A machine that tested blood at Royal Canberra Hospital (North) was not working at a critical time during a baby’s operation, a coroner’s inquest was told yesterday.
Brian Lankuts, aged five months, died on November 21, 1990, after surgery to correct a skull abnormality which threatened to compress his brain.
The coroner, John Burns, heard that a machine that tested electrolytes and potassium levels in blood was not working that day. A fall or rise of potassium can cause cardiac arrest and death.
According to Constable Paul McEwan, Sister Janice Edwards, a nurse with 24 years’ experience, said in a statement to him that both anaesthetists, Dr Raymond Cooke and Dr Nicholas Gammell-Smith, had been concerned at the drop in Brian’s electrolytes and had been angry and the fact the machine had not been working.
Sister Edwards had said also that drapes had been placed directly on to Brian’s body instead of being supported by an overhead table to keep them off his body, though a table had been available.
This had resulted in parts his body not being visible to the anaesthetists.
The tissue around Brian’s brian had been irrigated with ringer solution to keep it moist throughout the operation. About six litres had been used. She had thought this excessive. The solution had been too cool. The material used to insulate Brian had been wet and cold after the operation.
Earlier, Mr Burns ruled that evidence would not be excluded because the media might give it undue emphasis.
He rejected a submission to this effect from Stuart Littlemore, acting for three doctors: neurosurgeon Dr Nadana Chandran, maxillary facial and oral surgeon Dr Peter Vickers and plastic and reconstructive surgeon Dr Alan Ferguson.
Mr Littlemore, who presents the program Mediawatch on ABC television, submitted that certain evidence should be excluded because üThe Canberra Times@ would give it undue emphasis and because it would not assist the inquiry. He said it was public knowledge that several doctors were suing what he called the local paper over an article about Brian Lankuts.
Mr Burns allowed the evidence saying he would make decisions about admissibility on the relevance to the inquiry and the issues before it. How the media reported the evidence was not an issue. Anyone complaining about that could take action against the newspaper.
Dr Chandran and Dr Vickers are suing üThe Canberra Times@ along with two others who have not been mentioned in, and are not represented at, the inquest.
Counsel assisting, Steve Loomes, sought to tender the whole of a statement by Constable McEwan. However, this course was objected to by three lawyers, including Mr Littlemore, representing six doctors, and counsel representing the ACT Board of Health, Pamela Coward.
Some evidence about Constable McEwan’s conclusions about witnesses state of mind was excluded, but other material objected to was allowed in.
Constable McEwan said he had interviewed Sister Elizabeth Trama on November 29, 1990.
“”She stated that during the operation on Brian Lankuts she observed things that she thought might incriminate her colleagues,” he said. “” Brian’s head was being washed with cold water during his operation and she believed this could have related to Brian’s loss of body heat during his operation. One of the machines connected to Brian _ she did not state which one _ was switched one to 50 drips per minute. She believed this may have been too much.”
He agreed in cross-examination that when taking statements from nurses he had not taped them, but had taped his summary of them immediately afterwards.
He had interviewed Sister Kathy Eichorn. When later obtaining a signed statement from her based on the interview she had asked that sections of her statement be crossed out on advice from legal representatives of the ACT Health Authority. She had said the bits crossed out were true and if asked at the Coroner’s inquest she would state that they were true.
Constable McEwan agreed in cross-examination that the statements crossed out could have been statements of opinion.
Constable McEwan said he had taken statements from the head of intensive care at Royal Canberra, Dr James Kearney, who did not have a surgical role in the operation; surgical registrar Dr John Chen, who had only a minor role; an imaging technician, Ian Middleton, who had told of being called to service the broken machine, and a biochemistry technician at Woden Valley Hospital, Michael Penkethman.
Constable McEwan agreed with Hugh Selby, for the parents Michael and Carol Lankuts, that he had received no special training on how to conduct a preparation for a coronial inquest following a hospital death. He said that this was his first one.
He had been given no training in medical terms or what to expect in a hopital file. He had not been given a reciept for the hopital file when he had taken it from Royal Canberra (North) to pathology at Kingston. He had not counted the number of sheets in the file.
No photocopy of the complete file had been made.
He agreed that when he set out he had no training that would enable him to determie what was relevant and what might be the issues in the case.