Colleen Stefanyszyn vomited faecal matter before she died from a botched hysterectomy at Newcastle Private Hospital on 1 December 2008. Yes, that's 8 years ago and that's how long you have to wait for justice when our medical system lets us down.
This case frightens old people on a pension to keep up their private medical insurance even if they can't afford it because this lady had 'elective surgery' which means she was on a waiting list and the surgery cost her nothing - nothing but her life.
Private patients not only pay high premiums for the top cover, there is always a gap which sometimes runs into thousands of dollars. This is why thousands of people, especially the old who really can't afford to, drop out and choose to go on the waiting list and have their op for free.
NSW Supreme Court Justice Monika Schmidt accepted Newcastle gynaecologist and obstetrician Dr Oliver Brown's admission that he breached his duty of care to Mrs Stefanyszyn and that it resuled in her death.
During the surgery, a loop of suture "inadvertently looped around her bowel" resulting in a blockage. The result was that Mrs Stefanyszyn vomited faecal matter from the third day, starting with "a coffee-coloured fluid" and died on the fourth day after surgery.
"Despite Mrs Stefanyszyn not recovering from the surgery as was expected and her deteriorating condition, the cause of her symptoms was not investigated, the blockage was not identified and surgical steps necessary to remove it were not taken, with her death the result" Justice Schmidt found.
"The result was that the blockage was not identified or addressed, infection set in, she repeatedly vomited faecal material, she inhaled some of that material with resulting pneumonia, her electrolytic balance became disordered, her oxygen levels deteriorated and finally, she suffered a fatal cardiac arrest."
Justice Schmidt was also highly critical of the hospital and their staff who failed to record appropriate observations of the patient before she died.
"The hospital's failure "did not give rise to a mere possibility of injury, but actually materially contributed to her death which resulted from both its failures and those of Dr Brown" she said.
The matter returns to court on Friday when Justice Schmidt will consider whether the hospital should face contempt proceedings.
The judge was aware the hospital, Mrs Stefanyszyn's husband Walter and daughters Leigh and Megan had settled a compensation case.
Mr Stefanyszyn placed a notice in the Newcastle Herald on the second anniversary of his wife's death.
I have lost my soul's companion, a life linked to my own. Day by day I miss you more, as I walk through life alone, forever Wal.