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Medical history missed

Friday, 25th May, 2012

By Andrew Robertson

The doctor who assessed a two-year-old boy’s suitability for surgery before he died admitted to an inquest yesterday that the procedure should have been deferred.

Dr Moe Zaw completed the required pre-admission assessment prior to Leonard Crowe undergoing surgery in the BH Base Hospital for extensive dental work in July 2008.

The boy later died in recovery without regaining consciousness.

A coronial inquest into his death yesterday heard that Dr Zaw, who was working at the hospital at the time, did not read Leonard’s medical history files before giving the okay for the boy to undergo surgery.

This was despite the files being available to the doctor.

Dr Zaw agreed with counsel assisting the coroner, Ian Bourke, that had he read the files he would have delayed surgery until a pre-anaesthetic consultation could be performed.

The inquest also heard that the notes Dr Zaw was relying on to make his assessment mentioned the boy had a history of apnoea attacks and a club foot.

Dr Zaw agreed with Mr Bourke’s suggestion that the presence of a club foot could indicate an “underlying problem” or some “abnormality” in the health of a person.

He also accepted Mr Bourke’s suggestion that the boy had a complicated medical history that could have caused difficulties for an anaesthetist.

“Do you accept in filling out this form you were an important filter?” Mr Bourke asked the doctor.

“Yes,” said Dr Zaw, who now works in Sydney.

The inquest heard that since Leonard’s death it was now mandatory practice at the health service for all patients’ medical records to be reviewed prior to surgery.

Earlier yesterday, the dentist who performed surgery on Leonard told the inquest that there wasn’t an hour that went by that he didn’t think of the boy.

Dr Brian Devlin, who was aware that Leonard had breathing problems, said the surgery to remove 13 of his teeth and fill six others went smoothly.

Despite already being under a general anaesthetic, the inquest heard the boy was also given a local anaesthetic by Dr Devlin, who said this was done to prevent pain post surgery.

He said it was shortly after he had completed the surgery that he first discovered there was a problem with Leonard. 

He said he heard “muffled shouting” before meeting a nurse who was looking for one of the two anaesthetists who had assisted in the surgery.

He said he followed the nurse to recovery where he saw one of the anaesthetists, Dr Phillip Rosewarn, performing intubation on Leonard.

Dr Devlin said he then volunteered to speak to Leonard’s mother, Tina, who was in a waiting room, and told her there was a problem with her son.

He told the inquiry that in hindsight he should have requested Leonard have a pre-anaesthetic consultation prior to surgery and that he could have asked his mother for more information about her son’s medical history.

But under questioning from his own lawyer, Dr Devlin agreed he did not have access to Leonard’s medical records and that, ultimately, it was up to an anaesthetist to assess whether or not the boy was fit enough for surgery.

Dr Devlin told the inquest Leonard’s death was “a sad event” and offered his condolences to the boy’s mother who has been present throughout the inquest this week.

“There’s never a day or an hour that goes by that I don’t think of that day.”

The inquest has been adjourned to Sydney where it will hear from the two anaesthetists involved in Leonard’s surgery, as well as three experts.

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