
retued to his rOoms, having satisfied himself that the 'bleeding seemed to have stopped',
despite being aware that her blood pressure was 84/37 at the time, and leaving only 'RPA or
routine post operative observations' and 'intensive nursing' as his only orders or directions
to nursing staff regarding Mrs Sirwan's care.42 Furermore, Dr Lichter asserted that when
he retued at I I.45am (or perhaps as late as 12.0Opm), he did not do so in response to any
communcation with or request from the nursing sta, but of his own volition, to check on
Mrs Sirwan whilst he was back in the hospital preparg for his afternoon Iist.43
The evidence of the Recovery Room nurses is consistent with Dr Lichter's evidence' about
his whereabouts, except for the assertion made by some that communcation with Dr Lichter
about Mrs Sirwan's condition was ongoing, and in accordance with normal practice. It was
not clear however, who amongst them was actually communcating with Dr Lichter at ths
time, and what he was told.44 Whlst I find it unikely that the nursing staf would not
communicate, or at least attempt to communcate, with Dr Lichter about Mrs Sirwan's
clincal deterioration, in light of Dr Lichter's denial of any communcation durng ths
period, I am unable reconcile ths signficant divergence in the evidence, and am not
prepared to make an adverse finding against him on ths issue.
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Before leaving the hospital himself, Dr Lichter 'delegated' medical management to Dr
Wiliams by tellng nursing sta that he was there if they needed hi' .45 Dr Wiliams was
either within the Recovery Room or nearby, and in that sense more immediately accessible
to the Recovery Room nurses for medical input into the clincal management of Mrs
Sirwan. According to his evidence at inquest, Dr Wiliams was 'in the theatre complex for
most of that mornng and apar from being in the tea-room which is about ten metres away
from the recovery room, he was with the patient'. Except for the admistration of an
epidural to another patient from about 11.1 Oam- 11 .35am, when he was in any event only a
phone call and th metres away, he was available to monitor Mrs Sirwan, and agreed that
he was carng for her even though he wasn't with ar's length of her thoughout.46
Neverteless the nursing staf complained of a lack of 'medical support' in their care of
Mrs Sirwan, and felt that her medical management had been wanting. The combined
purort of their statements and evidence at inquest was that Dr Wiliams was in attendance
for short time after Mrs Sirwan's admission to the Recovery Room (til about lOAOam),
retued at about 1 1 .1 Oam when blood pressure dropped and ordered Ephedre, attended to
another patient requirng an emergency epidural between about 11.1 Oam-II.35am, and then
retued to the Recovery Room some time between i 1.45am-12.00pm when the decision
was taken to transfer Mrs Siriwan to another hospital for emergency
laparotomy/hysterectomy. Moreover, according to nursing sta, contacting Dr Wiliams
thoughout this period was problematic at times, and he was not as readily contactable as he
would have it,47
Ultimately, it is not so much the actual presence but the constrctive absence of Dr Wiliams
which is important, and the same can be said of Dr Lichter. It is not their actual presence
but the value of their medical input into the clincal management of Mrs Siriwan which is
germaine. What were they doing for her durng this period, and if they were not holding her
medical needs uppermost in their minds, why not and who was? I wil address ths below in
the context of the 'expert' evidence critical of their medical management, but it should be
noted that at ths time, apar from the Ephedrne ordered by Dr Wiliams and ongoing
admstration of Harans and Saline, 'medical management' amounted to waiting for
cross-matched blood. It was not until shortly after 11.00am that cross-matched blood first
became available. Mrs Sirwan received the first unit of cross-matched blood at
11.05am, the second at 1l.25am, the third at 1l.40am and the fourth at 1l.50am.48
The next key development in this chronology is the decision to transfer Mrs Siriwan to
another hospitaL. Despite hearg evidence from a number of witnesses either directly or
indirectly involved in this decision, I was unable to reconcile all the inconsistencies around
the sequence of events as they unolded. For example, when was the decision made? As
early as i 1.45am or closer to the time the ambulance was first called at 12.03pm?49 Who
intiated the transfer, and why? Although it was uncontentious that in the private hospital
setting, the decision to transfer was with the province of the treating doctor,50 it was not
clear whether Dr Lichter made ths decision based solely on his assessment of Mrs Sirwan
when he retued to the Recovery Room, whether he did so in response to a suggestion from
nursing sta concerned about her clincal deterioration, or whether the decision was
instigated by nursing staff 'escalating' Mrs Siriwan's care.S1 Although it was tolerably clear
that Dr Lichter's decision to transfer was informed by Dr Wiliams's indication that Mrs
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Siriwan would require at least a high dependency facility, or an int~nsive care facility postoperatively,
it is not clear when or where ths discussion took place.S2
In any event, by 12.03pm when Ms Catherie Joustra, the SEPH Emergency Coordinator,
called for an ambulance to transfer Mrs Siriwan to The Valley Prvate Hospital (TVPH), Dr
Lichter had already ascertained the availabilty of an operatig theatre for an emergency
hysterectomy, and appropriate post-operative care, and had aranged for another anaesthetist
to assist him as Dr Wiliams did not have practising rights at TVPH.S3 Records from the
Metropolitan Ambulance Service (MAS) indicate that the original call made at 12.03pm was
a request for a MICA ( Mobile Intensive Care Ambulance) unt, but after a telephone call
between the MAS Clincian and SEPH Nursing Co-ordinator where the level of urgency was
ascertained and it was confired that a medical escort would be provided by SEPH, an
ambulance in the vicinty was despatched at 12.1Opm ariving at the SEPH at 12.16pm.s3
(d) Arrival of the ambulance and the departure of Mrs Siriwan to the Monash
Medical Centre (12.16pm-12.55pm)
At some point, between the request for an ambulance and its arval or perhaps even shortly
thereafter Dr Lichter decided not to proceed with the plan to transfer Mrs Sirwan to TVPH
but to look for a public hospital which could take her. His reasons for doing so was that he
was reminded by someone that Mrs Sirwan had no medical insurance and it would be
expensive to proceed as a private patient with the likelihood that she would have a
protracted stay in hospital after the procedure.
54
Ths required Dr Lichter to make a number of telephone calls before finally speakg to an
Obstetrc Registrar at the Monash Medical Centre (MMC) and aranging for her transfer
there for an emergency hysterectomy. According to the medical records from MMC ths
call was made at 12.37pmSS some twenty-one minutes after the arival of the ambulance.
Apar from the delay occasioned by ths decision to seek a public hospital alternative at a
time when Dr Lichter conced.ed in evidence that time was of the essence, the fact that Mrs
Sirwan was unsured was readily ascertainable and prominently recorded on the SEPH
medical records and, in any event, Mr Sirwan had conveyed to Dr Lichter in no uncertain
terms that he was not concerned about the cost of any medical attention his wife required.S6
Given these circumstaces, Mr Saccardo was very critical of ths aspect of Dr Lichter's
actions to the extent of alleging a 'bad faith' motive for the change to MMC. It was asserted
that the transfer to TVPH would have required Dr Lichter to attend there himself to perform
the emergency hysterectomy, which in tu would have jeopardised his scheduled afternoon
surgery list. Dr Lichter denied that he had any motivation apar from wantig to save his
patient the expense of treatment as a private patient.S7 Whatever the motivation for the
change to the MMC at the time, it is now clear that one consequence of the change was that
Dr Lichter was able to commence his afternoon surgery list at the SEPH shorty after Mrs
Sirwan left by ambulance.
58
I note that some effort also went into clarfying the need for a medical escort, and
'negotiating' who it was to be. Whlst I am satisfied that Dr Wiliams, as an Anaesthetist,
- 10-

was better qualified to manage Mrs Sirwan's immediate clinical needs, and was the
appropriate doctor to accompany her, the confsion around who would go and his initial
reluctace were unelpfuL.
One might reasonably ask about Mrs Siriwan's clincal condition while the arangements for
her transfer were being revised, and what medical treatment she was receiving. As for the
latter, Mrs Sirwan was being transfused with packed cells and receiving inotropic support
and occasional Ephedre. As for the former, a number of witnesses from the SEPH who
provided statements and/or testified at the Inquest described Mrs Sirwan's deteriorating
clinical presentation at this time. Some of these descriptions were- 'she was in a critical
coruition aru required emergency management', 'patient very pale, laboured breathing, nil
peripheral pulses, pale & cool, unconscious, 5th unit blood in progress ... (later still
peripherally shutdown', 'she looked acutely unwell; exhibiting signs of a decreased level of
consciousness aru notable pallor... Vital sings were difcult to obtain, I attemped to gain a
BP, firuing a MAP of 39 (which is very low). My initial concern was the patients
poorlcompromised cardiac output ... I recorded the patients pupils as being size 2 aru
unreactive. Her eyes were slightly rolled back bilaterally'.59 No less eloquent was the
evidence of one of the ambulance officers Ms Krstia Bobetic - 'she was extremely pale
aru appeared to be in an altered conscious state ... I repeatedly stated my concerns for the
patient, including a concern that she would not survive the trip'.60
Crucially, Mrs Sirwan continued to bleed, with signficant blood loss noted when she was
moved onto th,e ambulance trolley for transfer.6! Furer blood was ordered, and the Blood
Products Register shows that five unts of packed cells (two '0 positive' and thee '0
negative') arved in the Recovery Room for Mrs Sirwan at 12.30pm, and were signed out
by an undentified person with a notation that it was "transferred with patient to".62
Although the identity of the person who signed the blood out was not ascertained, it seems
clear that it was the first of these unts (and the fifth unt of blood overall) which was being
transfused as Mrs Sirwan was transferred to the ambulance and depared for Monash
Medical Centre.
A number of witnesses testified that it would normally tae a maximum of 15-20 minutes
from the arival of an ambulance, to prepare and board a patient for transfer.63 Given all the
above circumstaces, it took about twice as long to transfer Mrs Siriwan from the arval of
the ambulacne crew in the Recovery Room at 12.16pm to the depare of the ambulance for
MMC at 12.55pm.
(e) En route to Monash Medical Centre and arrival there (12.55pm to i.04pm)
Durg the trip to MMC Ms Sirwan was accompaned in the back of the ambulance by Dr
Wiliams and Ms Southtrn. Mr Gethg was drving the ambulance and Ms Bobetic rode as
a front seat passenger. Before boarding Ms Bobetic gave quick instrctions about the
resuscitation equipment in the back of the ambulance and offered to have the ambulance pull
aside so that she could get in the back and asssit if necessar. She was clearly concerned
about the risk of Mrs Siriwan aresting en route, and kept an eye by lookig back.64 To the
extent that there is inconsistency between Ms Southern's evidence and Ms Bobetic's in ths
regard, I prefer Ms Bobetic's evidence.6S
- 11 -

At some point Mrs Sirwan began frothing at the mouth and was sucttoned by Ms Southern.
Blood was continuing to be transfused and oxygen delivered via mask. Shortly before
arval at MMC Mrs Siriwan went into cardiac arest. Dr Wiliams testified that - HI think
as I was pumping in the last of the blood she went into bradycardia as displayed by the
screen and the pulse became weaker aru disappeared as the line became straight ... I th
the person sitting in the passenger seat of the ambulance tued round and was surrised to
see us both just stading - sitting there like stued mullets. "66 When challenged about his
inaction in the face of his patient's dire circumstaces his justification was that he knew that
it would be hopeless as Mrs Siriwan was hypovolaemic and/or under-transfused and to
'perform external cardiac massage in those circumstaces would have been of no value' .67
Tragically, both Dr Wiliams and Ms Southern were wrong in one signficant respect.
Unbeknownst to them, someone had placed the remainng (probably four) unts of blood
signed out. at 12.40pm 'to be transferred with the patient,' in an Esky in the back of the
ambulance.68 Whether they forgot to tell Dr Wiliams and Ms Southern about its
availabilty or whether the message was lost in the confsion canot now be ascertained.
Someone at SEPH, probably the same person who signed the blood out and put it there,
must have told staff at MMC of the presence of the blood in the back of the ambulance.
According to Ms A vida Waren, an ambulance paramedic who happened to be in the
vicinity of the MMC Emergency Deparent testified that one of the nurses came out
yelling 'Where's the blood? Where's the blood?' in a way which suggested she was sure
there was blood in the back of the ambulance. Ms Waren looked in the back of the
ambulance which had just transported Mrs Siriwan found the Esky, looked inside and saw
that it contained blood, and handed the Esky to the nurse.69
At MMC a team of doctors was waiting for Mrs Sirwan who was imediately transferred
to the Resuscitation area for intubation and commencement of cardiopulmonar
resuscitation with a limited response. During an emergency laparotomy a large right broad
ligament haematoma and possible lower uterine segment ruptue were found but no
intraperitoneal blood, and the tubes and ovaries were normaL. An immediate hysterectomy
was performed. Despite transfusion of substantial amounts of blood, platelets and fresh
frozen plasma and ongoing resuscitation Mrs Siriwan failed to respond and was recorded to
have died at 2.I5pm. Her intra-operative blood loss was estimated at two to thee Iitres.70
5. COUNSELS' SUBMISSIONS
Comprehensive written submissions were received from Counsel representing all of the
paries, and oral submissions were also made. I do not propose to sumarse the varous
submissions. Perhaps predictably the submissions all had an adversaral tenor. On behalf
of the famly Mr Saccardo invited me to make adverse findings against Dr Lichter, and Dr
Wiliams for inadequacies in their clincal management and against SEPH for deficiencies in
aspects of their management of the facility and nursing management. All Counsel resisted
the makg of adverse findings against their respective clients.
The standard of proof for coronial findings is the civil standard of proof on the balance of
probabilities with the Briginshaw gloss or explication.?! Such findings should only be made
against a professional person in their professional capacity uness there is a comfortable
- 12-

level of satisfaction that negligence or unprofessional conduct has been established as
contributing to the cause of death.72
Applying that stadard to the totality of the material available to me I find no basis for
makng' any adverse findings against the Metropolitan Ambulance Service, and simply
note that I accept the accuracy of Mr Constable's submissions in ths regard, and adopt his
formulation 'that there is no evidence which iruicates any failure or omission by the MAS in
the care provided to Mrs Siriwan on 1 April 2004 or which could relate to any requirement
for change in the practices, protocols or operations of MAS. '
Similarly for the reasons set out in, Mr Olle's submissions on behalf of Dorevitch
Pathology, I find no basis for adverse findings against his client, and adopt his sunnar 73 -
'the clinical decision which were required to be made by the surgeon andor alUesthetist
were not those of the haematologist. It was Dr Levin's responsibilty to investigate a
coagulopathy, which he did. It was the responsibility of the laboratory staff to provide
blood aru conduct blood testing within a timely manner, which occurred. Problems arose
in achieving clotting, however apropriate enquiries were made of theatre staff to investigate
the possibility of contamination of the sample. Though initia( enquiries of the theatre
nursing staff raised the likelihood of contamilUtion, a subsequent discussion between the
laboratory collection nurse aru Dr Wiliams validated the sample. As a result of his
conversation with the collection nurse Dr Wiliams must have assumed a coagulopathy. '
The submissions made by Mr Blanden and Mr !hIe on behalf of the South Eastern Private
Hospital warant more detailed attention. Based on the totality of the material available to
me, I find no basis for adverse comment against SEPH on the basis of the quality of nursing
care. Without exception they strck me as competent and caring nurses doing the best they
could in a diffcult situation. Their concern for Mrs Sirwan's welfare thoughout the day
was evident and their distress and frstration palpable in some cases even as they testified.
Had they been properly empowered to escalate Mrs Sirwan's care I am confident they
would have. I note the new protocols for escalation of a patient's care developed since Mrs
Sirwan's death have the potential to secure better outcomes in futue,74
SEPH may be a private hospital facilty designed for patients with low acuity, low
comorbidities, low complexity of surgery and a fast tuover, and lacks the resources of a
tertiary hospitaL. The decision to admit a patient may be made by their doctor who assesses
the facilities as adequate for their needs. However, so long as any surgery is performed the
risk of complications requiring transfer to another facilty may be low but can never be
ignored. So long as women are admitted to give bir there wil always be a risk of known,
even if rare complications. This behoves the need to have established and well-rehearsed
processes for arranging such transfers, with clear role definition and lines of
communcation. The overall organsation of the transfer to MMC was a study in chaos.
Whlst recognsing that the priar responsibilty for Mrs Sirwan's transfer rested with Dr
Lichter, varous members of SEPH staf had a role to play, and it is unarguable that the
transfer could have been managed better. In the absence of a clear causal relationship
between the actions of any SEPH employee andMrs Sirwan's death, I do not consider any
adverse finding as such is waranted but do consider that a comment is waranted.
- 13-

One paricularly unedifying aspect of the evidence was the lamentable lack of knowledge of
the ready availability at SEPH of two units of '0 negative' or unversal donor blood suitable
for emergency use either in the absence of, or in anticipation of cross-matching.
Signficantly neither Dr Lichter nor Dr Wiliams were aware of its existence, and Dr
Wiliams at least said he would have transfused Mrs Sirwan with it had he known.
Although the responsibility for this state of affairs should be shared with the doctors,7S
SEPH should ensure that all doctors with practising rights are aware what facilties
and resources are available at SEPH. To the extent that their failure to transfuse '0
negative' blood imediately the need became apparent arose from the doctors' ignorance of
its existence, adverse comment is also waranted against SEPH. Here there is a clear causal l
relationship with Mrs Siriwan's death, as the timely provision of blood to compensate for
her post-par haemorrhage was a clincal imperative.
I have already said that adverse comments are not lightly made against professionals,
especially medical professionals, in their professional capacity and in relation to the death of
a patient. Regrettably there is compelling evidence to do so against both Dr Lichter and Dr
Wiliams arising from their clinical management of Mrs Sirwan on 1 April 2004.
Much was made of the postmortem confiration that Mrs Sirwan's cause of death was
'post-partum haemorrhage complicating amniotic fluid embolism', of the rarty of ths
condition and its association with a high maternal mortality rate. Both Mr Brookes on
behalf of Dr Wiliams and Mr Ross on behalf of Dr Lichter submitted that I could therefore
not be satisfied that any alleged deficiencies in clinical management were causative of death.
Though they couched their submissions in different language this was their effect. Mr Ross
was a strong possibilty that Mrs
submitted that causation could not be established as 'there
Siriwan' would not have surived in any event'. In so doing he cited his own client's selfserving
evidence and misrepresented the thst of the evidence of Drs White, Sinons,
Levin and the report of Dr CaldwelL.
In my view the available expert evidence not ony supports, but compels adverse
comment. Dr Bernadette White was the Obstetrician and Gynaecologist nominated by the
college to provide an independant report for the coronial investigation of Mrs Sirwan's
death. In her report Dr Whte stated that - "Amniotic fluid embolism is a rare coruition said
to occur in between 1:20,000 arul:80,000 deliveries. It has a high maternal mortality rate,
quoted as being between 26-61%. The diagnosis is essentially clinical aru can only be
confirmed at autopsy by the finding of fetal squames in the maternal
lungs. It may present
with features of anaphylaxis with cardiovascular aru respiratory collapse, or with the
development of coagulopathy ... Management is essentially supportive in reuscitation for
cardia-respiratory failure aru treatment of massive haemorrhage resulting from
coagulopathy ... £In Mrs Siriwanj The condition appears to have manifested primarily as
massive haemorrhage secondary to coagulopathy. "76 In short, all that was required for
appropriate clinical management was treatment for haemorrhage and/or anticipation of
coagulopathy, not a diagnosis of amotic fluid embolism.
Dr White was critical of a number of aspects of Mrs Siriwan's clincal management.
Without doing justice to the detail of her report and her evidence at inquest her criticisms
can be summarised as the lack of any clincal plan following the examation under
anaesthetic, the failure to treat for haemorrhage in a timely way, the failure to anticipate and
- 14-

to attempt to correct developing coagulopathy, and the decision to transfer a patient in
critical condition. It is no answer to say that there' was no defintive diagnosis of
coagulopathy until 12.15pm when Dr Levin rang theatre with the results of the clotting
studies. There was ample expert evidence that the possibilty of coagulopathy should
always be considered in the presence of ongoing haemorrhage. Coagulopathy can be caused
by amotic fluid embolism, but can also develop from the dilution of natual clotting
mechansms by transfusion of blood or fluid replacement therapy, in the presence of
haemorrhage.77 Moreover there was evidence that the appearance of a sample of
essentially unclottable blood should have alerted all concerned to the presence of
coagulopathy durng the examination under anaesthetic,78
Dr Caldwell was an Obstetrcian and Gynaecologist who provided a medico-legal report for
Mrs Sirwan's famly. His evidence was unchallenged in that he was not required to attend
for cross-examination. On my reading his report is essentially consistent with Dr Whte's.
He attrbutes Mrs Sirwan's bleeding to an atonic uterus and an amotic fluid embolism
causing coagulopathy, which conditions were not managed appropriately in that 'she was
not resuscitated suffciently with blood products, no attempt was made to reverse her
coagulopathy aru there was unnecessary delay in performing a hysterectomy. '
Dr Simmons was an Anaesthetist79 who provided a medico-legal report for Mrs Sirwan's
family. He testified at Inquest and was cross-examned at length about the opinions he
expressed about anaesthetic management, resuscitation and broader medical management of
Mrs Siriwan. He was critical of clinical management across these areas, highlighting the
eight key deficiencies80. Without doing justice to the detail of his report and his evidence at
Inquest, in sUmIar, his criticism were about delayed and/or inadequate replacement of
fluids, blood and blood products, and the inadequate monitoring of the patient to assess
response to therapy.
All this was entirely consistent with Dr Wiliams' pithy testimony that what was done for
Mrs Siriwan was "Too little, too late",Bl To allay Mr Brookes concerns in ths regard I have
not interpreted this as an admission against interest absolving me of the need to find
causation etc., but as reflective practice appropriate in .any professional person afer a
sentinel or adverse event. The same canot be said for Dr Lichter.
I have some sympathy for Dr Wiliams' in that he became involved in Mrs Sirwan' s clincal
management simply because she required anaesthetics for the examation under anaesthetic
and he was available. Thereafter Dr Lichter appears to have unairly abrogated
responsibilty for his patient to Dr Wiliams. True it is that Dr Willliams as an anaesthetist
was better placed to deal with issues of resuscitation, but Mrs Sirwan was Dr Lichter's
patient and he bore the priary responsibilty for her overall clincal management. It may
be that both doctors were unaccustomed to treating patients of such a high acuity. If so, the
least that could be reasonably expected was their identification of ths mis-match between
their capacities and her clincal needs, and the arangement of a timely transfer.
6. CONCLUSION
It is one thing to say that amiotic fluid embolism is a rare and serious complication of child
birth, which is unpredictable, unpreventable and may lead to maternal death despite the best
- 15-

\
medical management, and quite another to contemplate the circumstances surounding Mrs
Siriwan's death. With competent medical management including more timely and less
chaotic decision-makg, Mrs Sirwan had a reasonable chance of surival - in that sense I
find that her death was preventable.
8. RECOMMNDATION
That the Medical Practitioners' Board of Victoria considers the circumstances surounding
Mrs Sirwan's death and taes whatever action it deems appropriate against Dr Maurce
Lichter and Dr Emlyn Wiliams.
9. DISTRUTION OF FINING
Apar from Mrs Siriwan's family, the paries and any witnesses who request a copy of this
finding, I hereby direct that a copy is to be provided to each of the following -
The Attorney-General
The Minster for Human Service - Health
Director of Medical Services, Monash Medical Centre
The Medical Practitioners' Board of Victoria
i.
2,
3,
4.
5.
6.
7.
8.
9,
10.
11.
i~t~
Paresa Antoniadis Spanos
Coroner
25 Januar 200S
END NOTES
.
Exhibit "A", statement of Dr Maurice Lichter, page 2, lines 29-33. He noted a perineal graze which was not suturd and "mild bleeing
due to uterine relaxation corrted with rubbing uterine fundus".
Section 19( i) Coroners Act 1985
Section i 9(2) Coroners Act 1985
Sections 21(1) and (2) Coroners Act 1985
Dr Mattew Joseph Lynch's ronnal qualifications and title: MB BS. LLBCHons), FRCPA, Dip.Fore.Path., DMJ(Path), then Head.
Division of Pathology, Victorian Institute of Forensic Medicine. His autopsy report fonned par of the "balance of the brief' tendered as
Exhibit "FF".
Page 6 of the autopsy report
Pages 8-9 of the autopsy report
This par of the chronology is mostly taen from the statement of Chrstie Margart Hayes, pages 2~5t tendered as Exhibit "U", but is also
consistet with the SEPH medical rerd (Exhibit hFF') and par of Dr Lichter's evidence at inquest.
Trascript pages 26~27. Intertingly Dr Lichter's statement doe not refer to his attndance in person at 8.40am, nor to his depar soon
afer, but did cOncede that he did so durg XX by Mr Blanden at trscrpt page 82.
Page 6 of Exhibit "U"
Ibid at page 5
- 16-

12. Exhibit "H" page 2, paragraph 4
13. Tracript page 112
14. Exhibit "BB!' page 3
15. Tracript 10 October 200 page 16
16. Tracript 10 October 200 pages 17-18
17. Exhibit "C"and trcript pages 32-33
18. Tracript pages 33.34'
19. Exhibit "H" and transcript page 105
20. Tracript pages I I 2- I I 3
21. Tracript page 78
22. Exhibit "N"
23. Exhibit "A" page 3 line 9
24. Tracript pages 65-66
25. Trancript pages 73-74, 78
26. Tracript page 79 et seq, 90
27. Exhibit "N"
28. Tracript page 90
29. Trancript pages 269-282. Note that shorty after this conversation Dr Levin requested firt a thombin test and then a D-Di!ler test.
30. Exhibit "I". Note that this report also shows 'cross-matching' and 'coagulation studies' as tests reueste but stil outstading -
preumable as at 10.22am.
3 I. Exhibit "I" shows plateletS low at 120 with a reference range
32. Tracript page 37
of 150-450.,
33. Tracript pages 35-36. See also trcript pages 355-356.
It is at leat interesting that Nure Nacy did a spot test for haemoglobin (haemotube) when Mr Sirwan arved in the Recvery Room
which also showed haemoglobin at 7.9 - although ther is no evidence that she advised Dr Lichter (as opposed to Dr Wiliams) of ths
reult.
34. Exhibit "E" - the Post Anaesthetic Record sometimes referred to in the transcript as the Recovery Notes.
35. Ms Barlon's statement was Exhibit "Q". Ms Catacouzinos was living oversea and was unavailable to give evidence at the Inquest Her
statement formed par of Exhibit "FF" - the Balance of the Brief, and she was instrental in the compilation of Exhibit "R" - the
Handwrtten Group Statement comprising the observations of Ms Barallon, Ms Southern and herself in the Recovery Room and around
the trfer to Monash Medical Centr, and including the observations of Mr Danl Spenig from midday on.
36. Tracript page 176
37. Trascript page 303
38. Statement of Ms Catacouzinos, par of Exhibit "FF" page 1 pargraph 3 - page 2 pargrph i i
the
reord. but a degree of focus on what could properly be inferr from the reord, paricularly in Mr Brookes' (Counel reprenting Dr
Wiliam) cross-examnation of a number of witnesses.
39. See trscrpt page 302, 3045. and Ibid at pargrph 13. I note that at Inquest there was no serious challenge to the acurcy of
40. Ths is borne out by the vanous 'expert opinions' which wil be referr to below, but also by the whole tenor of the evidence of Dr
Wiliam, Ms Southern and Ms Barllon at Inquest, and the statement of Ms Catacouzinos.
41. Exhibit "A" page 2
42. Trascript pages 3, 33, 41-42, 62-63
43. Trascript pages 50, 55. 92 and 94-95
44. See Exhibit "L"pargraph pargrph 7, Exhibit "Q" paragrph )7, statement of Ms Catacouzinos pargrph pargraphs i 8 and 24,
ircrptpage 17, 182-183, 188-190. 192-194
45. Tracript page 85, 349-350. See too trancript pages 4, 32, 42 regaring the dual responsibilty for medical management of Mrs Siriwan,
- 17 -

according to Dr Lichter
46.' Tracrpt page 107-8, 117
47. Ms Barllon - Exhibit "Q" pargraphs 6, 10 and 20, trcript page 302! 307, 312; Ms Southern - inerentially Exhibit "L" paragraphs 8
10. transcript pages 173. 175, 178, 186; Ms CatacouzInos - statement pargrphs 5, 8,12 and the whole tenor of Exhibit "R"; Ms Nacy-
Exhibit "T" page 3. trscript pages 349-351
48. Exhibit "J". Note that one unit is 45Omls, so the four units trsfused commencing at these times meat that by about midday Mrs Sirwan
had received only 1800mls of blood (and other fluids) to compensate for her ongoing bloo loss frm shortly aftr 8,OOam that morng.
49. For example see transcrpt pages 13,50 and 70 for Dr Lichter's evidence
Nure Joustr's. .
on the issue of timing, page119'for Dr Wiliam', Exhibit "0" for
50. Letter frm Ms Liz Twer, Diretor of Nuring, SEPH and SEPH Transfer Policy No COC19 - par of Exibit "FF
51. For example see trscript pages 58, Exhibit "T" pargraphs 14-17 and Exhibit "0" pargrph 17.
52. Tracript pages
53. Exhibit "Y"
54. Exhibit "A" and trnscript pages 16-19.
55. See par of Exhibit "GO" the Monash Medial Records for a handwrtten entr by Dr D'Souza at 12.37pm and trcrpt page
Interestingly Dr 0' Souza's note of her telephone conversation with Dr Lichter also rerds a four litr blood loss, and the possibilty of
DIC (disseminated intrvascular coagulopathy).
56. Tracript pages 16-19.
57. Ibid. Note that both Ms Nacey's statement
surgery list.
Exhibit "T" and the note referred to in 55. mention Dr Lichter's concern with his afternoon
58. Exhibit "CC" the register copiled by Recover Room nures of all surgical proceur shows Dr Lichter pedormg surgery between
14:28-15:30,15:40-16:30, 16:4Q.17:01, 17:08-18:43, 17:46-18:09, On each occaion Dr Wiliams is shown as providing anaethestics.
59. Trascript page 104 - Dr Willams
Exhibit "R" - Handwrtten grups statement
Exhibit "Z" - Mr Spenig
60. Exhibits "V" and "W".
6 i. A number of witnesses give evidence of this - for example see Ms Catacouzinos' statement paragraph 25, par of Exhibit "FF'.
62. Transcript pages 2-3 10/10/06, Exhibit "AA".
63. Including Dr Lichter, Ms Bobetic and Ms Joustr.
64. Ms Bobetic's evidence - Exhibits "V" and "W" and trscript pages 391-394, 403-404cf: Ms Southern's at
page 184.
65. See trscript references and summar in Mr Constable's submissions on behalf of the Metrpolita Ambulance Service - pargrph 8.
66. Trascript page 154.
67. Ibid, and also at page 122.
68. Tracript pages
69. Exhibit "DO" and trscript page 31 10/10/06.
70. Exhibit "GO" the Monash Medical Records and for a summar see Dr White's statement Exhibit "M".
71. Briginhaw v Briginshaw (1938) 60 C.L.R. 336 esp at 362
Héalth and Community Services and Ors v
Gurich (1995) 2 V.R. 69 per Southwell, J; Chief Commissioner of Police v HaUenstein (1996) 2 V.R. i . Of coure the (annal
requirement to find 'contrbution' as such has since be removed, but I proee on the basis that some causal connection is nevereless
required to be established. See Mr Brookes submissions in this regar.
72. Anderson v Blashk (1993) 2 V.R. 89 at 95 per Gobba, J; Secreta to the Deparent of
73. I have some reservations about the timeliness of the provision of
bloo (fit reived at 11.00am) but in the absence of clear evidence
about when it was reived by Dorevitch and the failur by Ors Lichter/WiJlam to fast-trck the reuest at all, miltate against advere
comment.
74. At the risk of going beyond my proper scope, I note that in the hospital context the escalation of a patient's ca may, depending on the
circumstaces, car with it an implicit or even explicit criticism of the person reponsible for medical management. Without cultul
change it may be difcult to achieve in practice the ben'efits which look achievable on paper.
75. There was evidence that maternity hospitals arund Melboure commonly have two unis of '0 negative' blood for just such eventualities .
- 18-
6.

Dr Caldwell's statement, and the evidence of Dr While and Dr Levin.
76. Exhibit "M" pages 4-5.
77. Trascript pages 201,206.
78. Transcript page 234. 266.
79. Report datect6 March 2006, par of Exhibit "HH". Dr Simons is Senior Staf Speialist in the Deparment of Anaesthesia, Mercy
Hospital for Women. and Chair of the Special Interest group for Obstetrc Anaesthesia of the Australian and New Zealand College of
Anaesthetist
80. Ibid at page 8.
81. Transcript pages 134-135.
Appearances:
Senior Constable Paul Sambell
Senior Constable Viola Nadj
Senior Constable King Taylor
)
)
)
State Coroners Assistats Unit
Mr Fran Saccardo The Siriwan Famly
instrcted by Maurice Blackbur
Mr David Brookes Dr Emlyn Wiliams
instrcted by Gadens
Mr John Olle Dorevitch Pathology
instrcted by Phillps Fox
Mr John Constable Metropolitan Ambulance Service
instrcted by Tresscox
Mr Chrs B1anden with Mr Ben Ihe South Eastern Private Hospital
instrcted by Monahan & Rowell
Mr Noel Ross Dr Maurce Lichter
instrcted by Gadens
- 19-