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April 8th, 2013

Letter to Jillian Skinner N.S.W Health Minister

2/4/2013
Dear Ms Jillian Skinner,
I have not received even an acknowledgement of my letter to you written/ sent/ received 16th March 2013. It is now 2nd of April 2013. When will you respond in full to my letter to you please? It is not good enough to just claim “nothing to be gained by opening this case for further investigation and consider the matter now closed.” Please tell me what part of my husband’s brutalisation and death was acceptable practice in any country at any time. It appears you condone such disgusting practices if you choose to do nothing. Please tell me you do not condone the shocking botch of his surgery and its cover up. Please do not think that because my husband was a Quadriplegic that his suffering and death was any lesser importance than if he had been able bodied. It appears this way to me.

You are now responsible as the Health Minister. My husband deserves justice for how horribly he was forced to suffer and for being killed how he was. What we witnessed will never leave our nightmares. It just is not right Ms Skinner and you know it. He has just been put in the “too hard” basket. I do not know of what beliefs you have but it is on these sorts of things we will be judged.

Please take the time soon to respond. I am not going away and no matter what the doctors and hospital involved they will not be burying their criminal mistakes which cost my poor husband his life.
Yours sincerely,
Mrs Therese Mackay

Web www.withoutduecare.com

16th March 2013

Ms Jillian Skinner, NSW Health Minister
Parliament House
Macquarie St
SYDNEY NSW 2000

Dear Ms Jillian Skinner,
Before the Coalition came to power I had been supported by Nationals Andrew Stoner and the National candidate for Port Macquarie Leslie Williams. Both of them became actively involved and spoke at my book launches in 2010. That support petered out after the Election. You, Jillian Skinner when in Opposition bought a copy of my book from me when I was selling it in our local shopping centre and you were was visiting Port Macquarie. You were very polite and supportive, that time.

Now all three of you are in Government. I am in receipt of letters from you and Leslie Williams. You wrote “I believe there is nothing to be gained by opening this case for further investigation and consider the matter now closed.” Leslie Williams replied in almost the same words. Considering Ms Williams passionate speech at my book launch I am wondering what could have changed as she is now in a position to do something about it. If feels like hypocrisy to me.
We have a Health Minister and MP for Port Macquarie who find it acceptable and not worthy of justice that a frail disabled man was brutalised and killed in the shocking way my husband was and you consider “there is nothing to be gained” by investigation.
What about Justice, something I believed we had a right to expect in Australia? Justice for my husband who suffered horribly for five weeks after the cardiothoracic surgeon sent him out of theatre with his Pleural Lining being suctioned at ten times the safe amount (31kpa instead of 3kpa) and left it like this for 22 hours till a nurse discovered this. Then compounded their negligence by not telling us what had happened till I found out 7 months later. What about justice for those of us who love him and who will never heal from what we saw being done to him, no more than any relatives of people killed by crime or accident? For my husband to have Justice then the Specialists involved would have to be questioned and inconvenienced. Nothing much would happen to them as it is rare for any doctor in Australia to be made accountable. You see Ms Skinner, I believe that in a civilised country the worth of the vulnerable, such as my husband Don is more than that of the rest of us. And it is because he was so vulnerable he should have been treated carefully and with dignity by the Specialists involved – not the opposite. If this sort of behaviour is condoned by not investigating we are on a slippery slope backwards.

By your statement, that “there is nothing to be gained” it appears to me that a value judgement has been made. That judgement that the doctors involved have more worth and rights than my husband. That my husband’s quality of life was not considered high enough to be worthy of any real investigation apart from that of the HCCC which is a joke. Their medical person was such a fool he/she declared my husband would not have felt any pain because he was a Quadriplegic – when in normal life his pain levels were so dreadful and intense he was on Opiates just to enable him to sit up in the wheelchair.

I have proven on many issues what was done to Don. There is no doubt as it is in their notes what a disaster their “care” of him was.

Surgeon Dr Rodney Woods in the Jayant Patel case in Brisbane states in regard to Patel’s patient Mervyn Morris, “If he hadn’t had the surgery then I don’t believe he would have developed the various complications and the subsequent death.” Patel spent time in goal.

Please help me to understand the difference in what Professor DuFlou wrote in his report to the NSW Coroner in regard to the death of Don Mackay, “it is most unlikely that the deceased’s rapid, but lengthy, deterioration would have commenced when it did but for the patient undergoing the various transfers and treatment.”

Or of what Dr Phillip Hoyle Director of Clinical Governance RNSH wrote in his letter 2/1/08
“The very rapid progression from admission to operation meant that there was no assessment by the Spinal Unit or with the respiratory Unit preoperatively. I recognise that given the complexity of Mr Mackay’s condition, a more comprehensive assessment, with input from the spinal and respiratory teams prior to surgery, would have been wise.”

I challenge you Health Minister Jillian Skinner and Ms Leslie Williams to justify your weak stand. Justice should be for everyone, the same – not a convenience to be dispensed with because they consider there is nothing to be gained.

Lorraine Long from the Medical Error Action Group states that in Australia one Jumbo Jet full of people are killed weekly by medically caused deaths. God only knows how many are permanently injured. You would think a Health Minister would want to help find out why – one has to ask why you do not.

Please find attachment below with a brief outline of what was done to Don Mackay. This attachment was the flyer I produced to support the Petition which Mr Andrew Stoner delivered to NSW Parliament. On any one of those few points there is a case to answer – all together it is clear that the doctors involved acted negligently and as mentioned worse than that they covered it up.

After reading this Ms Skinner, please explain to me why you wrote to me, “I believe there is nothing to be gained by opening this case for further investigation and consider the matter now closed.” Please explain to me why any one of those points is deemed acceptable and not worthy of investigation in Court.

You have a duty to us the Taxpayers who pay for the whole system of government, before the doctors involved, before the Health department and before your own party. Either Don’s treatment was excellent or it was not. If it was not excellent and if it led directly to his suffering and death then whether or not you think anything is to be gained does not matter. My husband and us his family have a right to justice and you the Health Minister have a duty to bring this about.

Just as you have this duty, so I have one last honourable duty to my husband and our daughters, that of obtaining justice as he deserves.

Yours sincerely,

Mrs Therese Mackay

cc Mr Andrew Stoner, Ms Leslie Williams, Mr Barry O’Farrell, Media

_________________________________________________________________________________________________________________________

MEDIA RELEASE 28th Feb 2013

Shame on Health Minister Skinner and MP Leslie Williams

In 2007 my husband and father of our children, Don Mackay was killed by Medical Errors, Medical Negligence and subsequent cover up. This happened in a major Sydney teaching office. In 2010 I published a book called “Without Due Care” in order to expose what was done to him and how the health system worked to cover it up. (See my web page for further detail – www.withoutduecare.com ).

This happened under the NSW Labor Government. Before the Coalition came to power I was supported by Nationals Andrew Stoner and the National candidate for Port Macquarie Leslie Williams. Both of them became actively involved and spoke at my book launches in 2010. (I have DVD of their speeches). Jillian Skinner when in opposition bought a copy of my book from me when I was selling it in our local shopping centre and she was visiting. She was very polite and supportive, that time.

Now all three are in Government. I am in receipt of letters from Health Minister Jillian Skinner and Leslie Williams. Ms Skinner wrote “I believe there is nothing to be gained by opening this case for further investigation and consider the matter now closed.” Leslie Williams replied in almost the same words. Considering Ms Williams passionate speech at my book launch I am wondering what could have changed as she is now in a position to do something about it. If feels like hypocrisy to me.
We have a Health Minister and MP for Port Macquarie who find it acceptable and not worthy of justice that a frail disabled man was brutalised and killed in the shocking way my husband was and they consider “nothing is to be gained” by investigation.
What about Justice? Justice for my husband who suffered horribly for five weeks after the cardiothoracic surgeon sent him out of theatre with his Pleural Lining being suctioned at ten times the safe amount (31kpa instead of 3kpa) and left it like this for 22 hours till a nurse discovered this. Then compounded their negligence by not telling us what had happened till I found out 7 months later. What about justice for those of us who love him and who will never heal from what we saw being done to him, no more than any relatives of people killed by crime or accident?

I was reminded the sheer arrogance and insensitivity of the health Minister Skinner and Ms Williams, now on the health Care Complaints Committee by reading a statement made by Surgeon Dr Rodney Woods in the Jayant Patel case in Brisbane where he states in regard to Patel’s patient Mervyn Morris, “If he hadn’t had the surgery then I don’t believe he would have developed the various complications and the subsequent death.” Patel spent time in goal.

Please help me to understand the difference in what Professor DuFlou wrote in his report to the NSW Coroner in regard to the death of Don Mackay, “it is most unlikely that the deceased’s rapid, but lengthy, deterioration would have commenced when it did but for the patient undergoing the various transfers and treatment.”

Or of what Dr Phillip Hoyle Director of Clinical Governance RNSH wrote in his letter 2/1/08
“The very rapid progression from admission to operation meant that there was no assessment by the Spinal Unit or with the respiratory Unit preoperatively. I recognise that given the complexity of Mr Mackay’s condition, a more comprehensive assessment, with input from the spinal and respiratory teams prior to surgery, would have been wise.”

I challenge Health Minister Jillian Skinner and Ms Leslie Williams to justify their weak hypocritical stand. Justice should be for everyone, the same – not a convenience to be dispensed with because they consider there is nothing to be gained.

Please find attachment with a brief outline of what was done to Don Mackay was written 2008.

Royal North Shore Hospital Shame.
Donald William Mackay’s cruel death cries out for justice.

Outline of Donald Mackay’s treatment in RNSH and his subsequent death

On behalf of Don my husband of thirty-five years, our daughters, and myself, I request authorities begin an independent, open investigation into the surgery, treatment, care and subsequent death of Donald William Mackay. His death was a direct result of five weeks he spent in RNSH between 11th April 2007 and 17th May 2007 (the day he died). I request that the Cardiothoracic surgeon and team, the Spinal Ward doctors and nurses who ignored my husband’s worsening condition receive disciplinary action because of their negligence, which led to Don’s first Respiratory Arrest and inability to come off ventilation. ICU and Cardio Thoracic Specialists who withheld full disclosure of his condition from us should receive disciplinary action. Their non-disclosure led to Don being subjected to unnecessary torture, which lasted five long weeks. I request that the filthy practices and deplorable conditions he endured without choice in ICU be exposed. Legally, ethically, why and how are the medical practitioners protected from criminal charges?
This could happen to your loved one or yourself. I have no reason to think it has not since my husband’s criminal mistreatment inside RNSH.

1. My husband, Don Mackay had been a Quadriplegic for 25 years. On 11/4/07, he arrived at RNSH at 10pm from Port Macquarie. It was not an emergency. A doctor whose English was limited signed him up for the surgery within the hour that night. He cannot recall what he told my husband about that surgery. Why?
2. The next morning as I was driving from Port Macquarie, Don was being given dangerous and unnecessary surgery (Pleurodesis)
3. How could RNSH’s Cardio Thoracic surgeon just “assume” Don had been examined, by a cardiothoracic specialist in Port Macquarie? This was unprofessional.
4. There was no ECG prior to surgery although he had Pericardial Effusion. Why was that?
5. He had neither blood tests nor any pathology. How can they justify this?
6. The Admitting Cardio Thoracic Specialist who was also the surgeon saw no X-rays or Scans prior to surgery. (They were still in Port Macquarie Base Hospital.) What was going on?
7. The review by the Anaesthetist is admitted by RNSH to be “limited”. He was not seen before theatre. Limited why? Don had complicated medical problems and required proper assessment.
8. The Cardio Thoracic surgeon had not seen Don before Theatre and had not done a detailed examination. The person who signed him up the night before was not part of the surgical team. No one knew anything about his multiple conditions before surgery. How irresponsible and dangerous was that?
9. Ungraded Talc known to be connected to Acute Respiratory Distress Syndrome (which Don developed) was used. Since his death, they no longer use this. They were aware it was linked to Acute Respiratory Distress Syndrome (ARDS). Why was it used? Was it cheaper?
10. My husband’s right lung was meant to be suctioned until all the fluid was removed at the gentle suction of 3KPA. RNSH admit that a transcription error caused his lung to be suctioned (vacuumed) at 10 times that value at 31KPA. This was left like that for almost 24 hours and was not spotted by Cardiothoracic Doctors, and the Spinal Unit’s nurses till 8am the next day. All RNSH staff involved are culpable.
11. Cardiothoracic were ignorant of “Quadriplegic breathing” which makes it harder to breathe while sitting up when there are problems. They ordered him sat up in his wheelchair. He rapidly deteriorated. I begged the Spinal Nurse to return him to bed she refused. He suffered three hours of extreme torture trying to breathe against gravity. He had a Respiratory arrest that night. Why were they all so ignorant of his condition???
12. Cardiothoracic should have known not to sit up someone with suctioning of the lungs in progress as this can cause the Pleurodesis surgery to fail and can lead to Acute Respiratory Distress Syndrome. This happened. Why did they allow this?
13. It is the responsibility of the surgeon to see that all procedures pre and post surgery are followed. Almost none of the regular procedures were followed. There is no excuse for this?
14. Spinal nurses, Doctors, and Cardiothoracic were grossly negligent over the next days. He was treated badly as his condition became dangerous. He began to hallucinate and gasp for breath. This was extreme cruelty and shocking for him to experience.
15. On the night of the first of his respiratory arrests, he called my name for three hours according to his roommate and THEY DID NOTHING. I was five minutes away and had given them instructions to call me at any time if he needed me or things got worse.
The next five weeks in RNSH’s Intensive Care Unit were horror-filled. I cannot these get these dreadful images out of my head. I try to see him as he was before their negligence allowed him to be filled with infection, sepsis, fluid and God knows what. I cannot. I see my beloved husband tied and gagged by tubes. Both lungs drowning and full of fluid. MRSA and Klebsiellia Pneumoniae filled them with bloody mucus. I still see him with his tongue being forced painfully in and out, as he reached yet another respiratory arrest. One time he was breathing 50 breaths per minute. He was so frightened and I could not help him. An ICU nurse stood and did nothing. “I think he’s trying to talk”, she said blithely. AN ICU NURSE! It went on like this for five weeks. I feel like I have been in a war zone.
What I have relayed here is just the tip of the iceberg as to the dreadful suffering inflicted upon Don. Finally, he was allowed his wish, which was simply to get out of the filth and chaos, go home and die. Even then, after all they had done to him, it depended on conforming to their demand that the home respirator be taken away as soon as he got home. Apparently, there was not one other home respirator in RNSH or at Port Macquarie or anywhere else in the Northern Areas’ Health Service. Why was this?
It was a death caused by gross negligence, ignorance, stupidity, arrogance, filth and cost cutting. I should not have to be chasing justice on behalf of my husband, daughters and myself. Those responsible should be prosecuted and or receiving disciplinary action for killing my husband Don Mackay and robbing our daughters of their wonderful Dad. Those most responsible should not be still practising inside Royal North Shore Hospital. It would be better for NSW residents if they were not in the health system at all.
Royal North Shore Hospital buries its mistakes.
The Mackay Family. PO Box 248 Port Macquarie 2444 N.S.W

_________________________________________________________________________________________________________________________

8th April 2011

Without Due Care by Therese Mackay– Book Launch at NSW Parliament House 20/10/10 – Speech Given by Eve Hillary

In the free and prosperous 1970’s Donald and Therese Mackay lived as a typical Aussie couple. They rented a pretty cottage for $12 a week where they raised their two daughters, Alison and Melissa in the sleepy NSW town of Port Macquarie. Even then, Don and Therese cared about people. Their tireless community work clearly showed their humanitarian values.

‘Then one sunny day in January 1982’ – Therese writes in her book – ‘life changed’. Don broke his neck at work and became a quadriplegic. The public hospital system of the 1980’s gave him emergency care and rehabilitation. When he returned home, Therese became Don’s full time carer. Despite his severe disability Don overcame all obstacles and resumed his role as husband and father. Therese remained a devoted wife and incredibly, together they continued giving to their community. They supported social justice and access to good health care for all Australians.

In 2007, after a lifetime of social contributions, it was Don who needed help from the health care system. For 25 years, with Therese’s help, he had maintained his health and stamina despite the daunting challenges of his quadriplegia, but now fluid was slowly accumulating in his lung and it had to be drained. Medically it was a simple problem to fix, and people didn’t normally die from it. But the health care system that had treated Don so adequately for a broken neck 25 years earlier had disappeared and in its place a newly ‘reformed’ health system had emerged by 2007 which Don and Therese found unrecognizable, strange and frightening. This time a robust ginger haired Don wheeled his chair into an understaffed hospital with peeling paint and dirt encrusted floors. Instead of a simple low risk drainage procedure, doctors chose a high risk option not suitable for a quadriplegic. For the next five weeks Don suffered nightmarish complications and was reduced to a wretched state of being fully conscious but unable to breathe without a respirator. After five torturous weeks, doctors decided to withdraw Don’s ‘treatment’. This meant sending him home and without any further ado, taking him off the ventilator. Both Don and Therese knew this was a death sentence and Therese begged doctors to allow Don to have a home ventilator at least for a while longer but this was denied – the air ambulance officers were instructed to remove Don from the $500 machine that was the size of a breadbox, his only connection to life. The macabre medical arrangement was executed exactly as planned. On 17 May 2007 Don was transported back to his home in Port Macquarie, fully alert. He believed that his life no longer mattered to the health care system, and that health professionals had made the decision to ‘terminate’ his life. Those were the terms he was forced to accept if he was to be allowed to go home – and he desperately wanted to go home after what he had endured at the hospital. It wasn’t the way he had wanted to die and Therese had tried everything humanly possible to avoid such a terrible death for Don. For emotionally normal people it is agonizing even to imagine what Don’s last thoughts might have been when the ambulance officers removed from him the machine that helped him to breathe. After the medics left with the machine, Don lived for several hours longer, surrounded by Therese and his two daughters. Don was fully conscious and mentally sharp and his heart was still strong until the very end when he simply couldn’t manage another breath for himself.

Two months ago, Therese Mackay generously sent me her manuscript to preview. After reading ‘Without Due Care’, I cried for Therese and for her two daughters and I mourned for Don. After that, I wept again, this time for the hospital where I had once worked for over a decade. I had walked those corridors, worked in those intensive care units where Don had spent his final weeks – but had done so years before the ‘health care reforms’.

In 1987 I was a proud member of an intensive care health team in a public hospital with an international reputation for excellence. We attracted the best clinicians, VMOs and nursing staff in the country. We were affiliated with a top Sydney University, conducted world class research and ground breaking surgery. We pioneered transplantation and I was proud to be a part of medical technologies that helped people and saved lives. Yes, we had dying patients – most were unconscious, but we strove to give them as much comfort and dignity as possible. In my 35 years in high level health care, we had never withdrawn a ventilator from a patient who was not irreversibly brain dead, and I had never heard of a conscious patient having their ventilator turned off and be left to die because a system had deemed it. So, what happened?

I began my health care career in 1969 when the hospital system was not-for-profit and operated to serve the needs of the community. As a professional, I had an ethical code and my hospital’s regulations to live up to, but most of all I was there to serve the patient’s needs. I never considered my role as making money for a corporation.

Changes to the system began in the 1988 when the NSW Government awarded private health corporations lucrative contracts to build private hospitals on sites already occupied by public hospitals – called co-location. The corporations persuaded certain government ministers that their proposed private hospitals would take the pressure off the public system and save taxpayers money. Instead, it cost taxpayers even more, as private companies tapped a rich vein of public money through PPP’s (private public partnerships). Throughout the 1990’s the government bestowed contracts onto corporations like confetti until the NSW Auditor-General, Mr Tony Harris warned that public servants should not enter into grossly disadvantageous [to the taxpayer] deals with the private sector and that, ‘the Government is, in effect, paying for the hospital twice and giving it away [to the corporations].’ Dr Refshauge the NSW Minister for Health agreed. ‘We are not going to privatize hospitals. We believe that the public sector is important and should not be flogged off,’ he said in the NSW Parliament in 1997. The Parliamentary Member for the South Coast, John Hatton argued that deals should be transparent and revealed to the public, which has a right to know. Ironically, Donald Mackay, also spoke out against hospital privatization and joined in a campaign to return the privatized Port Macquarie Hospital back to the people of NSW. But overall, the deals continued and so-called hospital ‘reforms’ were fuelled by special interests and doctor advocates who spoke out in favour of the corporations.

I recall when the first spade of earth was turned on my hospital campus. With massive injections of millions of NSW taxpayer dollars, a health corporation built a luxurious marble and glass private hospital over the old car-park site adjacent to the public hospital. The citadel was obscured from view behind the public hospital building and nestled into a manicured enclave. By 1998 it opened to service the wealthy and well insured of Sydney’s North Shore. The health corporation ran its private hospital as a business; but with even more taxpayer funding and bequests from wealthy socialites , the corporation’s share price quintupled and investors were paid healthy dividends. With the global private sector takeover of the once public hospital systems in western countries came a new philosophy which was noted by several worried health professionals at the time. The New England Journal of Medicine (August 5, 1999) stated: ‘Our main objection to investor-owned care is not that it wastes taxpayers’ money, nor even that it causes modest decrements in quality. The most serious problem with such care is that it embodies a new value system that severs the communal roots and Samaritan traditions of hospitals, makes doctors and nurses the instruments of investors, and views patients as commodities’.

By 1999 my public teaching hospital, which had loyally served the northern Sydney public since 1885, had become orphaned in its own home by the co-located intruder. As in twin transfusion syndrome when twins share the same placenta unequally, the private hospital twin received all the life blood while the anaemic public twin was barely able to stay alive. As conditions deteriorated alarmingly in the public hospital, top medical and nursing staff left in droves resulting in a permanent staff shortage, the building fell into disrepair, the top storeys were water damaged from a leaky roof, the floors were dirt encrusted, the windows grimy, the toilets disgraceful and the medical equipment had deteriorated and become hopelessly outdated. By 2005, the once world renown public hospital resembled a third world setup. Even I left the hospital after seeing where it was headed. The health system had adopted a chilling model of economic rationalism that was well beyond any one person’s ability to fix. I desperately hoped that the monstrous system that had destroyed this Australian icon would not one day claim the lives of innocent people. It would be only a few short years before my worst fears came true.

It was into this health system and into this public hospital that Donald Mackay was admitted on April 11, 2007. He required thoughtful medical assessment, adequate nursing care and a safe and simple procedure to be performed in a hygienic environment. He required his basic, human needs to be met. Once, all Australian public hospitals were up to this standard of care. But Don got none of these. The system that had destroyed this once top public hospital would also come to destroy Donald, the man who cared for people. Then it would continue to destroy lives until it became the subject of a Parliamentary enquiry in 2007. Since then, not much has changed systemically.

Honoured guests, I give you Therese Mackay’s book: Without Due Care. She writes on behalf of Don, her family and for all of us. Please read it. We need to know what kind of health system we have, and how it came to be what it is. We need to know how our Parliamentarians voted on health issues, who the special interests are and whether they have the public interest at heart. Why? Because this could happen to you or your family. Instead, this must never happen again. Please give your support to those candidates and others who genuinely strive to improve the system and work in the public interest.

Eve Hillary

Journalist, Health professional
Author of Sarah’s Last Wish: a chilling glimpse into forced medicine

www.sarahs-last-wish.com

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1st March 2011

Outrageous document from the NSW Coroners Court


Reveals what Tara Norton Senior Coronial Advocate, State Coroners Court, Glebe NSW wrote in an Internal document giving her opinion of me after I had approached the NSW Coroner to have my husband Don’s Death certificate changed.  That death certificate was changed to add “Treatment” as a cause of death. I recently received some documents after requesting Right to Information which has replaced Freedom of Information. It is always wise to obtain such documents. I am reproducing pages 4 and 5 of this document and after that a copy of my letter written to request the statements from the doctors involved in don’s treatment and death. None of these were released and it appears to me they didn’t even take their statements. (My comments in response to Tara Norton’s outrageous claims appear in italics and red.)

“…Since receipt of the expert report, Mrs Mackay has written to a number of people within the Coronial jurisdiction, requesting that a further expert report be obtained. Mrs Mackay has spoken to a doctor by the name of Dr John MARX. (Dr John A Marx MB BS, BSc. (Hons) Pressure Medicine Institute Melbourne, Australia – he is a medical aviation specialist). Evidently this doctor has written about the effects of air pressure on the human body. Mrs Mackay spoke with him about the effect transporting the deceased by air ambulance would have had on his lung capacity. From the information passed on to Dr. Marx by Mrs Mackay, he has informed her that the pressure in the aircraft could be a factor in the deceased’s death. I have contacted the Medical director of the Air Retrieval Unit of the NSW Ambulance Service at Bankstown Airport, Dr Koel HOBIG. Dr Hobig states that a patient such as the deceased with quadriplegia is not automatically a problem to transport by air simply because of his quadriplegia. He stated that the main issue is the patient’s oxygen saturation level which is an immediate indication of their lung status. He states that in some cases in fixed wing aircrafts the pilot will be instructed to fly at 20,000ft instead of the 30,000 but this is only if the oxygenation is poor and the weather conditions permit it. He stated that the pleural effusion is not really a problem unless it has compromised the deceased’s oxygen saturation level. From the medical notes, I have established that when the deceased was admitted to Royal north Shore Hospital his oxygen saturation level was 95% on room air. He had no ventilation or oxygen support and was maintaining a reasonably high O2 sat level. Following the procedure his saturation levels started to decrease but at the time of transfer were stable and not an issue. (I spoke with Kathy Sheppard who worked with Wingaways and she told me he was given Oxygen when aboard the plane – and I have those written records – sadly Kathy was killed last year when the ambulance plane she was on crashed.)

Dr Marx has evidently also commented on whether the Pleurodesis being conducted the day after he was transported was appropriate. I feel that Dr Bannon has commented on the appropriateness of the attempt to drain the fluid, and the Pleurodesis that followed. (It was the other way around –Pleurodesis first then drainage. This is of vital importance– clearly Tara Norton is confused about the whole procedure) He stated that the procedures were appropriate but also placed the deceased at high risk because of his quadriplegia and associated medical conditions. (well that explains why they went into his lungs minus ALL normal and expected pre operative procedures as noted in the chapter in my book called “A catalogue of errors” One would have thought they would have been even more careful with an at risk patient – not less careful. But Tara is convinced she has the truth) I do not see that an expert report from Dr Marx will assist in this regard. (Dr Marx is very highly qualified but he is not one of their doctors – Dr John A Marx MB BS, BSc.(Hons)Pressure Medicine Institute Melbourne, Australia)

I am of the opinion that Mrs mackay continues to struggle with the death of her husband and comments from persons such as Dr Marx, who appears to have been given a distorted picture of the deceased’s treatment by Mrs Mackay, are compounding her grief. (Unbelievable! and defamatory. Ms Norton was not in the room when Dr Marx and I talked – how would she know what was said –but appears comfortable with what appears very unprofessional comments. She was not at the hospital and appears not to have even taken statements from anyone who was there apart from me. All who visited can back my statements up –but then it was a medical death and that gets special treatment) Mrs Mackay obviously loved her husband dearly and provided an exemplary level of care to him over the 25 years he was a quadriplegic.(I did ,but again MS Norton has no knowledge at all of what our lives were like and she “assumes” what the situation was) It is clear from his medical records that the deceased had suffered with respiratory problems since September 2006 (Make that Christmas 2006 Tara – and how come it took so very long for him to get treatment? No one has answered that) He developed the pleural effusion which despite attempts to drain it, failed. (There was one half hour attempt to drain it – not attempts Tara! It was done quickly in Radiology in Port Macquarie so they could do a CT scan. They stopped because they did not want to take too much quickly – or might collapse the lung. He was sent home that day with less than half taken off – and left to our own devices TILL the Pleurodesis over a month later. It was a reaccumulation not a recurrence – a big difference.) The next treatment was a Pleurodesis which carried with it significant risk given the deceased’s medical history. (Well then why the big hurry after we had waited too long without any care at all in our home – also Don’s Spinal doctor said it should never have been done and she would know) His deterioration appears to have been one of the possible consequences of such a procedure. (BINGO! Finally they admit this – they have denied this up until this very statement) I feel that the expert report obtained by Dr Bannon shows that the treatment was appropriate, however when Mrs Mackay receives this report, I am sure she will read the report differently to the way in which I have interpreted it and will raise a number of issues in her own mind about the decisions made during the management of the deceased. (As it was Dr Bannon couldn’t even get the timeline in order and his report was a dogs breakfast – something which could have been corrected had anyone thought to talk to me about it. Its nice to have your reactions prejudged by someone who has never met you. The whole family and friends must have also been similarly afflicted as we all reacted the same at Dr Bannon’s badly researched “report”) I am of the opinion that, other than the cause of death that was to be slightly amended as suggested by Dr Duflou, there are no other avenues of investigation that could be conducted that might assist in this matter. (“was to be “it was amended and I consider adding “treatment “to the death certificate as no small amendment – why the adjective in what should be a professional opinion) I do not feel that Mrs Mackay will be happy with the outcome of (their typo) in this jurisdiction, regardless of the enquires that are conducted, as she appears determined that the deceased died in horrific circumstances that were entirely caused by the medical system. (Ms Norton relies a lot on things that “appear” assumes much and used “in my opinion” and thats all it is “her opinion about a person she has never faced, based on what? I do not consider this a responsible way for anyone working for the NSW Coroner to act.) It is never a good outcome when we fail to assist families in coming to terms with the death of a loved one, but I cannot see what else can be done at this time to assist Mrs Mackay. Further expert reviews by Dr Marx (there were none at all so how can there be “further reviews”) or any other medical practitioner will no doubt just raise further questions and at the end of the day, the outcome will not be altered. (How can she possibly know this?) The deceased was at high risk when he underwent the procedure, however the procedure was necessary (not according to his Spinal Specialist) As her correspondence indicates, Mrs. Mackay continues to raise various issues in just about every aspect of the care and treatment provided to the deceased and in addition to that, is still raising new issues as potential “causes” of her husband’s death. (Please Tara Norton list all the issues I raised which have been disproven. I am sure Mr Peter Garling QC would be very interested in your “opinion” of his Garling Inquiry which gave my evidence credibility) A copy of Dr Bannon’s report should be sent to Mrs Mackay as soon as possible as she has been waiting for this report for some time now. If we were to send a 30day letter with the doctors report, I predict Mrs Mackay will send a lengthy submission to Your Honour requesting multiple experts look at various aspects of the care. (Now she is making “predictions” –very neutral and scientific of her) It is for this reason that I respectfully recommend that this matter be dispensed with.


Tara NORTON
Senior Coronial Advocate,
State Coroners Court
Glebe
14 April 2009.


I am pleased to finally receive this document and to see the sweeping lack of neutrality. Tara Norton makes sweeping statements about my actions as if I was the only one involved in pushing my husband’s case. Our whole family both sides and over 2,000 local people who signed a petition asking for an inquiry agreed with me and my actions. Every single thing I claimed I have proven – and as far as I know the Coroner has not even obtained statements from the hospital involved in the mismanagement of my husband’s care – a mismanagement which caused him a lingering and horrible suffering and death. I am awaiting response from the NSW Coroner’s office as to any statements from doctors involved in Don’s time at the hospital. I believe they do not exist. I believe they never even were asked to give statements. Such is justice in Australia in these times that the victim’s family are “judged” but those who had the care of that victim are treated with kid gloves. A medically caused death is still a death. The person is just as dead. When it is caused by “Treatment” they don’t just die – they are killed. The victim and relatives close by are left just as traumatised as if the person was tortured and killed out on the street – but have to pursue their own justice as there are no “police” to act for those who suffer medical malpractice. But just because we are traumatised doesn’t mean we are unhinged and can’t think straight and research as per normal. The research our family did during Don’s mismanagement and after his death was clearer and more succinct than that done by the Coroner’s Office and the Health Care Complaints Commission. Both bodies had a woeful idea of the timeline and an incomplete understanding of proven and admitted facts which were recorded by the doctors and nurses themselves in the notes.

 

Therese Mackay
12/2/2011

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NSW Coroners Office – Mr Paul West

31st January 2011
Dear Mr Paul West,
I am in receipt of the documents mailed to me by you 27/1/2011. Thank you.

What appears to be missing is any response from the Cardiothoracic admitting specialist and/ or from any of his staff. Also missing are any statements at all from ICU doctors and/ or the Hospital. Also I see no statement from the local GP.

It would be assumed that any investigation of gross medical error, which it was would include at the very least taking statements from the doctors involved. Were doctors approached by the Coroners’ office? If so I would like to see all that documentation. If not then there is real cause for concern for those of us who go to your office reporting wrongful death.

I now seek all documentation contained in mine or my husband’s file 107/08 – Also I request a list of all documentation generated out of both approaches to your office.

As well I am disturbed by Tara Norton’s statement 14/4/2009 – in which she gives an opinion of me; a person she had never met. I gave evidence at the Garling Inquiry and Peter Garling QC thought my evidence truthful enough to include in his report. He even went so far as to copy the crucial part of the notes where the Cardiothoracic doctor’s handwriting was so bad – a gross medical error followed and went unnoticed for 22 hours – causing a    noticeable decline in his condition prior to the first Respiratory Arrest.

I think what your office got wrong was that what was done to my husband was so bad and so prolonged that it was unable to be believed. All was true as stated in my book “Without Due care” Launched in NSW Parliament House by Mr Andrew Stoner and Mr. John Hatton. They obviously thought I had a grasp on the truth. Even Dr Y who had been my husband’s Spinal doctor many years ago gave credence to what I wrote after reading my book. As well Dr L my husband’s spinal specialist said to me directly that Don should never had the Pleurodesis – just a lung drain and biopsy and then if it reaccumulated to drain it again because his lungs were so fragile.  Against the opinions of the above Spinal Specialists, Tara Norton and Dr Bannon cast aspersions at to my credibility because of my loss.

I would assume that when someone you love is wrongfully killed to become emotional is a sign of good mental health –but it does not mean you are untruthful, nor than you can set known facts down. As it was Dr Bannon couldn’t even get the timeline in order and his report was a dog’s breakfast – something which could have been corrected had anyone thought to talk to me about it.

I hope to hear from you as soon as possible and I certainly expect to hear that the doctors mentioned above provided statements as a matter of course.
Thank you

 

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Without Due Care – Book Launch at NSW Parliament House 20/10/10 – Speech Given by Author Therese Mackay

First of all, I would like to thank Mr Andrew Stoner, Leader of the Nationals/Member for Oxley for his invaluable help in holding my book launch here in the Parliament House. Also I would like to thank him for his support over the years – support which got the issue of what was done to Don outside of the Hastings Valley – and into the Sydney media.

It is only right that this book is launched here as it is under this very roof that lack of accountability, cost cutting and the enabling of a top heavy administration has been allowed to flourish for the past 15 years, under Labor – actions which have caused the running down of the public health system in NSW.

I would like to thank John Hatton who has come from the South Coast to be here and support this book launch. My husband Don and John got to know each other back in the early 1990’s and Don developed a great respect for John. Thanks also to Eve Hillary, Author od Sarah’s Last Wish; and Lorraine Long who heads the Medical Error Action Group.

I thank my daughters Melissa and Alison and their husbands Chris and Andrew;  my sisters Veronica and Joan and my friends Carmel, Dorothy and Colin. Without their emotional support, the quest for justice and change would be much harder. The printers are here, John and Catherine Duffy from Coorangbong Printing a big thanks to them. And I am very grateful for all of you who have come here, many from a distance.

Writing this book has been the very hardest thing I have ever done in my life and ever hope to do. Many tears were shed in its writing and re writing. There were times when I thought of giving up – but I was so haunted by what I had witnessed inflicted on Don, after a few days I would have to get back into it. I had no choice in this. It was just the right thing to do.

Don had suffered unbelievable pain and indignity over the past 25 years but it was nothing compared to the horror that was unleashed on him in this hospital.  Because we love him, on us too. I will never fully recover from what I know and what I saw in those last five weeks. What Don had to go through before death still makes me feel physically ill as the pictures play again and again in my mind.

This book is my way of freeing myself and our family and thus freeing Don. I am hoping to get justice for my husband. It was all preventable and arose from ignorance, arrogance and a fundamental lack of care.  It eases with time but without warning we can be thrown back into it.

My husband and the father of Melissa and Alison –   Don Mackay, died because of what was done to him in a major Sydney teaching hospital: a wrong and totally unnecessary operation; a lung mistakenly suctioned for 22 hours at 10 times the correct rate; a severe MRSA, or golden staph infection inside his lungs; deadly Klebsiella pneumonia and sepsis which developed during the 36 days he spent there.   The hundreds of errors and the numerous instances of lack of caring listed in this book are only those I witnessed or discovered during the 12 hours. I was with Don each day for over five nightmarish weeks. Common sense tells me many more must have occurred while I wasn’t there. For my own sanity I believe it is best that I am not able to find out what else happened to him.

Knowing the grievous impact on Don of the errors they had made, senior doctors at the Sydney Hospital effectively imposed a blanket ban on any information getting to us about every aspect of Don’s condition, its causes and treatment, alternative options, possible adverse effects of treatment and the probable and actual outcome. Though this may seem an extremely unlikely way for staff of a major hospital to behave, particularly with patients’ rights so well defined these days, it is true. Such morally unacceptable conduct needs to be fully exposed to the public and to the authorities, so as to end – I hope forever – what appears to have become standard practice within this particular, once highly renowned, Australian hospital.

If Robin Cook, the author of medical horror stories, had written a novel based on the torment Don endured without choice, he could not have matched the reality of what happened inside the chaos, grime and cold detachment of that major hospital. No one would have considered it credible. People don’t really believe that it can have been that bad. Most can only take in the bits and pieces you can tell them.    In Cook’s horror novels, there are always one or two villains, deranged doctors or nurses or whatever; but what caused Don’s death was no aberration of humanity, no psychopathic doctor or demented nurse. The  fact is Don wasn’t brutalised and killed by evil, dark forces. No, his suffering and death were caused by entirely ordinary doctors and nurses, most of whom I would not recognise again.  No doubt most of them go home at the end of each shift with no idea what their lack of compassion, cleanliness and sense of responsibility mean to vulnerable patients like Don. This attitude carries right through, to the NSW Health Care Complaints Commission (HCCC), which almost always absolves the medical practitioners, and on to the NSW Health Department, the NSW Labor Government’s Health Minister and the Premier. No one can be pinned down. No one is accountable, no one responsible. This is becoming ‘hospital culture’ in NSW, and it chills me to the bone.

I make no apologies for my criticism of the Health Care Complaints Commission who have failed yet again to give fair and unbiased service tour small family and the people of NSW. I believe they are a big part of the problem.   I should not have to be chasing justice on behalf of my dead husband, daughters and myself. I have now exhausted every single investigative avenue within NSW, jumped through all their hoops, and found after three hard, sad and lonely years of struggle that the system is designed solely to deplete your energy, and not to achieve justice and change. Therefore that system must be changed.

Thank you

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Below is the speech John Hatton gave at the “Without Due Care” book launch at NSW Parliament House on the 20/10/10

POOR QUALITY CONTROL IN NSW HOSPITALS – John Hatton AO

The number of medically trained and experienced administrators in NSW is continuing to plummet. The result is a dreadful demise in the ability to assess the quality of patient care.

The book ‘Without Due Care’ by Therese Mackay is a horrendous analysis of the torture of a quadriplegic patient at Royal North Shore Hospital. The result of incompetence, ignorance, poor assessment and disgraceful patient care.

Hospitals have become businesses first and foremost, with the result often being the sacrifice of rational, evidence-based yet empathic care for dollar-driven outcome measures. In this environment good management practices, quality control, and staff supervision often fail to be implemented.

Hospital administrators, whether doctors or nurses, are typically paid less than clinical staff who have similar or even inferior qualifications and experience. Public Holiday and after-hours shift penalty rates which are denied to hospital administrators add up to less total pay.

Nurses and doctors in hospital administrative positions, a substantial part of whose ‘reason d’etre’ is quality control, are faced with higher stress levels, more responsibility and less pay and are leaving in droves.

Of the few who choose to remain, some are very dedicated, highly stressed and on the brink of burn-out. Increasingly however, they are evolving into power-hungry incompetents, disempowered from making worthwhile and ethical decisions by the system that has selected and promoted them.

Medical administrators were ‘invented’ largely to ensure that the quality of health care delivered by medical and surgical specialists, radiologists, physiotherapists and allied health professionals is provided to a high standard in the most efficient and effective way possible.

Reduction in the number and quality of medical administrators means an alarming decline in the quality of patient care. Thus it was the case of Don Mackay.

Scientific, clinical assessment followed by empathetic treatment with thorough independent assessment by competent, trained, caring clinicians is vital, yet lacking in many State hospitals.

Evidence based, scientific careful assessment, appropriate and empathetic treatment of Don Mackay was all lacking.

He literally was tortured to death by incompetence.

The fact that CEO’s can be dismissed without notice or reason, and doctors can be pressured or bullied into overriding the patient’s best interests has a devastating effect on public hospitals.

The increasingly widespread lack of courageous leadership in our state hospital system; the inability to stand up to bullying (rife in many public hospitals); and the lack of incentive in the form of adequate remuneration and support for highly skilled hospital administrators at all levels, guarantees repetition of the shocking case of Don Mackay.

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21/1/2011

Dear Ms Jillian Skinner,

It is clear that Mathew Daly never intended responding to my letter (see below) written 3/11/2010. He has now moved on to another position during the reshuffle of the health services recently. I have also contacted Carmel Tebbutt’s office a couple of times. Absolutely no response there either. Is there not some rule that when you write to a public servant and the Health Minister that they have to respond? I have not even had the courtesy of an acknowledgement from Mr Daly.

Are you aware of who I can direct my letter to  – being the person who has replaced Mr Daly? In my opinion he and the NSCCAHS behaved dreadfully in sending out their media statement and their only motive had to be to ensure there was as little publicity as possible – this is not something we taxpayers expect those who work for us to do. I would like a response from them explaining their actions.

As I have not had response from Mr Daly and as Ms Tebbutt the Health Minister has not ensured that he do his job and respond, I am sending copies of this letter to the media an action which I hope will ensure some action from Ms Tebbutt. In 2007 I gave evidence at the RNSH Inquiry before you and Ms Tebbutt and afterwards she approached me and expressed sympathy for what my husband and our family had gone through but when she finally became the Health Minister and in a position to do something she did nothing at all.

There is now a webpage about my book “Without Due Care” www.withoutduecare.com.au and I suggest that the Health service and the health department avail themselves of a copy so as to educate themselves as to why the health system failed my husband don so badly that after five brutal weeks of their negligence, his health was so damaged death came.

Yours sincerely

Therese Mackay

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3/1/2011

Dear Mr Daly,

It is now exactly 2 months since I sent the letter below. I have sent two reminders to you and was finally rung by Mary Dowling but only after I contacted the Health Service. After a conversation that went round in circles and got nowhere, she asked me to forward this letter to her. I chose not to do this as you would by now have had three copies of this letter and attachment.

As it was not addressed to Ms Dowling but to you there was no purpose in sending it to her.

I ask you that as CEO of the NSCCAHS, you please reply promptly to my letter addressing the points that I have raised.

Regards,

Therese Mackay

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12th January 2011 – Written by Peter Brown of Port Macquarie

I am one of those privileged to have known Don because of interests we had in common. He was, despite his disabilities a person who was very pro-active; for he had great concern for Australia and it’s future direction. What happened to Don in one of our major hospitals shouldn’t happen to anyone and is a wake up call to us all about the parlous state of much in our hospitals and medical system. When systemic failure and gross ineptitude lead to the untimely death of a patient there needs to be accountability at all levels, this has not happened in this case and it seems in many others. If we are all to have faith in medical practice in our hospitals we must insist as a community that malpractice is exposed and those responsible held to account.

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Media Release.

“Without Due Care”

The Book the NSW Health Department

Would like to Suppress.

11/11/2010

The NSW Health Department, represented by the North Sydney and Central Coast Area Health Service, has taken the extraordinary step of releasing a Media statement to Sydney Media at the time of the Sydney Launch of “Without Due Care” in October. The book written by Therese Mackay describes in meticulous detail the systemic breakdown within NSW Health which led to five weeks of suffering and the subsequent death of her Quadriplegic husband Don in May 2007.

The book was written hopefully to raise awareness and be used as a teaching tool by health authorities. In a letter written to Mr Matthew Daly CEO of the NSCCAHS, whom she met in 2008 Mrs Mackay says,

“I was very disappointed at the reaction of your Health Service by way of its media statement around the time of the Sydney launch of my book “Without Due Care”. (Please find attached)

 

Rather than an adversarial response, and in the interests of actually learning from what was done to Don and our family I would have at least expected for your people to address the multitude of areas of failure of the health system, not go to some length to just try to undermine my credibility. All your people had to offer in their attempt to discredit me was a perceived unwillingness to meet with your people. Not much in the way of doing me discredit considering the conversation Mary Dowling, you and my family and myself actually had when we met in early April 2008. Not a one of us could recall what was said or what the meeting was all about. From our point of view it served no purpose at all as there was nothing on offer other than talking around and around and getting nowhere.

 

As well my unwillingness to go to Conciliation with the HCCC is understandable in the light that I believe that after Conciliation what is discussed is confidential. Please correct me if I am wrong but that is my understanding. I would not agree to confidentiality in any area concerning Don’s brutal treatment and unnecessary death.

 

Just to set the record straight, first of all I handed a copy of my Manuscript to Premier Rees when he visited Port Macquarie in about 2008/2009. Then last year when the Health Minister Carmel Tebbutt visited PMBH I handed her a copy. These copies had all the doctors and hospitals’ names in it. The published version carries no such names unless in an official capacity such as the head of the HCCC and yourself and such.

 

There has been ample time for your people to address the issues I raised and point out where I was actually wrong. This was never done. No one has ever been able to point out to me one thing I have claimed which is not the truth, but too much effort has been spent in trying to cover up and put a spin on what really happened.

Therese Mackay has yet to receive a response from Mr Daly. She has copies of the Area Health Service’s statement and as well her responses and can provide these.

On Friday 12th Mrs Mackay will be out the front of the St George Bank Horton Street Port Macquarie promoting “Without Due Care”.  It is a sad indictment on our health system and legal system that in Australia in 2010 those individuals trying to expose and obtain justice for medical error and death are forced to stand out on the street to expose systemic failure of our health system, or just go away and do nothing.

There is no workable process which can obtain justice within the Health Department or the courts in which justice can be served and Therese Mackay has proven this.

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Media Release – January 2011

WITHOUT DUE CARE – AN AUSTRALIAN HOSPITAL TRAGEDY

Therese Mackay will launched her book Without Due Care – An Australian Hospital Tragedy on October 20 at NSW Parliament House.  The release of Without Due Care is the final chapter in Therese Mackay’s fight to shed light on the corruption and negligence she found endemic in the Australian health system when her husband Don Mackay was killed as a result of surgical errors and medical misconduct in May 2007, just two days before the date originally set for their daughter Melissa’s wedding.

From the time he broke his neck in 1982, the Mackay family had lived with the knowledge that wheelchair bound Don would not grow old.  What they could never have anticipated was that a life that had already been so cruelly impacted by a workplace accident would be brutally cut short as a direct result of the mistreatment and mistakes of the very people – specialists, surgeons and nurses – entrusted with the care of a frail yet vibrant and fun-loving man.

“My beloved husband, Don Mackay, died as a direct result of what was done to him in a major Sydney teaching hospital.  A wrong and totally unnecessary operation was performed; his lung was mistakenly suctioned for 22 hours at 10 times the correct rate; a severe golden staph infection occurred inside his lungs; and deadly pneumonia and sepsis developed during the five nightmarish weeks he spent in the hospital,” says Therese Mackay.

Before taking the extraordinary step of self publishing Without Due Care Therese exhausted all avenues she could within the system in an effort to bring some justice to her husband’s death, and to help ensure that similar levels of gross negligence would not be repeated.  Therese took part in the Government Garling Inquiry and an internal inquiry at the hospital, both leaving her desperately unhappy with the knowledge that they would ultimately bring about no change to the system.

Having removed names of hospitals and staff from her book for legal reasons Therese says, “At the end of writing this book I find that the individuals involved who caused so much suffering to my husband Don and to us his family, no longer matter to me.  I do hope though they will take on board what I have described in the spirit of change and improvement of outcomes for those accessing the NSW health system.”

Written with raw emotion, Without Due Care not only details the terrible mistakes that led to Don Mackay’s death, but takes the reader inside a close and loving family and marriage that was ripped apart by a callous system.

In demanding to know what ‘what went wrong’ with Don’s treatment and care Lorraine Long from the Medical Error Action Group wrote in the foreword of Without Due Care, “Medical negligence in Australia is made all the worse for affected families because Australia’s health system is saturated in cover-ups; a system so ruthless it does not matter if trusting patients end up dead.”

Therese adds, “I hope that my story will be used as a teaching tool for those delivering health care, and as a warning for those of us entering the health system.”

 

Without Due Care went on sale Wednesday October 20 for a RRP of $27.99 AUD plus $6 P&H.  Copies can be ordered from T.Mackay PO Box 248 Port Macquarie NSW 2444 and online at www.withoutduecare.com.au.  For further stockist details please phone Cooranbong Printing Ph: 02 4977 1111.