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Coroner slams doctor over failures leading to man's suicide

POOR post-operative care of late Lismore dental prosthetist and Parkinson's disease sufferer Kenneth Mawby has led to a professor being referred to the Queensland Heath Ombudsman by the NSW Deputy Coroner.

On November 19, 2008, Mr Mawby underwent a deep brain stimulation DBS operation at Brisbane's Wesley Hospital where a "brain pacemaker" was implanted.

The DBS device was designed to reduce symptoms of Parkinson's disease by sending electrical impulses to specific areas of the brain.

Shortly after the operation, Mr Mawby's wife Cheri and adult sons Paris and Adam noticed changes in his personality, including uncharacteristic behaviour, which they were told would be self-limiting.

"One problem we had was that the doctors didn't take what we were saying about Ken seriously," she said.

CORONOR'S REASONS FOR REFERRAL

  • All expert witnesses gave evidence that showed the execution of the post-operative plan was very poor.
  • This effectively left Mr Mawby in jeopardy without the help he needed.
  • Professor Silburn showed little or no sign of remorse for any of the failings of Mr Mawby's post-operative care and, until then, no sign of sympathy or empathy for the Mawby family.
  • I believe that Professor Silburn not only gave sworn evidence concerning the purported handover to Dr O'Sullivan that was objectively untrue, but that he did so with the intention of misleading the court.
  • In doing so, Prof Silburn not only failed to take responsibility for the failure of the post-operative plan but he falsely implicated others, especially Dr O'Sullivan, to avoid blame.
  • Changes made to Prof Silburn's practice and the practice at Neurosciences Queensland were made long after Mr Mawby's death as a result of peer pressure.

After absconding from hospital twice, experiencing mood swings, confusion and restlessness, Mr Mawby was discharged from the Wesley Hospital on December 1, while his neurologist, Professor Peter Silburn, was on annual leave.

"He was left without any specialised support and we were unprepared to deal with the sudden onset and degree of those behavioural changes."

When Mr Mawby returned home to Lismore with his family, he continued to experience mood swings, was agitated and his behaviour fluctuated between manic and calm.

After an especially difficult morning on January 5, 2009, Mr Mawby left the house and was found soon after, deceased.

ABOUT PARKINSON'S DISEASE

  • Caused by cells that produce dopamine (a chemical allowing smooth coordinated function of muscles and movement) dying.
  • Symptoms appear when about 70% of dopamine producing cells are dead.
  • There is no known cure
  • Symptoms include shaking, stiffness of muscles, slow movement, pain in arms and legs.
  • Named after English doctor James Parkinson, who published the first detailed essay on the illness in 1817.

Mrs Mawby said the family was only told of the possible emotional and psychological implications of the operation as these conditions manifested post operatively.

"There was not enough emphasis on the seriousness of the behavioural results of his operation," she said.

"It's not always the physical success of the operation; it really can affect people emotionally, and Ken wasn't given that specialty post-operative care."

A coronial inquest into Mr Mawby's death by Hugh Dillon found there was poor post-operative communication and care, and inadequate record-keeping by Prof Silburn, for which he was referred to the Queensland Health Ombudsman.

Mr Dillon also found Mr Mawby's mood disorder persisted from two days after his surgery to the date of his death due to the "significant but unquantifiable measure" to the DBS device stimulation and prescribed medication.

"The DBS was implicated to some degree to Ken's suicide."

*If you need help, are experiencing suicidal thoughts or urges to harm yourself, phone Lifeline on 13 11 14 or go to their Crisis Support Chat web page.

Topics:  parkinson's disease suicide wesley hospital


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