More glories of public medicine in New Zealand

Repeated negligence leads to death

Wellington Hospital junior doctors told a dying Napier student to walk home to the Newtown flat where her body was found a day later, an inquest has found. Cassandra (Cassie) Ann Laurent, 19, was found dead by flatmates at her Newtown home on July 25, 2003.

Wellington coroner Garry Evans found the talented graphic art student died of pneumonia after a series of oversights by unsupervised junior doctors. Cassie had been discharged from Wellington Hospital's emergency department three times in the six days leading up to her death. Each time, she showed worsening flu-like symptoms and stiffness in her limbs and neck. On her first visit to the emergency department, a chest X-ray revealed lung abnormalities pointing to pneumonia. But the film was not read by a radiographer until the day Cassie died and a report was not made available to emergency staff until four days after.

Wellington coroner Garry Evans found that all four doctors who examined Cassie were juniors, not one of whom sought a reading of the X-ray or an opinion from senior staff. The court heard that the first doctor to examine the young woman considered a diagnosis of pneumonia but did not prescribe any antibiotics for it because the X-ray "looked normal" to her.

The inquest was told that even if Cassie had been prescribed antibiotics on her third visit, on July 23, there was a very good chance she would have survived anyway. Instead, she was kept overnight before deciding she felt better and was left to walk home after being discharged by another junior doctor.

Today, Cassie's uncle and godfather Mark Laurent expressed anger at the hospital's actions. "They made her walk home so she could curl up in bed and die. "Her lungs at that point were consolidating, going hard." One doctor had not even consulted Cassie's electronic file, stored within the hospital's computer, a decision which probably cost Cassie her life. "He didn't even bother to read her notes, and the first doctor had put 'possible pneumonia' in her file."

Cassie was "no dummy", Mr Laurent said. She would have known she was dying but respected the opinions of doctors who said she was okay....

Experts told the inquest raised concerns that, despite Cassie's worsening condition, no-one asked for a second chest x-ray. More experienced doctors were likely to have diagnosed and treated her pneumonia.

Mrs Laurent said her daughter had died because of simple failures and vowed to take legal action so that further deaths could be prevented. "In this day and age and with the technology, it's just unbelievable they didn't read her X-rays in time. The health system is a bit of a joke. "The whole crux of it is; who let her die? Someone has to be held accountable. "Those four doctors - are there repercussions for them? "They'll walk away and think: 'Thank God that's over'. But what about next time?"

One junior doctor told the inquest a four to five-day wait for films to be read was not unusual....

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