21-23 October 2009, 26-28 October 2009, 1-3 February 2010

Medical Practitioners Board of Victoria v Williams & Anor (Occupational and Business Regulation) [2010] VCAT 1277

The Tribunal having made findings under s 45A(1)(a) of the Medical Practice Act 1994, that both respondents have engaged in unprofessional conduct of a serious nature with respect to each of the allegations made against them, the Tribunal orders and directs that:

The proceeding be listed for a Directions Hearing on a date to be advised by the Registrar.

Dr I Freckelton SC with Ms S Hinchey instructed by Minter Ellison, Lawyers

Mr D Brookes SC with Ms D Galbally instructed by Perry Maddocks Trollope, Lawyers

Mr C Blanden SC with Mr R Harper instructed by Perry Maddocks Trollope, Lawyers

1. At 8:05am on 1 April 2004 at the South Eastern Private Hospital, Mrs Piyanat Anna Siriwan was delivered of a healthy baby daughter. Dr Maurice Lichter, her obstetrician, was in attendance.
2. At 2:15pm on that same day, Mrs Siriwan died at the Monash Medical Centre. A coronial inquest held in October 2006 found that death occurred from post partum haemorrhage complicating amniotic fluid embolism.
3. This proceeding is about the professional conduct on that day of Dr Lichter, and Dr Emlyn Williams, an anaesthetist.
4. Under s 59(2)(g) of the Health Professions Registration Act 2006 (HPR Act), the Medical Practitioners Board of Victoria referred to this Tribunal a number of allegations with respect to each practitioner. The allegations are that they each engaged in "unprofessional conduct" as defined in s 3(1) of the Medical Practice Act 1994 (MP Act)[1].

1. The Board's submissions contain a summary of the facts. They are essentially not in dispute. It is convenient to set them out here. They contain references to documents filed in the proceeding and references to statements made by and evidence given by witnesses in the hearing. Those references and who the witnesses are will become clear later in these reasons.

The Initial treatment of Mrs Siriwan for post-partum haemorrhage ('PPH')

(a) After giving birth shortly subsequent to 8.00am, Mrs Siriwan commenced to haemorrhage. This is not especially unusual with between 5 and 10% of women haemorrhaging after birth[2]. However, Mrs Siriwan's modest stature and build, being 158 cms in height and 60 kgs in weight, meant that excessive blood loss was more concerning from the outset.

(b) A little after 8.07am Mrs Siriwan lost 400 mls of blood. Around 8.15am Dr Lichter left the patient. Then around 8.20am Mrs Siriwan lost another 200-300mls and Dr Lichter was contacted. He ordered the administration of 10 units of Syntocinon to encourage uterine contraction.

(c) At 8.30am Mrs Siriwan's bleeding continued heavily and her blood pressure dropped to 80/60. Dr Lichter was contacted again and ordered Misoprostal 400mch PR.

(d) Dr Lichter was asked to return to the Labour Ward and did so, inserting an IV line and a catheter. He concluded at about 8.40am that the bleeding was settling. An infusion of Syntocinon was commenced in Hartmann's and Mrs Siriwan's diastolic pressure improved a little.

(e) At 8.45am Mrs Siriwan started to bleed heavily again and clots were identifiable. By this point her blood loss was in the order of 1100mls. She became short of breath and dangerously ill. She needed to be given oxygen. Dr Lichter was not present, at this time.

(f) Following this, Mrs Siriwan's condition further deteriorated to a point where her blood pressure was difficult to record at all. A Code Blue was called by the senior midwife, Robyn Blythe. A haemacell infusion was commenced to improve her fluid balance and Dr Lichter who returned at 9.30am, ordered an increase in her Syntocinon rate. According to Nurse Joustra, at this time Mrs Siriwan's estimated blood loss was 1500 mls[3]. Despite this, Dr Lichter did not order blood, plasma or platelets.

(g) Shortly after the Code Blue and his attendance, Dr Lichter elected to undertake an examination under anaesthetic ("EUA") to try to identify the cause of Mrs Siriwan' s haemorrhaging which already had put her life at grave risk. The EUA commenced at about 9.30am and concluded at about 10.l5am[4].

(h) During the procedure, Dr Lichter focused upon attempting to induce Mrs Siriwan's uterus to contract.

(i) Dr Lichter also sought to ascertain whether retained birth products were responsible for the bleeding, regarding this as the most likely scenario. However, he recognized that the bleeding could have its cause in a tear to the vaginal tract, the uterus or similar, or a coagulopathy[5].

(j) At the commencement of the EUA, Nurse McManus described 'a large whoosh of blood ... expelled from the patient's vagina onto the floor and into a bucket', approximately a litre[6]. This took the patient's blood loss to in excess of 2 litres. Dr Lichter agreed that Mrs Siriwan continued to lose blood in the course of the procedure until he had packed the uterus with gauze.

(k) Shortly after inducing anaesthesia (at around 9.30am), Dr Williams took samples of blood for cross matching and clotting studies[7]. At the same time he placed an urgent order for four units of blood.[8]

(1) Dr Williams said that in the normal course of things, he would have expected the blood to be available within 20-30 minutes of the urgent request being made.[9] Dr Lichter gave similar evidence.

(m) During the EUA, Dr Lichter found no reason for the bleeding (save for the failure of the uterus to contract after the birth) in the course of his examination.

(n) As a result of being unable to get Mrs Siriwan's uterus to remain contracted, Dr Lichter decided to pack the uterus with an internal uterine tamponade in the form of five gauze packs. This was only a temporary measure to try to stop the bleeding[10].

(o) Uterine tamponade is an acknowledged procedure that has been described as inhibiting bleeding as follows:

By insertion of a uterine pack consisting of a gauze roll that is tightly packed into the uterus in such a manner that pressure is applied directly on capillary/venous bleeding vessels or surface oozing (of the deciduas) from within the uterus, thereby resulting in either a significant reduction or stoppage of uterine bleeding.[11]

(p) However, uterine tamponade is a 'rarely used treatment' for post-partum haemorrhage.[12] Dr Lichter had only done such a procedure on one occasion some three decades before, when a registrar.[13]

(q) Bakri balloons are now used to a similar but better effect. They were not being utilized widely in 2004 and were not available at the time at South Eastern Hospital.[14]

(r) The disadvantage of uterine packing is the masking of blood loss through the absorbency of the gauze - 'you don't then really know whether the patient is continuing to bleed'.[15] In addition, in the same way that retained products of conception would do, the presence of the gauze packing precludes the contraction of the uterus so it is only a short-term measure. As Dr Lichter noted himself, the EUA did not succeed (to his knowledge at the time) in causing the uterus to contract.[16]

(s) Dr Lichter suspected that Mrs Siriwan had uterine atony.[17]

(t) He contacted Dr Levin, a haematologist, to set in train ascertaining whether Mrs Siriwan had a coagulation problem and organized for Dr Williams to request clotting testing and to order blood.

(u) Nurse MacManus observed that by the end of the EUA, once the packing was in situ, the observable bleeding stopped 'temporarily' and then the packing started to act as 'wick', '. . .it started to slowly seep through.'.[18]

(v) During her time in theatre, Mrs Siriwan' s BP 'remained above 100mmHg'.[19]

(w) Dr Caldwell said that on the basis of Mrs Siriwan's blood loss of about 2.1 litres at the commencement of the EUA, Mrs Siriwan would have then needed four to five units of blood and about four or five litres of fluid to try and catch up 'and then you're still probably light'.[20]

(x) The examination under anaesthetic concluded at 10. l5am. Dr Lichter observed his patient for a time in the operating theatre (perhaps about 15 minutes)[21], and then for a number of minutes, possibly about 10[22] or 15[23], in the recovery room. Dr Lichter did not make a note of his observations in any of the relevant records.

(y) Dr Lichter's post-operative instructions were for routine post-anaesthetic observations and intensive nursing, no more.[24]

(z) Dr Lichter provided no detailed hand-over to Dr Williams, rather saying to him: 'will you be here if anything happens in the meantime, otherwise I will be in my rooms'.[25]

(aa) Dr Lichter did not specifically communicate to Dr Williams the need for blood products, such as plasma and platelets[26] or that Dr Williams should follow-up in relation to the blood if there was a delay - he relied upon Dr Williams with whom he had worked for many years.[27]

(bb) No discussion took place between Dr Lichter and Dr Williams about any drop in Mrs Siriwan's blood pressure and the potential for the cause to be internal bleeding.[28]

(cc) Dr Lichter absented himself from the Recovery Room from about 10.35 until about 11.45[29], during that time receiving no contact from Dr Williams or any nurses in relation to Mrs Siriwan[30] and making no inquiries about her medical status[31].

(dd) The Recovery Room Record appears on the Post Anaesthetic Record within Mrs Siriwan's medical record.[32] Significant observations made while Mrs Siriwan was in the recovery room are as follows:

BP 84/37; HR 110; pt unconscious; airway insitu, jaw support PV loss slightly vaginal packs x 5 insitu

BP 94/46, HR 117; pt unconscious; jaw support Bare hugger on

BP 83/46, HR 116; pt unconscious; jaw support, PV loss moderate

BP 74/44, HR 130; pt unconscious; jaw support, Mrs Siriwan received the first unit of cross-matched blood

BP 80/35, HR 128; pt unconscious; pad changed; Ephedrine 15 Mg IV

BP 84/45, HR 125; pt unconscious; Mrs Siriwan received the second unit of cross-matched blood

BP 117/46, HR 136; pt unconscious; Ephedrine 15 mg IV; Mrs Siriwan received the third unit of cross-matched blood

BP 107/85; no HR recorded; conscious; PV loss moderately; patient rousable; Mrs Siriwan received the fourth unit of cross-matched blood

BP 54/33; HR52; pt rousable/drowsy (Sats 89%) Lochia +++; Linen changed; to be transferred with pt; awaiting MICA transfer; Anaesthetist refused to insert art line when suggested

BP 129/61; HR 111; pt unresponsive; large blood loss continues; 4th unit of blood finished

(ee) Around 11 .30am, Nurse MacManus spoke to Dr Williams about Mrs Siriwan.

(ff) At about 11 .45am Dr Lichter returned to check on Mrs Siriwan.

(gg) Shortly after this time a conversation took place between Dr Lichter and Dr Williams, the outcome of which was that an emergency hysterectomy did not take place at South Eastern Hospital.

(hh) By 12.03pm, Ms Catherine Joustra (SEPH Emergency Coordinator) had called for an ambulance to transfer Mrs Siriwan to The Valley Private Hospital (TVPH). Dr Lichter ascertained the availability of an operating theatre at TVPH for an emergency hysterectomy and post-operative care and arranged for another anaesthetist to help him as Dr Williams did not have practising rights at TVPH.

(ii) Metropolitan Ambulance Services' records show the original call made at 12.03pm was a request for a Mobile Intensive Care Ambulance unit.

(jj) At 12.l0pm, the ambulance was dispatched, arriving at SEPH at South Eastern at 12.16pm.

(kk) Between the request for an ambulance and its arrival, Dr Lichter decided not to transfer Mrs Siriwan to TVPH, but instead to look for a public hospital.

(ll) At about 12.40pm, a further five units of packed red cells arrived in the Recovery Room for Mrs Siriwan.[33]

(mm) At 12.37pm, Dr Lichter called an Obstetric Registrar at the Monash Medical Centre (MMC), and arranged Mrs Siriwan's transfer there for an emergency hysterectomy. The history given by Dr Lichter to staff at MMC notes that there was an estimated volume of blood loss at this time of 4 litres.[34]

(nn) Ms Bobetic, one of the ambulance paramedics who attended at SEPH in order to transfer Mrs Siriwan, raised concerns about Mrs Siriwan being transported in the ambulance given her parlous condition.[35]

(oo) At 12.55pm the ambulance departed for MMC. Mrs Siriwan was accompanied by Dr Williams and Ms Southern in the back of the ambulance, with Mr Gething driving and Ms Bobetic as passenger, having been told by Dr Williams that she was not required in the back of the ambulance.[36] During the trip, Mrs Siriwan began to froth at the mouth, having started to develop pulmonary oedema[37]and was suctioned by Ms Southern. Blood continued to be transfused, and oxygen was delivered via face mask.

(pp) There is no record of Mrs Siriwan receiving ephedrine in the ambulance, although Dr Williams has said he is sure it was administered.[38] The bag of blood that was being transfused ran out en route. Dr Williams said that he did not know that there was an esky in the back of the ambulance with him containing further units of cross matched blood. Shortly before arrival, Mrs Siriwan went into cardiac arrest.

(qq) Dr Williams did not undertake any external compressions on Mrs Siriwan's heart when she arrested in the ambulance.[39] He believed it was futile as her heart had stopped because of exsanguination.[40]

(rr) Upon arrival of the ambulance at the Monash Medical Centre, Mrs Siriwan was immediately transferred to the resuscitation area for intubation and cardiopulmonary resuscitation with limited response. A hysterectomy was immediately performed, but Mrs Siriwan failed to respond to ongoing resuscitation.

(ss) Mrs Siriwan died at the Monash Medical Centre, Clayton at 2.l5pm. Her death was subsequently attributed to post partum haemorrhage complicating amniotic fluid embolism.

1. The essence of the allegations against Dr Lichter are that he :
   • Failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability;
   • Failed appropriately to manage Mrs Siriwan's continuing blood loss;
   • Failed to address Mrs Siriwan's coagulopathy; and
   • Inappropriately transferred Mrs Siriwan from the South Eastern Private Hospital to the Monash Medical Centre.

2. The essence of the allegations against Dr Williams are that he:
   • Failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability;
   • Failed appropriately to manage Mrs Siriwan's continuing blood loss;
   • Failed to address Mrs Siriwan's coagulopathy; and
   • Failed appropriately to manage Mrs Siriwan's deteriorating condition before and during transfer from the South Eastern Private Hospital to the Monash Medical Centre.

1. The allegations were heard together because they arose out of the treatment of Mrs Siriwan following her delivery.
2. The hearing was in two parts. The first part was in October 2009, on 21-23 and 26-28. Dr Lichter was then unavailable for the hearing to continue and it could not resume until 1 February 2010. It continued until 3 February 2010 and adjourned for written submissions on the findings we should make with respect to each practitioners' conduct.
3. Those final submissions were received on 13 April 2010.
4. The Board called the following witnesses
   • Dr Bernadette White, MRCOG, FRANZCOG, FRCOG, Obstetrician and Gynaecologist, Head of Unit, Obstetrics and Gynaecology and Clinical Director, Obstetric and Maternity Services, Mercy Hospital for Women.
   • Dr Edwin Caldwell, FRACOG, Specialist Obstetrician and Gynaecologist
   • Dr Scott Simmons, FANZCA, Head of Anaesthesia, Mercy Hospital for Women
   • Dr Mark Levin MBBS, FRACP, FRCPA, Head of Department of Haematology, Dorevitch Pathology
   • Catherine Joustra, Registered Nurse Division 1, Emergency Co-ordinator at South Eastern Private Hospital at the time
   • Maureen Nacy, Registered Nurse Division 1, Manager Theatre Operations, South Eastern Private Hospital at the time
   • Fran Hertolous (formerly Catacouzinos), Registered Nurse Division 1, agency nurse working at South Eastern Private Hospital at the time
   • Christine Hayes, Registered Nurse Division 1, and midwife working as a registered midwife at South Eastern Private Hospital at the time
   • Barbara MacManus, Registered Nurse Division 1, certificate in midwifery, Assistant Unit Manager at South Eastern Private Hospital at the time
   • Kristine Bobetic, ambulance paramedic

1. Dr Lichter and Dr Williams both gave evidence and were cross-examined.
2. Extracts from the coronial hearing, codes of practice, standards of conduct, journal articles and similar material were tendered in evidence by the parties.

1. The Board's allegations are that the practitioners engaged in unprofessional conduct as defined in paragraphs (a) and/or (b) of the definition of "unprofessional conduct" in s 3(1) of the MP Act.
2. "Unprofessional conduct" is defined in these circumstances as follows :

"unprofessional conduct" means all or any of the following -

(a) professional conduct which is of a lesser standard than that which the public might reasonably expect of a registered medical practitioner; or

(b) professional conduct which is of a lesser standard than that which might reasonably be expected of a medical practitioner by her or his peers; or

1. Section 45A of the MP Act relevantly for this part of the proceeding states :

45A. Finding and determinations of a formal hearing into conduct

(1) After considering all the submissions made to a formal hearing into the professional conduct of a registered medical practitioner the panel may find that -

(a) the practitioner has, whether by act or omission, engaged in unprofessional conduct of a serious nature; or

(b) the practitioner has, whether by act or omission, engaged in unprofessional conduct which is not of a serious nature; or

(c) the practitioner has not engaged in unprofessional conduct.

1. We accept that the law as to unprofessional conduct and its gravity is to be measured by the extent to which it departs from proper standards[41]. We are also conscious that conduct is to be assessed by its nature and not by its consequences[42], with the rider that this is insofar as the consequences were reasonably foreseeable.
2. We accept that the standard of proof is on the balance of probabilities and that allegations need to be proven to our reasonable satisfaction. We are mindful that this standard varies in accordance with the seriousness of the allegations, or the gravity of the consequences.
3. In summary, with respect to what constitutes "unprofessional conduct", the authorities stand for propositions which follow.

Categories (a) and (b) require reference to the reasonable standards of the community and of professional peers of good repute and competence. Morris J in _Vissenga v Medical Practitioners Board of Victoria[43]_observed :

I wish to revisit the words of paragraphs (a) and (b) of the definition of unprofessional conduct. In both of these paragraphs attention is directed at professional conduct which is of a lesser standard than that which might "reasonably" be expected of a registered medical practitioner by the public or by the peers of the practitioner. In my opinion, neither the public nor the peers of a medical practitioner expect perfection at all times. Human frailty visits every person, including those who are medical practitioners. Reasonable members of the public, and the reasonable peers of medical practitioners, understand this. Reasonable people are tolerant of occasional lapses, particularly if these lapses do not form a consistent course of conduct or, if taken separately, are insufficiently serious to warrant intervention by those charged with acting on behalf of the State.

The difference between unprofessional conduct of a "serious" nature and unprofessional conduct which is not of a serious nature is clearly a matter of degree, and judgment. In Kozeniauskas v Dental Practice Board of Victoria[44], when considering the distinction between unprofessional conduct of a serious nature, and unprofessional conduct falling short of that mark, Morris J observed that -

Clearly enough, the difference goes to the gravity of the conduct and must depend upon, not only the facts of the case, but also the assessment of the conduct in the context of the conduct of professional practice generally.

In Re Parr and Nurses Board of Victoria (1998) 16 VAR 118, Kellam J, at 123, stated :

In my view the question of whether or not a nurse has engaged in unprofessional conduct of a serious nature must depend upon the facts of each case. Clearly such conduct would not be serious if it was trivial, or of momentary effect only at the time of the commission or omission by which the conduct was so defined. It must be a departure, in a substantial manner, from the standard which might be reasonably expected of a registered nurse. The departure from such standards must be blameworthy and deserving of more than passing censure.

1. Whilst the hearing concerned allegations about both medical practitioners, it is convenient to deal with each practitioner separately. We follow the sequence the Board has addressed the allegations in its submissions and will consider those about Dr Lichter first.

1. The allegations made by the Board against Dr Lichter about the events on 1 April 2004 are that he :

"(a) failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability

(i) The first recorded observations at 10.40 hours in relation to Mrs Siriwan in the recovery room, being systolic blood pressure of 84/37 and heart rate of 110bpm, were consistent with hypovolaemia, which was not adequately addressed by you in that you did not provide, or instruct others to provide, Mrs Siriwan with sufficient fluid replacement to reverse the hypovolemia.

(b) failed to appropriately manage Mrs Siriwan's continuing blood loss

(i) Following your examination of Mrs Siriwan under anaesthetic, which commenced at about 9.20 hours on 1 April 2004, you packed Mrs Siriwan's uterus with gauze vaginal packs:

(a) without staying to monitor your patient in the recovery room for any or any adequate period of time to ensure that the bleeding had stopped; and/or

(b) without leaving orders for observation, which would have adequately indicated to recovery room staff what signs they were to look for that may have indicated ongoing blood loss and/or when to contact you; and/or

(c) failed at any time prior to at least 11.45am to contact staff in the recovery room about your patient and/or attend at the recovery room yourself to make appropriate observations of the health of your patient.

(iii) You did not commence aggressive transfusion of blood products for Mrs Siriwan in consideration of her continued blood loss.

(i) You made no attempt to reverse Mrs Siriwan's coagulopathy. While you ordered that blood be sent to pathology for cross-matching and a coagulation profile, you did nothing further regarding coagulopathy, a condition which should have been apparent to you.

(d) inappropriately transferred Mrs Siriwan from the South Eastern Private Hospital to the Monash Medical Centre

(i) You, with Dr Emlyn Williams, decided to transfer Mrs Siriwan to Monash Medical Centre, a decision which was inappropriate, given that Mrs Siriwan's condition was not stable and she was in extremis."

1. With each of the allegations we need to be satisfied whether or not they are made out. If we are so satisfied, we need to make a finding of whether or not the conduct constitutes unprofessional conduct.
2. Dr Lichter gave evidence and was cross-examined. He gave his evidence in a forthright way. We were troubled by his tendency to lay the blame on others rather than taking responsibility himself. For example, he was critical of the anaesthetist and the nursing staff for not contacting him after he left the recovery room to attend to his rooms, when it had been his own intention not to be away as long. We accept that his recollection of events almost six years after the event will not be perfect. Allowing for this lapse of time, where he has made statements earlier such as his written responses to the Board and given evidence at the earlier coronial inquest, we generally prefer his earlier recollections, made closer to 1 April 2004.
3. Allegation (a) is that Dr Lichter failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability.

(i) The first recorded observations at 10.40 hours in relation to Mrs Siriwan in the recovery room, being systolic blood pressure of 84/37 and heart rate of 110bpm, were consistent with hypovolemia, which was not adequately addressed by you in that you did not provide, or instruct others to provide, Mrs Siriwan with sufficient fluid replacement to reverse the hypovolaemia.

1. It will be recalled that the examination under anaesthetic had concluded at 10:15am and that Dr Lichter had remained in the theatre for some 10 to 15 minutes and then in the recovery room for about 10 or 15 minutes.
2. Dr Lichter conceded in his evidence that the observations recorded by the nursing staff at 10:40am were consistent with hypovolemia and that he was aware of those observations.
3. He submitted that it was reasonable for him not to have provided or instructed others to provide Mrs Siriwan with fluid replacement to reverse the hypovolemia for the following reasons :

(a) as at 10.40 hours the cross matched blood was not yet available and hence could not be provided to Mrs Siriwan [see also Caldwell T574];

(b) an urgent request of Dorevitch pathology for 4 units of cross- matched blood to redress the blood loss had already been made by Dr Lichter in conjunction with the anaesthetist Dr Williams in the course of performing the examination under anaesthetic (EUA)) [see Exhibit S; Levin T202-204, T207-8];

(c) Dr Lichter was entitled to rely on Dr Williams' expertise as to whether the 4 units ordered was sufficient to address the situation [Simmons T496-497];

(d) likewise, an urgent request of Dorevitch pathology for coagulopathy studies to be carried out had already been made [see Exhibit S], and hence in the event that the studies demonstrated a clotting problem (which they subsequently did and of the most serious nature), it was reasonable for Dr Lichter and Dr Williams to rely on Dr Levin and Dorevitch pathology to advise them in a timely manner if additional blood was required and what if any blood products were needed to attempt to redress the situation [see discussion further below and the evidence of Dr Levin T186-7, 216-217, 223];

(e) Dr Williams and the Recovery Room nursing staff had been instructed and were well aware as at 10.40 hours that the blood once available, needed to be administered as quickly as possible to redress Mrs Siriwan's blood loss [Williams T684-685, T710];

(f) Dr Williams had agreed to monitor Mrs Siriwan in the Recovery Room [Lichter T851; Williams T71 1, T793] and in addition by reason of his expertise was the appropriate person to issue any additional instructions as to fluid replacement [Williams T683-684, T686, T710, T717, T729; see also White Day 3 T11; Nacey Day 3 T126, 141; Hertolous Day 2 T143; Simmons T531-532];

(g) Dr Lichter was entitled to rely on Dr Williams to have known whether there was 0 negative available [Day 3 White T23] and if there was, to make the necessary arrangements to have it delivered [Caldwell T560];

(h) Dr Lichter had been reassured by Dr Williams that the observations at 10.40 hours, although of concern, were due to the fact that there was insufficient blood volume and as soon as the blood was given, the situation would improve [Lichter T1008; see also Williams T795, T810, T820-821];

(i) having made an urgent request for blood and in circumstances where Nurse Southern [Lichter T885] and Dr Williams had advised him that the blood was on its way[45] [Lichter T950], it was reasonable for Dr Lichter to assume that the arrival of the blood was imminent.

He further submitted that to the extent that the 4 units of blood requested of Dorevitch Pathology may have been insufficient to reverse the hypovolemia by reason of an underlying coagulopathy problem of the most serious kind, both Dr Lichter and Dr Williams were entitled to rely on Dr Levin and the scientific personnel at Dorevitch laboratory to give them prompt advice as to the true nature of the problem that they were facing and how much additional blood and what if any blood products were in fact needed to attempt to redress the situation in circumstances where:

(a) at 10.49am the staff at the Dorevitch laboratory had obtained the first result that the blood would not clot and that tests were run on at least two more occasions which again demonstrated that the blood would not clot, the results of which were communicated to Dr Levin at 11 .03am [Levin T209]

(b) at 11.03am or shortly afterwards Dr Levin had formed the view that the blood sample had not been contaminated and that the test results that the blood would not clot were likely to be accurate [Levin T214];

(c) by 11.05am or thereabouts Dr Levin knew that the clotting abnormality found by the laboratory:

• presented enormous difficulty to those treating the patient [Levin T216];
• could not have been an any more abnormal result and the situation any more serious [Levin T223];
• meant that any blood transfused was going to go out as quickly as it was put in and hence the 4 units of blood requested was never going to be anywhere near sufficient [Levin T217];

• that the treating doctors were facing an ultra serious coagulopathy problem that was going to need immediate and significant attention [Levin Day 2 T217];
• additional blood and fresh frozen plasma and platelets were available at Knox hospital and could have been delivered to SEPH faster than if it had come from South Melbourne [Levin T224];

Despite having such knowledge Dr Levin conceded that:

(a) he did not contact anyone about the abnormal coagulopathy results (T220)[46]

(b) for reasons which he could not explain he failed to contact the staff at the laboratory to advise them that Mrs Siriwan's treating doctors were going to need a lot more than just four units of blood and in addition fresh frozen plasma, platelets and cryoprecipitate [LevinT2l7,T186].

1. Mrs Siriwan suffered significant blood loss after giving birth. It was sufficiently serious to require an examination under anaesthetic to try and establish the reason for the blood loss. Dr Lichter as an experienced obstetrician was aware that there could be a number of causes, one of which on his own evidence was his suspicion there may be a coagulopathy issue.
2. We agree it would have been desirable had there been better communication with Dr Levin and the laboratory. Yet, given the amount of blood loss and Dr Lichter's own suspicion that there was a coagulopathy problem, he was on notice. In those circumstances, we do not accept that it was reasonable for Dr Lichter not to have himself provided, or instructed others to provide, Mrs Siriwan with fluid replacement to reverse the hypovolemia, even without explicit pathology results.
3. We are satisfied his failure to adequately address her hypovolemia was unprofessional conduct of a serious nature.
4. In making this finding, we accepted the evidence of Dr Bernadette White and Dr Caldwell. We are conscious of Dr White's extensive expertise as an obstetrician and gynaecologist. She was an impressive witness - careful in the answers she gave and measured. Dr Caldwell's evidence was consistent with Dr White's and we accepted it, noting his long and extensive experience.
5. Overall, Dr White gave evidence that Dr Lichter's immediate treatment for post partum haemorrhage was appropriate; that examination under anaesthetic and whilst she might not have done so, as it is rarely used and she did not understand why he had chosen to do so, his decision to pack the uterus was reasonable. Where she expressed concern about the standard of his conduct related to his decision thereafter, after the packing and during hours between theatre and his later decisions. In her opinion, he had not responded in a timely way.
6. Specifically, we accepted Dr White's evidence that -

The treatment of post-partum haemorrhage is the same whatever the underlying cause is. It's identifying why the haemorrhage is occurring, trying to correct it, adequately resuscitating the patient, dealing with coagulopathy.[47]

1. We accepted her evidence that in this circumstance, she would expect a competent obstetrician to adequately resuscitate the patient in conjunction with the anaesthetist -

It's something that you probably have started to do before you even got to theatre. So that's making sure you've got a drip in so you can give fluid more rapidly ... you would be giving some sort of fluid ... you would want to be getting blood cross-matched because once you're getting up to over a litre and you're taking the patient to theatre, you really don't at that stage know how quickly it's going to come under control, what the ongoing blood loss is going to be ...[48]

1. Dr White said that given the fact that Mrs Siriwan continued to bleed despite the uterus being empty and no tears being observed -

It's very likely she was going to require a blood transfusion at that point. If she's already lost over two litres of blood and was continuing to bleed ... you would be expecting you would need to get blood and you would probably want it soon.[49]

1. Dr Caldwell gave similar evidence and we accepted it. He said that you would need to get four to five units of blood and four to five litres of fluid 'as soon as you could possibly do it'.[50]
2. Dr Caldwell said that if the blood had not arrived by 10.25am, as the obstetrician -

I would be enquiring from pathology very quickly as to what's happened to the blood, why haven't we got it. You need it straight away, it's two hours since she started bleeding, it's over two hours ... and she's lost an awful lot of blood ... I would be taking that step. I would be jumping up and down.[51]

He said that if he was informed that the blood that had been ordered would not be available until 11 o'clock, he would have said "have you got an O negative blood, please, send it to me.[52] Dr Lichter did not give any instructions about fluid replacement. He seeks to excuse himself, saying he was entitled to rely on others to attend to those matters. That conduct is not consistent with the approaches suggested by Dr White and Dr Caldwell.

1. We are satisfied that Dr Lichter's failure to adequately address Mrs Siriwan's hypovolemic instability and blood loss is unprofessional conduct of a serious nature. It is serious because it is a significant departure from the reasonable standards of treatment recognised by one's peers such as Dr White and Dr Caldwell, whose evidence we accepted.
2. Allegation (b) is that Dr Lichter failed to appropriately manage Mrs Siriwan's continuing blood loss. It is in 3 parts and is about the management of Mrs Siriwan's blood loss. The first part(b)(i) concerns the packing of the uterus . There are three areas where inappropriate management is alleged.

(i) Following your examination of Mrs Siriwan under anaesthetic, which commenced at about 9.20 hours on 1 April 2004, you packed Mrs Siriwan's uterus with gauze vaginal packs:

(a) without staying to monitor your patient in the recovery room for any or any adequate period of time to ensure that the bleeding had stopped; and/or

(b) without leaving orders for observation, which would have adequately indicated to recovery room staff what signs they were to look for that may have indicated ongoing blood loss and/or when to contact you; and/or

(c) failed at any time prior to at least 11.45am to contact staff in the recovery room about your patient and/or attend at the recovery room yourself to make appropriate observations of the health of your patient.

1. Dr Lichter's submissions about part (i)(a) were that -

The expert evidence of Dr White[53] was that 30 to 60 minutes was an appropriate period of time for the treating obstetrician to have observed the patient following the packing of the uterus in order to gain a sense of whether "you were winning or not" [Day I White T34-35].

Dr Lichter estimates that he observed Mrs Siriwan in theatre following the packing of the uterus for about 10 to 15 minutes [Lichter T848; see also Williams T790]. Mrs Siriwan was transferred from theatre to the Recovery Room at 10.20 hours. Dr Lichter stayed in theatre for a short time to write up his operation notes and post-operative instructions before moving to the Recovery Room to further observe his patient. Dr Lichter was not able to recall precisely how long he remained with Mrs Siriwan in the Recovery Room. However the evidence demonstrates that he was advised of the 10.40 nursing observations and hence the likelihood was that he remained with Mrs Siriwan in the Recovery Room for around 15-20 minutes[54].

If the time Dr Lichter spent observing the patient in theatre is added together with the time he spent observing her in the Recovery Room, the total time spent by Dr Lichter observing Mrs Siriwan following the packing of the uterus was in the order of half an hour.

It is submitted that it was reasonable for Dr Lichter to have left the Recovery Room after the half hour of observation of Mrs Siriwan for the following reasons:

(a) During the time that Dr Lichter observed Mrs Siriwan in theatre:

• Dr Lichter observed the uterus to remain tight [Lichter T848];
• there was no evidence of bleeding through the pack; [Lichter T848]
• Mrs Siriwan's vital signs were stable, consistent with the bleeding having stopped [Lichter T848; see also Williams T794];

(b) During the time Dr Lichter observed Mrs Siriwan in the Recovery Room:

• her vital signs had been assessed by Dr Williams as acceptable [Lichter T852; Williams T795];
• the uterus had remained firm [Lichter T852];
• the bleeding appeared to have stopped [Lichter T852; Williams T687, T837]

(c) It was reasonable for Dr Lichter to have believed that the arrival of the blood was imminent [see previous discussion];

(d) Dr Lichter's reasons for departing the Recovery Room were reasonable in that:

• he went to speak with the patient's husband and mother in law to explain to them the morning's events and the prospect of Mrs Siriwan undergoing an hysterectomy [Lichter T852];
• he needed to go back to his rooms, which were very close by, to check that nothing, urgent or serious had arisen from the cancellation of his morning list;

(e) Dr Williams had agreed to monitor the patient in the Recovery Room in Dr Lichter's absence and had undertaken the responsibility for fluid replacement [see previous discussion; see also Simmons T530-531];

(f) It was reasonable for Dr Lichter to expect that Dr Williams would call him if Dr Williams became aware of a significant deterioration in Mrs Siriwan's vital signs or significant ongoing blood loss [Williams T796-7; Simmons T530-532];

(g) Ms Siriwan was being monitored by experienced nursing staff in the Recovery Room who knew:

• that Dr Lichter had gone back to his rooms and could be called quickly back;
• to contact both Dr Williams and Dr Lichter should Mrs Siriwan's condition not improve [Nacey TI54-6];

(b) the theatre had been readied for an urgent hysterectomy to be performed should the need arise.

In the circumstances set out above, it is submitted that it was reasonable for Dr Lichter to have left the patient, at least for a short time, for the reasons that he did. This proposition was supported by the expert evidence called in this case when the above matters were put to them in cross examination [see Day 3 White Tl0-13; Caldwell T574, T627-629, T650].

1. Again, we agree generally with the observations made by the Board about these submissions. We agree that they are endeavouring to emphasise the time Dr Lichter actually spent with Mrs Siriwan in theatre recovery and in the recovery room rather than reflecting on the state of his patient.
2. The Board submitted that where there was a decision to pack the uterus the following was required for post-operative observations of the patient -

Danso and Reginald[55] maintain that when uterine tamponade is employed, 'all patients should be managed in a high-dependency or intensive care unit with very close monitoring of their vital signs, fluid input/output, fundal height and vaginal blood loss.' (emphasis added)

In addition, they contend that 'Continued oxytocin infusion may be necessary to keep the uterus contracted over 12-24 h.'[56] Further, they contend that 'prophylactic broad-spectrum antibiotic cover should be administered.'[57]

Given the uncertain prospects of success of the procedure of packing the uterus with gauze, it was incumbent upon Dr Lichter to himself monitor the relevant signs for 30- 60 minutes[58], being cautious about the relevant timeframe, bearing in mind his inexperience with the procedure, or at least ensuring that the monitoring system he set up was going to alert him if there were any signs of deterioration in the patient and/or of ongoing blood loss.

The evidence indicated that once Dr Lichter had made the decision to pack the uterus, it was essential for him to monitor the feel of the uterus abdominally - 'if [the uterus] is continuing to fill up with blood and clot it will expand again and will be what is called a rising fundus where the uterus is apparently getting bigger because it's filling up with blood, so the blood may not be flowing out that you can see coming out the vagina, but if the uterus is soft and expanding then you know something is not right, that there is ongoing bleeding within the uterus even though you can 't actually see it.'[59]

Dr White said in relation to packing, that it would 'take a bit of time before you know really whether it's working or not. It's not a point I can do a check now, everything's OK, I know I've got the situation under control. It was only going to become apparent over a period of time whether that treatment had worked or not. So her state at the time where they decided to extubate and take her to [recovery], it may have been that she was OK at that point, but really, it was what happened after that that was going to influence the way this all unfolded.'[60] (emphasis added).

She said that while she has never packed a uterus with gauze, she would have thought that within the next half an hour to an hour 'you would have a pretty good sense of we're on top of it.. I don't think the uterus is expanding, the blood pressure is coming up because we have replaced the fluids lost.'[61]

Dr White stated that she thought that most obstetricians would stay with their patient in recovery until they were sure that they had the situation 'under control'.[62] She said that if they did leave the recovery area, they would likely be ringing back in the next 20 to 30 minutes to monitor the condition of their patient, 'because you'd be very concerned and you'd perhaps be seeking some reassurance that given that you weren't perhaps entirely confident that what you had done was going to be successful...'.

Dr Caldwell said that if he had decided to pack the uterus, he would 'wait and see what happened... If I was satisfied that all her vital signs were improving and that the blood loss was certainly slowing down or there was virtually none, then I would go but not before, you know, I'd be terribly worried about this patient.'[63] (emphasis added)

During her evidence, Dr White was asked to comment on Mrs Siriwan' s observations as at 10.40am and at 10.50am. Her evidence was as follows:

'Knowing that the blood pressure systolic throughout the course of the operation was over 100 and taking into account the fact that the patient was still unconscious 15 minutes after the procedure and there is her vagina loss slightly even with the vagina packs in situ, what do you say about the patient's state at that time, 10.40? Look obviously he had no grounds to be reassured at that stage in that she remains tachycardic, hypotensive, unconscious.., but certainly I don't think there were any grounds to feel reassured at 10.40 on the basis of the observations recorded there.'[64]

'...at 10.50 she's still very hypotensive . She's tachycardic, she's still unconscious, I'm still wondering why she hadn't woken up, the PV loss is recorded as moderate. I don't believe that I would leave under those circumstances.'[65]

Dr Caldwell said that at 10.40am, Mrs Siriwan '[was] not very well and she obviously needed [a] transfusion of blood...urgently, urgently'.[66] He said that he would not have had any hesitation in obtaining 0 negative blood at this stage.[67]

1. We accept the evidence and opinions expressed by Dr White and Dr Caldwell and observations set out above, and about what would reasonably be expected of a competent obstetrician in these circumstances. The evidence was clear that at no stage was Mrs Siriwan stable enough for Dr Lichter to have left at all. We are satisfied that Dr Lichter did not stay to monitor his patient for any adequate period of time to ensure that the bleeding had stopped. He did not remain despite the fact he had used a procedure he had possibly only used once many years before, when he was a Registrar. He did not remain to check the fundal height, or remain to monitor Mrs Siriwan's vital signs which would have caused a reasonably competent obstetrician grave concern. Whilst no one would criticise Dr Lichter for stepping out briefly to talk to Mrs Siriwan's husband, Dr Lichter did not simply do that. He went to his rooms to check on his very full appointment list that morning. Nor do we accept that it was reasonable in the circumstances for him to have relied on others to have called him back earlier.
2. Dr Lichter's submissions about part (b) of allegation (b)(i) of the particulars relating to whether after packing the uterus he left orders for observation which adequately indicated what signs to look for about ongoing blood loss and when he was to be contacted, were are follows :

Following the performance of the EUA, Dr Lichter left the following orders for the recovery room staff for the monitoring of Mrs Siriwan's condition :

(a) routine post anaesthetic observations [see Exhibit LL and Lichter T871 -872];

(c) to watch out for blood loss and to contact him urgently if any such loss was observed [Lichter T849, 874, 877, T984].

Although Drs White and Caldwell gave expert evidence that an additional observation to the above should have been carried out - namely monitoring of the fundus height - it was conceded that it was not an observation which the Recovery Room staff nursing staff would be expected to feel confident about carrying out [White T40] and that Dr Lichter was the person able to make a meaningful assessment of fundus height [Caldwell T606-607]. Hence it is submitted that Dr Lichter left adequate orders as to what observations the recovery room staff were to carry out.[68]

Furthermore, consistent with Dr Lichter having left adequate instructions for the recovery room staff and having adequately informed them of the seriousness of the situation at hand, the evidence demonstrates that the nursing staff were aware that:

• Mrs Siriwan had lost a lot of blood by the time she was admitted to Recovery (Nacey 120);
• the packing of the uterus was not intended to have been definitive treatment but rather was an attempt to stem the blood flow with the patient needing to be closely monitored for haemorrhage [McManus Day 3 T98-99, 102; Nacey 122-1 23; 150-151];
• there had been discussion in the operating theatre as to the need for hysterectomy and the undertaking of packing as a treatment alternative before proceeding to the step of hysterectomy;
• the risk of bleeding was to be monitored visually and through observation of the patient's vital signs (Nacey 122);
• Dr Lichter was intending to undertake a hysterectomy if packing was ineffective and wanted to be notified if bleeding was observed by the nursing staff (Nacey 150-151; 155-156);
• Dr Lichter would perform a hysterectomy at any time necessary should the patient's clinical situation be such to warrant the intervention (Nacey TI55-156);
• Dr Lichter had gone to his rooms and that the nursing staff could and should call him at any stage during the morning should any issue with haemorrhage arise (Nacey T135,151-152,154).

• the packing was not necessarily definitive treatment and that a hysterectomy may be required at a later time [Williams T791-792];
• he was to monitor the risk of ongoing bleeding in the Recovery Room Williams T70];
• it was part of his role to contact Dr Lichter should Mrs Siriwan's vital signs indicate ongoing bleeding [Williams T796-797. See also Nacey T126].

It is submitted that the issue at hand is not the adequacy of the post operative instructions left by Dr Lichter, but why Dr Lichter was not contacted by those monitoring Mrs Siriwan following his departure from the Recovery Room in circumstances where her vital signs and observations as recorded on the post anaesthetic chart [Exhibit M] warranted such a call [see for example Caldwell T576-577, 579, 599]. All the nurses understood the importance of any ongoing bleeding and the importance of communicating that fact to Dr Lichter. Similarly, Dr Williams understood the importance of reporting any deterioration in her medical condition. The instructions cannot be said to be inadequate if their essence was understood. The failure here was not in the adequacy of the instructions but the fact they were not followed.

The explanation is that there was a failure in communication within the nursing staff and between the nursing staff and Dr Williams in that they all believed that Dr Lichter had been contacted when in fact he had not [Hertolous Day 2 T159; Southern Day 3 T81; Nacey Day 3 T141, 152- 153, 154-5].

By reason of the relatively untested character of the technique and the risk that the uterine packing would mask any ongoing bleeding, very careful monitoring of the patient, particularly in terms of her potential to continue to bleed was required once the procedure was concluded and the patient transferred to the recovery room :

'You would certainly be needing to watch the patient very closely. Firstly you would want to be looking at her observations, whether her pulse and blood pressure were improving and hopefully coming back to something like what they should have been doing and that is kind of reassuring that you perhaps have got the situation under control. You would be wanting to look at the amount of blood vaginally, knowing that there might be a substantial amount staying in the uterus that's been absorbed by the packs and I think that it would be important [to get] a sense of what does the uterus feel like, because once you have packed the uterus you can feel the uterus easily abdominally....

So observations would not just be about vital signs, blood pressure, heart rate etcetera, but also physically examining the patient's uterus? - I think it would be all those things combined to really get an assessment of the situation and as I say. You're in a fairly desperate state here.'[69] (emphasis added)

Dr White said that if the obstetrician did decide to leave the patient 'he would want some indication of whether the uterus is well contracted and what the blood loss was and that he would have made it clear if he was going to leave at what point he wanted to be told if things weren't going the way that he hoped they were going to go in leaving the hospital so, what are called reportable levels.., tell me if the blood pressure...drops below 100, tell me if the pulse rate is over 120. Tell me if you think there is ongoing blood loss ...'[70]

Under cross-examination, Dr White said that if Dr Lichter was going to leave his patient, it was 'essential' that he leave orders addressing the state of the uterus, the state of the bleeding and asking that he be kept informed.[71]

In relation to the issue of what post-operative orders would be appropriate in this case, Dr Caldwell said 'This is a very seriously ill woman.., who could easily still die and I therefore would like explicit instructions of exactly what I want done. Just RFO and intensive nursing is just normal and this is not a normal case.'[72] In relation to the particular observation that he would want, he said '... he should have given very explicit instructions to the nursing staff who were looking after that patient as to what he wanted to be notified about... One, increasing continuing blood loss from the vagina, which could be observed by looking, two, what was happening to the uterus, was it soft and boggy and expanding or was it... hard and contracted therefore controlling bleeding. He would want to know both of those things and.., the nursing staff should have been given careful instructions as to what to do. They can put their hands on the uterus, feel it, is it expanding, getting bigger, soft, hard and staying the same, the blood loss ceased or increasing, is the patient's blood pressure and pulse changing.' He said that he would both tell the staff verbally about what he wanted and also write it down.[73]

1. We do not accept Dr Lichter's submissions that the orders he left were adequate. The written post-operative orders Dr Lichter left were simply for routine post-anaesthetic observations and intensive nursing. Dr Lichter's evidence was that he also told the nursing staff to watch out for blood loss and to report it; further that they and Dr Williams should call him if anything changed. He may well have said something in addition to what he noted, and it may be what he recollects now, but the fact he was not contacted would suggest that if he had asked to be, he did not emphasise the request. We do not accept that the issue in this allegation is why Dr Lichter was not contacted.
2. His instructions were far from adequate and fly in the face of the evidence of Dr White and Dr Caldwell about what would be appropriate in circumstances of a desperately ill patient. In making this finding, we agree with the Board's submissions and accept the evidence particularly of the professionals, referred to above. Bearing in mind Dr Lichter's lack of experience carrying out this procedure, he at the very least should have ensured that the monitoring system he set up was going to alert him if there were signs of deterioration in his patient and/or ongoing blood loss. To have failed to make a note of his observations in any of the relevant records; to have left post-operative instructions for 'routine post-anaesthetic observations and intensive nursing' and no more, and to have provided Dr Williams with no detailed handover, simply saying to him 'will you be here if anything happens in the meantime, otherwise I will be in my rooms' was woefully inadequate and a significant departure from the conduct one's peers would regard as reasonable in the circumstances.
3. We agree with the Board's submissions that to have left such inadequate instructions constitutes an abrogation of his professional responsibilities. It was an insufficient response to a clinically serious situation that had been the subject of an unorthodox attempt to preserve her fertility. If, as was reasonably foreseeable, that did not succeed, Mrs Siriwan's life depended upon early detection of the failure of the procedure and an immediate response. This was Dr Lichter's responsibility as the treating obstetrician, the person best placed to interpret matters such as the state of the fundus.
4. Dr Lichter's submissions about part (c) of allegation (b)(i) of the particulars relating to whether after packing the uterus he failed at any time prior to at least 11:45am to contact staff or attend at the recovery room were as follows :

The evidence indicates that the time Dr Lichter was away from the recovery room was between 50 minutes to slightly over one hour.

Whatever the period, Dr Lichter's evidence was that:

(a) he only intended to be away for 20 minutes at the most [Lichter T853J;

(b) he was away much longer than he expected [T854];

(c) he considered that he should have returned earlier.

Dr Lichter's failure to return earlier should be viewed against the following ameliorating factors:

(a) one of the reasons for Dr Lichter leaving the Recovery Room was to speak with Mrs Siriwan's husband and her mother in law to update them about what had occurred and what may follow;

(b) that conversation may have taken longer than he appreciated [Lichter T853];

(c) he had subsequently gone to his rooms to check that there were no matters of serious concern arising from the cancellation of his morning list;

(e) Mrs Siriwan was being cared for in the interim by experienced nursing staff and Dr Williams;

(f) no one had called him in circumstances where he could have reasonably expected a call if Mrs Siriwan was not progressing in the way that was hoped [see previous discussion] which had probably had lulled into a false sense of security [Lichter T854].

It is submitted that having regard to the above ameliorating factors, Dr Lichter's failure to return earlier, although open to comment, does not warrant an adverse finding or penalty against him. Support for this can be found in the evidence of the expert obstetric witnesses called in this case who identified the period of ½ hour to 1 hour as a reasonable period of time for Dr Lichter to have been away for the reasons that he did and in the circumstances that he did [White Day 3 T15, T28-29; Caldwell T579-580].

1. We note Dr Lichter's concession that he should have returned earlier. We are not satisfied the so called ameliorating factors referred to excuse his failure to contact staff or to return earlier. It was not reasonable in the circumstances.
2. Allegation (b)(ii) is that Dr Lichter failed to appropriately address Mrs Siriwan's continuing blood loss by not performing a hysterectomy.
3. Dr Lichter's submissions were as follows :

The evidence of Dr Bernadette White on this issue was that:

(a) the decision to proceed to a hysterectomy in the case of a young woman is a very difficult decision to have to take [White Day 3 T6; see also Simmons T528];

(b) it was reasonable for Dr Lichter to have tried other methods to stop the bleeding first which he thought might be effective and to wait until he had no other option available to him than a hysterectomy [White Day 3 T6];

(c) packing of the uterus is a recognised treatment for post partum haemorrhage [White Day 1 T31-32];

(d) packing of the uterus was one of the options that warranted consideration by Dr Lichter [White Day 3 T15];

(e) it was reasonable for Dr Lichter to try packing of the uterus to stem the bleeding as there was a possibility it was going to be effective [White Day 1 T33, T35, T58; Day 3 T6; see also Simmons T528]

Dr Caldwell's view differed in that he did not consider packing to be an option at all, the only circumstances in which he would employ such a measure was if he was "in the middle of nowhere" [Caldwell T624-625]. It is submitted that Dr Caldwell's opinion on this issue is an idiosyncratic view and not in line with accepted obstetric practice in 2004. Indeed Dr Caldwell conceded in cross-examination that other practitioners do things differently [Caldwell T627, T655] and that current opinion may differ from his view [Caldwell T630-631 cf T646]. Hence it is submitted that Dr Caldwell's opinion is of little or no assistance to the Tribunal on this issue[74].

Insofar as to whether it was reasonable for Dr Lichter to have departed from the Recovery Room at around 10.40 hours as opposed to taking steps to return the patient to theatre at any time prior to 11.45 to perform a hysterectomy:

(a) please refer to paragraphs 8-9 of these submissions;

(b) the theatre had been prepared for the event that Dr Lichter determined that the packing had ceased to be effective and a hysterectomy was required.

Dr Lichter's evidence is that he returned at about 11 .45am or thereabouts in order to review Mrs Siriwan only to discover that she was in a parlous state and had been obviously bleeding. His immediate determination was that a hysterectomy needed to be carried out there and then.

Dr Lichter however was prevented from carrying out a hysterectomy at SEPH by reason of:

(a) Dr Williams refusing (on Dr Lichter's version of events) to carry out the anaesthetic for the procedure or alternatively Dr Williams persuading Dr Lichter (on Dr William's version of events) that it was not safe to proceed with a hysterectomy at SEPH, the net effect, it is submitted, being the same ie Dr Williams was not prepared to administer the anaesthetic thus leaving Dr Lichter with no choice but to transfer the patient elsewhere [see discussion at para 26 below];

(b) no other anaesthetist being available at SEPH - the only other anaesthetist in the hospital being involved in a procedure at the time [Nacey Day 3 T127].

In such circumstances, Dr Lichter had little choice but to take steps to arrange an urgent transfer of Mrs Siriwan to another hospital [White Day 3 T15-16] and it is submitted cannot be reasonably criticised in the circumstances for not carrying out a hysterectomy.

Insofar as the conflict in the evidence between Dr Lichter and Dr Williams on this issue is relevant, it is submitted that Dr Lichter's evidence that Dr Williams refused to carry out the anaesthetic is to be preferred. Dr Williams' conduct prior to and after the discussion with Dr Lichter is consistent with such a refusal as it demonstrates a marked reluctance on his part to be involved in the management of Mrs Siriwan, namely:

(a) His departures from the Recovery Room in circumstances where he was expected to stay with the patient (Hertolous Day 2 T142- 143, 147-148; Nacey statement paragraph 16 CB 346;

(b) That following his departure he was difficult to obtain [Catacouzinos statement paragraph 8 CB 350] and found on occasion to be in the tea room instead [Hertolous Day 2 T142; Nacey Day 3 T136; Nacey statement paragraph 13 CB 345; Barallon statement paragraph 6 CB 339; handwritten notes signed by various nurses CB 357; McManus statement paragraph 18 CB 395; Sperring statement paragraph 9-10 CB 386; Williams T684, 71 7-71 9]

(c) His initial refusal to accompany the patient into the ambulance to Monash Medical Centre in circumstances where he was the most appropriate person to do so [Southern statement paragraph 15 CB327; Barallon statement paragraph [1854] EngR 13; 14 CB 340; Nacey statement paragraph 21 & 28 CB 347 & 348; Catacouzinos statement paragraph 21 CB 351-352; handwritten notes signed by various nurses CB 357; cf Williams T757]

(d) His failing to carry out resuscitative measures whilst in the ambulance [Southern statement para 20-21 CR328; Bobetic statement CR 370; cf Williams T767-769].

Dr White said that on the basis of the post-operative record at about 11am, 'if you really felt the packing has not been effective.., the patient is continuing to bleed, she is not getting any better, really there were very limited options available at that stage ... you were going to have go back into theatre. If you had the expertise of trying a procedure like tying off the uterine arteries. ... or if you did not have the expertise to do that ... then really a hysterectomy was about the only option left at that point.'[75]

Dr White said in relation to taking the decision to perform a hysterectomy, 'it's a difficult decision to take but yes I think that there are circumstances where you felt you had not adequately controlled the bleeding you really don't have much choice because that is really the situation that is potentially fatal.'[76]

Dr Caldwell said that if he had a uterus that he was having trouble making contract, 'I would think the sooner that uterus were removed the safer the patient would be, the best chance the patient would have of surviving, because you've got two very nasty problems, (a) her uterus is not contracting and (b) blood is not clotting. Both can cause catastrophic haemorrhage.'[77]

1. We accepted Dr White's evidence that the decision to perform a hysterectomy is a very difficult one. Yet, both she and Dr Caldwell's evidence which we accept is that when it had reached the point that the situation is potentially fatal, there is no choice.
2. Dr Lichter reached that point and decided that a hysterectomy was needed when he returned at about 11:45am and found Mrs Siriwan in a parlous state and continuing to bleed.
3. Whether Dr Williams refused to carry out the anaesthetic or persuaded Dr Lichter it was not safe to proceed at that hospital, the evidence suggests that Dr Lichter did not make much, if any, concerted effort to persuade Dr Williams otherwise. In his evidence during the hearing, he conceded in hindsight that there were shortcomings and misunderstandings although on the day he had thought the situation was obvious to everyone. He conceded he had probably not communicated adequately and accepted responsibility for that. It was his joint responsibility with Dr Williams. Mrs Siriwan had needed a hysterectomy right there and then, if her life was to have been saved.
4. Allegation b(iii) is that Dr Lichter failed to appropriately manage Mrs Siriwan's continuing blood loss by not commencing aggressive transfusion of blood products for her in consideration of her continued blood loss -

(iii) You did not commence aggressive transfusion of blood products for Mrs Siriwan in consideration of her continued blood loss

As previously stated in these submissions, Dr Lichter, in the course of the EUA, and in conjunction with Dr Williams, ordered 4 units of cross matched blood to be obtained from Dorevitch pathology and for coagulopathy studies to be carried as a matter of urgency.

As to the allegation that the blood which had been ordered needed to be administered 'aggressively' it is submitted that:

(a) Dr Lichter was entitled to rely on Dr Williams to ensure that the blood ordered was obtained and administered in a timely manner;

(b) Dr Lichter was entitled to rely on Dr Williams' expertise as to how 'aggressively' the blood was to be administered to Mrs Siriwan once it became available; and further

(c) Dr Williams was well aware that the blood needed to be administered 'aggressively' and indeed upon its arrival to the Recovery Room ordered the nursing staff to administer it 'forcibly' and 'as quickly as possible' [Williams T685].

Further, insofar as it is alleged that additional blood and blood products should have been obtained and administered aggressively to Mrs Siriwan it is submitted that

(a) Dr Lichter was entitled to rely on Dr Williams to make this assessment in circumstances where:

• such matters fell within the expertise of Dr Williams [Simmons T496-497];
• Dr Williams had assumed the responsibility of monitoring Mrs Siriwan in the Recovery Room in Dr Lichter's absence;
• Dr Williams knew or ought to have known whether 0 negative blood was available;
• Dr Williams was with the patient when the first blood arrived and was put up [Williams T747, T807] at around 11 .05am and was therefore in a position if he had remained with the patient to assess whether the administration of the blood in fact achieved the result expected by him, namely rectification of Mrs Siriwan's hypovolemia [Williams T795, T807, T810, T820-821; see also Dr Lichter T1008-1009] and if it did not, to take appropriate steps to address the deficiency or reinitiate contact with Dr Levin for advice;

(b) both Dr Lichter and Dr Williams were also entitled to rely on Dr Levin to urgently contact either of them in the event that the coagulopathy studies demonstrated a clotting problem of such seriousness that an immediate escalation in the quantities of blood to be administered and associated blood products was mandated [see previous discussion and discussion to follow].

1. Dr White's evidence which we accepted was that any obstetrician in these circumstances would have had running in the back of their mind, the thought that there was a risk of coagulation failure, a matter you might well end up dealing with. In those circumstances, a blood transfusion was likely to be required. In her opinion what was necessary to address Mrs Siriwan's hypovolemia and developing coagulopathy was ongoing very substantial replacement of blood, fluid volume and blood products.
2. Dr Lichter shifted all responsibility for these matters to Dr Williams and claims that was appropriate in the circumstances. We do not accept that that was reasonable conduct. We prefer Dr White's evidence of what a reasonable and prudent obstetrician would have done in the circumstances.
3. Allegation (b) is about appropriately managing Mrs Siriwan's blood loss. We are satisfied that Dr Lichter did not appropriately manage her blood loss, in the areas of how he managed the packing of the uterus, his failure to perform a hysterectomy and in not commencing aggressive transfusion of blood and blood products.
4. Where urgent measures needed to be undertaken in a concerted and assertive way to deal with her blood loss, given Dr Lichter's knowledge and experience, and his suspicions of a coagulopathy problem, his conduct on the day was woefully deficient. It represents such a departure from the standard of conduct expected of one's peers that it amounts to unprofessional conduct of a serious nature.
5. We turn now to the third allegation. Allegation (c) is that Dr Lichter failed to address Mrs Siriwan's coagulopathy.

(i) You made no attempt to reverse Mrs Siriwan's coagulopathy. While you ordered that blood be sent to pathology for cross-matching and a coagulation profile, you did nothing further regarding coagulopathy, a condition which should have been apparent to you.

It is submitted that having made the urgent request for coagulation studies in the course of the EUA, both Dr Lichter and Dr Williams were entitled to rely upon Dr Levin to contact them in a timely manner should the results of the studies raise the prospect of a serious coagulopathy problem which the 4 units of blood which had been ordered had no prospect of redressing [see previous discussion]. Further, the evidence demonstrates that by 11 .05am, Dr Levin was not only armed with sufficient information to raise immediate and alarming concern but had in fact arrived at the opinion that Mrs Siriwan's treating doctors were in all likelihood facing an extremely serious coagulopathy problem which mandated immediate and significant attention by way of the provision of large amounts of additional blood along with fresh frozen plasma, platelets and cryoprecipitate. In such circumstances, the situation demanded that Dr Levin make immediate contact with the practitioners treating Mrs Siriwan and apprise them of the true situation that they were facing. The failure of Dr Levin to do so remains unsatisfactorily unexplained. The consequence of the failure however meant that the practitioners treating Mrs Siriwan were not able to appreciate the true enormity of the coagulopathy problem which they were facing let alone have any chance of taking adequate measures to redress it or to get 'in front of the game' [Levin Day 2 T126]. When viewed in this context, it is submitted that Dr Lichter's actions in engaging Dr Levin to provide urgent advice as to Mrs Siriwan's coagulopathy status and in arranging Dr Williams to administer the blood ordered and to monitor Mrs Siriwan's resuscitation in Recovery whilst awaiting Dr Levin's advice, were reasonable in the circumstances and that the coagulopathy problem which existed could not have been reasonably apparent to him [see previous discussion at paragraphs 2-4; see also White Day 3 T21].

1. The Board in relation to this allegation relied on the following evidence of Dr White -

In relation to this issue, Dr White said that 'Any patient who has a substantial postpartum haemorrhage is at risk of coagulation failure and so any obstetrician dealing with a big post-partum haemorrhage has in the back of their mind, is the blood still clotting, am I running into coagulation failure... it's something you know you may well end up dealing with ... you do want to get a test done to tell you what the current status of the clotting is and you're also going on your own assessment because you've got plenty of blood there, you can see whether it is clotting or not."

Following the initial "whoosh" of blood at the commencement of the procedure, the Assistant Nurse Unit Manager in the theatre described Mrs Siriwan's ongoing blood loss through the procedure as being like 'raspberry topping'[78] or 'raspberry cordial'.[79] The evidence indicated that her description of the expelled blood was consistent with coagulopathy.[80] In the circumstances, a blood transfusion was likely to be required quickly[81]. In relation to the obstetrician's care of a patient with a suspected coagulopathy, Dr White said, 'I don't think you would be leaving if you had an untreated coagulopathy until you felt that you had got that underway as well as stopping the bleeding.'[82]

What was necessary to address Mrs Siriwan's hypovolaemia and developing coagulopathy was ongoing very substantial replacement of blood, fluid volume and blood products.[83]

1. Whilst there was an abject failure on Dr Lichter's part to make any attempt to reverse her coagulopathy, it should have been part of a two-pronged attack on the situation according to Dr White's evidence, which we accepted. Her views are set out in the Board's submissions as follows :

Dr White agreed that by 11 .45am Mrs Siriwan required an urgent hysterectomy. She said that because you have a situation where there's a patient with ongoing bleeding and coagulation failure as well, the obstetrician needs to undertake a two pronged attack - 'proceed with the hysterectomy in order to save the patient's life ... whilst at the same time doing whatever you can to control or improve the blood clotting ... by giving things like fresh frozen plasma, platelets, anything that you can administer that will improve the clotting.., when you get a patient who has a massive post-partum haemorrhage these patients may end up being transfused with 20 units of blood that is because it's going in and it's coming out. So you've got to keep putting it in and basically you have got to block all the holes in the colander which is what the hysterectomy is designed to do. So you've really got to be doing both things... the blood will come out but you've got to keep putting it in while you're dealing with something to stop it'.[84]

1. Dr Lichter's submissions emphasize the lack of any communication from Dr Levin. In our view, this does not excuse Dr Lichter. He suspected a coagulopathy, the source of which is irrelevant when it comes to what is the appropriate treatment. He ought to have put in place steps to treat a coagulopathy in his patient. He did not do so.
2. Dr Lichter's failure to address the ongoing bleeding in the circumstances is not conduct that one would expect of an obstetrician in these circumstances. We accept Dr White's opinion. The attempt to shift the responsibility to Dr Levin does not change our view.
3. We are satisfied this failure is unprofessional conduct of a serious nature.
4. The fourth allegation is that Dr Lichter inappropriately transferred Mrs Siriwan from the South Eastern Private Hospital to the Monash Medical Centre

(i) You with Dr Emlyn Williams, decided to transfer Mrs Siriwan to Monash Medical Centre, a decision which was inappropriate, given that Mrs Siriwan's condition was not stable and she was in extremis.

1. Dr Lichter submitted that upon his return to the recovery room at 11:45am, it was his preference at all times to perform a hysterectomy himself at South Eastern as soon as possible. Ultimately, the ambulance did not leave for Monash Medical Centre until 12:55pm.
2. We accept that Dr Williams refused to carry out the anaesthetic and that there was no other anaesthetist available at the hospital. The reality was she needed a hysterectomy if her life was to be saved. The delay that ensued until she was transferred was wholly unacceptable. Sufficient urgency was not displayed by Dr Lichter.
3. We accept Dr White's evidence acknowledging that if an anaesthetist would not assist to perform the hysterectomy and there was no other anaesthetist available, then Dr Lichter had no choice but to transfer Mrs Siriwan.
4. The difficulty in this case was the state Mrs Siriwan was in. She required further aggressive resuscitation prior to her removal. We accepted Dr Simmons' assessment of her condition at 12:10 based on observations of Registered Nurse Catacouzinos that she was unconscious with laboured breathing and very pale with nil peripheral pulses.
5. In Dr Simmons' view :

'This is a description of a patient in extremis who is not stable.' He said that 'It is not appropriate to transport a patient under these circumstances'.[85]

Further, in his view, at the time when transfer of Mrs Siriwan was being considered by Dr Lichter -

'Further resuscitation with blood products and coagulation factors and attending to any surgical causes of ongoing haemorrhage is appropriate. Insertion of an endotracheal tube is indicated. This is to provide high inspired oxygen concentration, maintain adequacy of ventilation with a reduced work of breathing and to protect the airway. Monitoring should be increased to include direct arterial blood pressure measurement via an arterial line; this also provides for ease of blood sampling and for arterial blood gas analysis which is likely to be required at this point.'[86]

1. We agree with the submissions of the Board with respect to the transfer process. They were -

First, it took an inappropriately and indefensibly lengthy time. Sufficient urgency was not displayed by Dr Lichter to accomplish the transfer and too much weight was given to bureaucratic niceties. As was canvassed in question from the Tribunal, Mrs Siriwan could have been transferred almost straightaway to Monash Medical Centre given the degree of emergency that her condition entailed. To assert otherwise, as was implausibly done by Dr Lichter during evidence, should be interpreted as an ex post facto rationalisation to place administrative procedures before a dying patient's welfare.

If Dr Lichter was encountering logistical problems that could not readily be overcome, it was his professional responsibility to reopen the discussion with Dr Williams about doing the hysterectomy onsite and organising for Mrs Siriwan to be transferred to a suitable location with suitable post-operative care facilities immediately afterwards.

It appears that considerations relating to the insured status of Mrs Siriwan intruded upon Dr Lichter's reasoning processes. In the circumstances, and particularly in light of the condition of his patient and the sentiments expressed by her husband, this was unprofessional and seriously so.

Further, during the period of in excess of an hour between the time when Dr Lichter ascertained Mrs Siriwan's condition, inadequate measures to treat the patient of Dr Lichter and Dr Williams were undertaken. Other than the transfusion of four units of blood and someone ordering further blood, no significant treatment appears to have taken place. As Dr Lichter himself conceded[87], he should have turned his mind to the haematological causes of what had been taking place in his absence and ensured that blood products were procured immediately. Given how dire the condition of Mrs Siriwan was, the failure was indefensible.

1. It was clear to Dr Lichter as soon as he returned, that Mrs Siriwan needed a hysterectomy forthwith if her life was to be saved. She was in extremis. In those circumstances, where it was decided to transfer her, the urgency of that process should have been uppermost in Dr Lichter's mind. The delay, and Dr Lichter's involvement with it, canvassing other hospitals, checking insurance etc was wholly unacceptable.
2. Faced with delay, he should have reopened discussions with Dr Williams about performing a hysterectomy and transferring her after that, but failed to do so. Further, he should have ensured during that time that blood products were procured immediately. He failed to do so. The life-endangering outcome of delay for Mrs Siriwan at this stage was reasonably foreseeable and Dr Lichter's inattention to her treatment was seriously unprofessional.
3. We are satisfied this allegation is made out.
4. It is conduct of a lesser standard than is reasonably expected of practitioners by either their peers or members of the public. It was unprofessional conduct of a serious nature.

1. The allegations against Dr Williams are that he :

"(a) failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability.

(i) You were present when Mrs Siriwan was admitted to the recovery room at about 10.25 hours on 31 March 2004. You returned to Mrs Siriwan when called by nursing staff at about 11.10 hours. You ordered ephedrine for maintenance of Mrs Siriwan's blood pressure at about 11.15 hours. The first recorded observation at 10.40 hours in relation to Mrs Siriwan in the recovery room, being systolic blood pressure of 84/37 and heart rate of 110 bpm, were consistent with hypovolemia, which was not adequately addressed by you in that you did not provide Mrs Siriwan with sufficient fluid replacement to reverse the hypovolemia.

(b) failed to appropriately manage Mrs Siriwan's continuing blood loss

(i) In the period between 10.40 hours and 12.20 hours on 31 March 2004, you did not commence aggressive transfusion of blood products for Mrs Siriwan in consideration of her continued blood loss.

(i) In the period between 10.40 hours and 12.20 hours on 31 March 2004, you made no attempt to reverse Mrs Siriwan's coagulopathy, a condition which should have been apparent to you.

(d) failed to appropriately manage Mrs Siriwan's deteriorating condition before and during transfer from the South Eastern Private Hospital to the Monash Medical Centre

(i) In the period between 10.40 hours and 12.20 hours on 31 March 2004, you did not stay with Mrs Siriwan, did not manage her condition by means of aggressive resuscitation, and you did not ensure adequate oxygenation for Mrs Siriwan by insertion of an endotrached tube.

(ii) At about 12.00 hours, you, with Dr Maurice Lichter, decided to transfer Mrs Siriwan to Monash Medical Centre, a decision which was inappropriate, given that Mrs Siriwan's condition was not stable and she was in extremis.

(iii) In the period from 12.55 hours until 13.05 hours, Mrs Siriwan was in transit from the South Eastern Private Hospital to the Monash Medical Centre, during which time she arrested. You, who accompanied Mrs Siriwan in transit, did not commence any measures for basic or advanced life support."

1. Dr Williams gave evidence and was cross-examined. We accept that the events Dr Williams was giving evidence about had occurred almost six years ago and would not be fresh in his mind and that giving evidence and being cross-examined is a stressful experience. He was tentative in his answers and gave us the impression that he sought to answer questions in the best light possible for the situation he finds himself in. We accept that when he initially responded to the Code Blue, his responses were appropriate. What this hearing is about concerns those times when he was more fully involved in her care.
2. The submissions for Dr Williams canvassed the discrepancies between several versions of the post-anaesthetic observation charts and several alterations to them. They were not matters pressed by Dr Williams in the hearing. Whilst it may be these discrepancies were not cleared up in the hearing, the substance of their recording is consistent. We agree with the Board that putting aside the discrepancies, the notes paint a very concerning picture of Mrs Siriwan's condition.
3. The submissions made for Dr Williams also touched on the respective roles and responsibilities of others. The submissions sought to shift responsibility from the anaesthetist to the obstetrician and the hospital. They concern matters to do with, for example, who should have had responsibility for the timely delivery of the required products; who should take responsibility for implementing a treatment plan to reverse the coagulopathy where its exact cause is not known; whose role it should be to be vigilant about the effects of a coagulopathy etc. His submission is that he found himself in a dire predicament because the primary caregivers had made "fatal errors".
4. As there is an overlap between allegations (a) and (b), it is convenient to deal with them together.
5. The first allegation is allegation (a). It is that Dr Williams failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability.

(i) You were present when Mrs Siriwan was admitted to the recovery room at about 10.25 hours on 31 March 2004. You returned to Mrs Siriwan when called by nursing staff at about 11.10 hours. You ordered ephedrine for maintenance of Mrs Siriwan's blood pressure at about 11.15 hours. The first recorded observation at 10.40 hours in relation to Mrs Siriwan in the recovery room, being systolic blood pressure of 84/37 and heart rate of 110 bpm, were consistent with hypovolemia, which was not adequately addressed by you in that you did not provide Mrs Siriwan with sufficient fluid replacement to reverse the hypovolemia.

1. The second allegation is allegation (b). It is that Dr Williams failed to appropriately manage Mrs Siriwan's continuing blood loss

(i) In the period between 10.40 hours and 12.20 hours on 31 March 2004, you did not commence aggressive transfusion of blood products for Mrs Siriwan in consideration of her continued blood loss.

1. If we are satisfied the allegations are made out, we then need to make a finding of whether or not the conduct constitutes unprofessional conduct.
2. The Board's submissions address fluid replacement and her blood loss in two phases. First, during the examination under anaesthetic and then in the recovery room.
3. These two allegations essentially concern whether or not Dr Williams failed to address Mrs Siriwan's blood loss and haemodynamic instability by not providing sufficient fluid replacement and failed to address her continuing blood loss by not commencing aggressive transfusion of blood products.
4. With respect to these allegations, the Board's submissions particularly relied on and referred to the evidence of Dr Simmons. Dr Simmons, it will be recalled, is an anaesthetist specialising in obstetrics and gynaecology. We found him to be an impressive witness, considered and well qualified to give evidence.
5. The Board's submissions, particularly relying on the evidence of Dr Simmons, were as follows :

Dr Simmons gave evidence that in terms of resuscitation of Mrs Siriwan, once airway and breathing were secured, the circulatory problems which she faced because of ongoing haemorrhage were the prime concern. He said that : 'the principles of management would be to gain some estimate of the amount of blood loss relative to what the patient's able to tolerate, and then restore circulating volume, and restore circulating red cell mass, restore coagulation factors and platelets all in the context of trying to have normal haemostasis of body temperature and acid base balance.'[88]

Dr Simmons said that loss of blood is notoriously underestimated and clinicians should be erring on the side of caution.[89] He said that even the loss of 1/3 of the circulating volume of a person's blood would produce 'a very significant insult to the normal body function'.[90]

Dr Simmons said that tachycardia is a 'fairly early sign in pregnant people in terms of hypovolemia [due to] blood loss.'[91] He said that a systolic blood pressure reading of 80 would be 'a very significant indicator that there is ... a significant volume depletion event here ...'[92].

Dr Simmons said that previously fit and healthy young people present a particular problem, because 'their general wellbeing actually is extremely well maintained until they're really very sick ...'[93]

Dr Simmons also said that with ongoing blood loss, the anaesthetist needed to be aware of the potential for the onset of hypothermia and acidosis.[94] He said that the onset of these conditions may compromise 'maintaining blood pressure and adequate perfusion of tissues ...'[95]. He also said that clotting factors are very temperature and PH dependent and may be adversely affected by the onset of hypothermia and acidosis.[96] For this reason, Dr Simmons said that it was important that all fluids which were given to Mrs Siriwan were warmed prior to administration so that they did not exacerbate any hypothermia.[97] He said that he would be critical of a failure on Dr Williams' part to institute a fluid warmer as well as monitoring his patient's temperature, 'insofar as it's standard practice and they are relatively easy to do.'[98]

Dr Simmons said that 'simply haemorrhaging to an extent where there is actually loss of clotting factors of the circulation will ultimately produce a problem of coagulation ... typically the initial response to hypovolemia would be to put in non-red cell containing products, significant blood loss with crystalloid and colloid back to restoring normal blood volume would in itself produce a dilution or coagulation problem or at least be starting to head down that sort of track.'[99]

Dr Simmons said that he would expect a competent anaesthetist to be anticipating and taking steps to address blood loss and loss of clotting factors, even prior to obtaining the results of testing for coagulopathy.[100]

The evidence indicated that crystalloid fluids are relatively inefficient in staying in the circulation : 'they're rapidly lost'[101], whereas colloid solutions tend to 'stay within the circulation and preserve volume over a period of time more effectively.'[102]

Dr Simmons said that 'one litre of crystalloid would have a fairly reasonable instant effect over a period of a few minutes or so; maybe even up to half an hour. But an hour [later] the amount that's actually remaining in the circulation ... may be as low as two or 300 mls ... So the fact that there's been one litre of blood loss at that point in time putting back crystalloid ... a volume of one litre is not a simple arithmetic assessment. It may be transiently OK but it's certainly not going to be OK in the longer term.'[103]

He said that as at 9.15am when Dr Williams saw the patient 'Well certainly it's likely that the blood loss ... is significant and almost certainly more than has been advised to you by the staff, the physiological changes to the extent that there's now hypotension to the extent that a code blue's been called, and the extent of the volume resuscitation at that time is probably still inadequate in the sense that it's catching up'.[104] He said that the clinical signs at 9.15am, namely a blood pressure of 90 systolic and a heart rate of 109, should have been telling the anaesthetist that the patient needs further fluid resuscitation.[105]

Dr Simmons said that a competent anaesthetist should have been aware of the time lag that would be involved in obtaining cross-matched blood and blood products: 'the sooner you start the clock running the better off you are, even if you don't ultimately have to use it at least you know it's available to you'.[106]

Dr Simmons said that he would expect that the anaesthetist and the obstetrician would work together as a team in the operating theatre, 'sharing information and looking at what the situation is, what the effect of the interventions are.' He said he would expect the anaesthetist to inform himself of how much ongoing blood loss there was, even to the extent of physically getting up and having a look at how much blood was on the floor or drapes in the operating theatre.[107] Dr Caldwell gave similar evidence: '[The anaesthetist would] either be asking the obstetrician or he'd pop around and have a look, see how much blood was coming out or in a bucket on the floor.'[108]

Dr Simmons said that he would expect the obstetrician to be communicating relevant matters to the anaesthetist including the amount of blood loss occurring in terms of volume, the rate at which it seems to be continuing, whether the blood is clotting or not clotting,[109], the appearance of the blood,[110] whether he has found any lacerations or injuries to the genital tract and the degree of uterine tone.[111] He said that if the anaesthetist is tied up with the patient such that he cannot make his own observations and the obstetrician is not spontaneously communicating about the matters referred to above, he would expect the anaesthetist to ask questions about those things so that he could stay informed.[112]

In Dr Simmons' opinion, at 9.30am, by reason of her large blood loss, inadequate fluid replacement and the fact that the source of the bleeding had not been identified, with 'no real indication as to how long it's going to be before the [bleeding] has been dealt with',[113] Mrs Siriwan required further aggressive fluid replacement by Dr Williams.[114]

Dr Simmons said that fluid replacement during the EUA appeared to be acceptable, as Mrs Siriwan's systolic blood pressure remained above 100 throughout the procedure.[115] However, he said that where 'a patient [has] suddenly lost two litres, a third of their blood volume and you instantaneously or effectively replaced it appropriately in a short period of time with fluid that did not have clotting factors, there would be a reasonable likelihood, it would be a bit difficult in any given patient to say the exact likelihood, but a reasonable likelihood that that in itself would be starting to produce a coagulation defect in that patient'.[116] He said that in those circumstances, he would expect a competent anaesthetist to identify the possibility that there could be a coagulation problem and anticipate the need for clotting products such as fresh frozen plasma even prior to obtaining the results of testing for a coagulopathy.[117]

He also said that he would expect Dr Williams to be evaluating the loss of red blood cells, not only by sending a sample off for testing, but by use of a Haemacue at the bedside.[118]

Dr Simmons said that as she had just undergone an anaesthetic, Dr Williams retained 'immediate responsibility for the care of the patient, until ... [she was] stable and appropriate to hand over to someone else.'[119] In relation to when it would be acceptable for Dr Williams to leave his patient, he said, 'you would not want to leave the patient if the patient was not able to maintain a clear airway; that they weren't ventilating; they seemed to be having other difficulties in terms of circulatory control or they were unstable. So if the nursing staff were obviously working quite hard to maintain an airway, couldn't obtain normal physiological parameters ... to assure you ... that there was that stability and they were within any acceptable range, then you would expect the anaesthetist to continue to provide immediate care to the patient.'[120]

He said that in such circumstances, he would expect the anaesthetist to stay 'until such time as those things had been addressed, and that could be any period of time ... there needs to be some view as to what the plan of management is going to be ... and you would attempt generally to err on the side of that if there was ... any doubt about stability or ongoing problems that still needed to be dealt with, then you would have a very low threshold for taking the patient back to theatre and undertaking further management options.'[121]

Dr Simmons said that he would not have left this patient.[122]

Dr Simmons stated that it was Dr Williams' responsibility to provide sufficient fluid replacement to reverse the hypovolemia.[123] He said 'With adequate [fluid] replacement, systolic blood pressure could be anticipated to be of the order of at least 95-100mmHg in conjunction with improvement in the reflex tachycardia to below 100 bpm.'[124]

Dr Simmons said that given Mrs Siriwan's presentation and obvious hypovolemia, he would have expected Dr Williams to specifically seek from the transfusion service some information as to when the blood was going to be available.[125] He said that this would enable you 'to plan what the next 30 or 40 minutes is going to look like.'[126]

Dr Simmons said that at 10.40, for Mrs Siriwan 'to be unconscious, requiring jaw support, and airway in situ and tolerating that, that would be uncommon. This is someone who is really taking more than the average patient's time to recover and the heart rate and blood pressure are still consistent with inadequate volume replacement at that point in time.'[127] He said 'Ultimately the anaesthetist caring for the patient who is unstable and has circulatory problems, is in a sense in exactly the same situation as the principals prior to take the patient to theatre. In other words, there is a limit on how much you can continue to just simply resuscitate and attempt to restore normality without considering the ... possibility of other surgical interventions being required.'[128]

'The recovery room record from 1040 to 1150 documents a heart rate consistently greater than 110 beats per minute and indeed for the most part greater than 120bpm. Combined with systolic blood pressure readings, except for two occasions, consistently less than 100mmHg, the picture is consistent with ongoing significant hypovolemia ... There is also a progressive increase in respiratory rate, this being 32 at 1120 and 1125[130] and although the airway was expelled by the patient at around 1140, it had to be reinserted to maintain an adequate oxygen saturation; this together with the other features above is indicative of evolving hypovolemic shock ...'

Dr Simmons said that with the ongoing bleeding that was observed between 10.40am and 11.00 am, the four units of blood that had been ordered may not be adequate.[131] He said that he would probably have arranged for six units of blood to be cross-matched and some clotting factors[132], 'and impart to [the transfusion unit] the need of urgency...'[133] He also said that he would have expected Dr Williams to follow up the results of the blood tests that were sent off from theatre, even if he was busy, in which case, he should have delegated that task to someone else.[134]

In evidence, Dr Simmons said that while fluid management during the EUA might have been reasonable, once Mrs Siriwan was admitted into the recovery room 'the possibility of ongoing significant blood loss was very apparent ... [and] to have those clinical features meant that this is ... an ongoing dynamic situation which now requires further responses'[135] and later in his evidence : 'it's relatively common in my experience to have to continue to re-evaluate, re-examine the patient, and sometimes you have to take the patient back to theatre two or three times ...'[136]. He said that in the sense that Mrs Siriwan's situation did not really change between 10.40am and 11.00am, that 'is now of some concern in terms of increasing time urgency'[137]. He said that in addition to maintaining airway and breathing, Dr Williams at this time ought to have been attending to 'restoration of fluid volume which would be rapidly infused at body temperature, then contact the ... obstetrician.'[138]

In relation to Dr Williams' obligation to keep Dr Lichter informed about his patient, Dr Simmons said that he would have contacted the obstetrician if 15 minutes or so after the surgery he had recognised that there was the likelihood of ongoing blood loss.[139] He said that it is not a minor decision to take a patient back to theatre, '... So it's not unreasonable expectation to progress down this pathway in a series of steps ... so to have a conversation with the obstetrician along the lines of well everything was OK 10, 15, 20 minutes, maybe even an hour ago, whatever it might be. But now we've got a situation where it looks to me like we're still behind in terms of volume, haemoglobin's 79(sic) , I'm considering transfusion, the patient's cold, the patient's barely conscious, there's some difficulty maintaining airway, I would be concerned that we need to be doing more to address the bleeding situation. That's the type of conversation I would have with the obstetrician'[140] He said that he would expect a competent anaesthetist to have a conversation along the same lines[141]: '[an anaesthetist] can't continue to resuscitate ... effectively forever unless there is some attention to those things that can be potentially surgically corrected. So a conversation and discussing the clinical picture of the patient, and expressing concern in the first instance should be a trigger to the obstetrician to accept that there is some issue that maybe potentially needs resolving, to alert them to the fact that some further investigation of the source of the postpartum haemorrhage may be appropriate ...'[142]

Dr White also said that she would have expected that in the situation Dr Williams found himself in with Mrs Siriwan, he would have communicated directly with Dr Lichter :

' ... as things unfolded here, ... she was very hypotensive to the point of being given ... a couple of doses of ephedrine, and if I wasn't there I would kind of think the anaesthetist would ring me and say look, we are not winning here, I am really concerned. I am giving her ephedrine to maintain her blood pressure, I think you're going to have to do something. I would have expected that I would have had some communication that things were not looking good.'[143]

In Dr Simmons' view, the replacement of red cell mass should be guided by specific measurement. Spot estimates of haemoglobin concentration can be made at the bedside with simple portable devices. He said that once the haemoglobin reading of 7.9 became available, he would have wanted to know when the blood was becoming available. 'if it was within a few minutes I would wait for that blood and I would transfuse the patient.'[144] If the blood was not going to be available for 20 minutes, he said that if necessary, uncrossed matched blood can be given, specifically O-negative blood.[145] He said that fluids should not be withheld when a patient is hypovolemic awaiting cross-matched blood. He said that even if the anaesthetist did not know that there was O negative blood available on the ward, he would expect the anaesthetist to ask the staff, and also that knowing there was a Dorevitch laboratory within the hospital ought to have alerted Dr Williams to the possibility of obtaining O negative blood if necessary.[146]

Dr Simmons said that once the cross-matched blood had arrived 'you simply would be pumping this blood in as fast as you can put it in, and that would take ten minutes.'[147]

In Dr Simmons' view, 'it is also likely that on the basis of the volumes required, together with the most conservative estimate of blood loss that the development of a significant coagulation defect could be anticipated during the period in recovery. Administration of blood products, specifically in the form of Fresh Frozen Plasma would be appropriate in this context ... In the context of the description of blood loss from Registered Nurse Catacouzinos at 'point 25' of her statement and the stated estimated blood loss upon arrival at MMC being four litres, it would also have been appropriate to arrange for a platelet transfusion'.[148]

Dr Lichter testified that he expected that Dr Williams would be assertive in following up the blood needs of Mrs Siriwan, for instance endeavouring to secure their arrival promptly if they had not arrived by about 10.30.[149] The obligation of Dr Williams was to make telephone calls and ascertain and address any reason for delay.[150]

It was Dr Williams' responsibility to inspect relevant observation charts himself and make sure that he was fully apprised of any relevant changes to the indicators of Mrs Siriwan's wellbeing, including her respiration, pulse, blood pressure, oxygen saturation, conscious state and any continuing haemorrhaging.[151] Personal inspection of charts would have been (and ordinarily is) a way of addressing any legitimate absences that might interrupt familiarity with a dangerously ill patient's state.[152]

It was also Dr Williams' responsibility himself to initiate communication with the nurses caring for Mrs Siriwan to ascertain any information to which he might otherwise not be privy in relation to her condition.[153]

1. Dr Williams' submissions follow the Board's approach and separately address allegation (b).
2. Dr Williams' submissions which discuss the evidence are as follows :

Having attended upon Mrs Siriwan in the labour ward Dr Williams was aware when she came to the operating theatre at about 0920 hours that she had suffered a severe post-partum haemorrhage. He fully appreciated that having lost a large volume of blood Mrs Siriwan was hypovolemic and in need of fluid replacement.

He responded appropriately upon her arrival in the operating theatre at 0920 hours by immediately inserting a wide-bore intravenous cannula in preparation for giving blood and other fluids to improve her haemodynamic stability. He then took blood for cross-matching and ordered four units of blood for transfusion.[154] He marked the pathology form[155] 'URGENT' and 'PPH BLOOD LOSS +++' to indicate the severity of the patient's haemorrhage and that he required the blood for transfusion as soon as it could be delivered. He was aware that the Dorevitch pathology laboratory was on-site and expected the blood to take 20-30 minutes to arrive.[156] Soon after this he took a blood sample for clotting studies. These actions are all in accordance with Dr Simmons' evidence as set out in paragraph 53 of Counsel assisting the Board's submissions regarding appropriate principles of management (body temperature is discussed later).

Dr Williams was aware that one litre of Hartmanns and one litre of Haemocell (2 x 500ml flasks) had been given intravenously to address the haemorrhage and consequent hypovolemia in the labour ward and he continued to provide intravenous fluids whilst Mrs Siriwan was in theatre while waiting for the blood to arrive. The EUA took approximately three quarters of an hour and in that time Dr Williams infused approximately three litres of crystalloid and one litre of colloid fluids.[157]

Nurse McManus[158] and Dr Lichter[159] both gave evidence that upon placing Mrs Siriwan's legs into the lithotomy position there was a substantial 'gush' of blood, estimated to be around a litre in volume. Dr Williams saw blood in a bottle at the patient's side but was unable to view the bleeding as it occurred, comment on the appearance of the blood, or say how much the loss had been.[160]

This was a significant event because it was noted by Nurse McManus that the blood at this point in time 'was changing ... it was getting lighter in appearance, it wasn't like full blood, it was weakened if you could say that ...'[161] Dr Simmons said this was a 'significant finding' that would alert one to the fact that 'you are now behind in terms of red blood cell replacement ...'[162] Dr Williams was not made aware by either Dr Lichter, who was also viewing the loss as it occurred or Nurse McManus of the amount or change in the blood.

Dr Simmons said he would expect the blood loss in the operating theatre to be communicated by the obstetrician to the anaesthetist and added that if that did not happen the anaesthetist could make an inquiry[163]. Because Dr Williams could see the bottle containing blood he did not make further enquiries, but his position at the head of the patient prevented him from viewing the bleeding as it occurred and so he could not have known about the changing consistency and colour.

Mrs Siriwan's blood loss by the end of the procedure was estimated by observers to be just over two litres, comprising an estimated loss of 1100 mls in labour ward[164] and an approximate one litre gush in the operating theatre.[165] Including the fluids given pre-operatively, the volume of fluid replacement given up to the end of the procedure totalled four litres of crystalloid and two litres of colloid - six litres of fluid in total. This volume (excluding the blood which had been ordered and was expected to arrive shortly) amounts to more than that required in Dr Caldwell's evidence, that you would need four or five litres of fluid plus four or five units of blood to try to catch up.[166] Dr Simmons' evidence was that as the patient's blood pressure was maintained at 100 mmHg systolic throughout the procedure this was 'acceptable' fluid replacement.[167]

In paragraph 57 Counsel Assisting the Board appears to criticise Dr Williams for not warming the patient or intravenous fluids administered in the operating theatre. Dr Simmons said that a temperature of 35 degrees or below (emphasis added) is associated with problems in terms of cardiac function and other issues.[168] Dr Williams' evidence was that Mrs Siriwan's upper body would have been placed under a blanket whilst on the operating table as is usual practice (her legs were in lithotomy position and so could not be covered in the same way) and the Hartmanns fluid given intravenously was taken from a warming box, as is standard procedure in the operating theatre.[169] He did not specifically monitor her temperature as he was expecting the procedure to be brief, and it was.

Once in the recovery unit the patient's temperature was recorded at 35.7 degrees Celsius, whereupon a Bair Hugger air-warming device was applied and the patient's temperature rose to 38 degrees Celsius.[170] It is submitted that there was nothing improper about the management of Mrs Siriwan with regards to warming both her and the intravenous fluids administered to her whilst in the operating theatre. Her temperature did not fall below 35 degrees and so she was not placed at risk of the complications described by Dr Simmons.

At the end of the procedure Dr Williams was advised by Dr Lichter that they needed to remain in the operating theatre to be certain the bleeding had stopped after packing the uterus. Soon thereafter he was told by Dr Lichter that the bleeding had indeed stopped and hence the patient was extubated and taken to the recovery area.[171] Dr Lichter agreed with this sequence of events, 'Oh, I was very happy that I in fact stopped the bleeding. I was very confident'.[172]

Having been told the bleeding had stopped, Dr Williams described his role, 'The patient needed to regain consciousness ... and the blood loss needed to be replaced with a combination of crystalloid, colloid and blood'.[173] It was not unreasonable for Dr Williams to rely on Dr Lichter's assessment of his patient's condition and the efficacy of the uterine packing he had performed for the express purpose of stopping Mrs Siriwan's haemorrhage.

Although frustrated by the delay in the arrival of the blood, Dr Williams believed that because he had marked the request as urgent that it would be delivered as soon as it was available. Dr Williams acknowledged that O negative blood would have been used had he known about it, but he did not enquire about it because, 'I had ordered blood and expected it to be available sooner than it was'.[174] Dr Lichter too was unaware of its availability, despite having worked at South Eastern Private for many years. The fact that no nursing staff suggested its existence despite their concerns for the patient, suggests a systemic failure in the hospital protocol on this issue.

Dr Williams gave about five or six doses of ephedrine to maintain Mrs Siriwan's blood pressure during her stay in the recovery unit.[175] The blood for transfusion finally arrived at 1105 hours and in appreciation of the patient's condition Dr Williams ordered that it be forcibly pumped in as quickly as possible.[176] According to Dr Simmons, this order was entirely appropriate.[177] The nurses in recovery were well aware of this instruction,[178] however they did not manage to infuse the blood at the speed requested. The fifth unit was commenced some time before 1255 hours but the exact time cannot be discerned from the post-operative observation charts or the fluid balance chart.

Had the blood then been made available earlier the resuscitation of Mrs Siriwan might have been more effective. This would have been possible if the cross-matching and request for blood had been organised by Dr Lichter at the time of insertion of the intravenous line at 0840 hours. Dr Lichter admitted that this was an opportune time to do this;[179] Dr Williams' evidence was that it would have been desirable for the blood to have been ordered at 0840 given that bleeding was a problem at that time.[180] Nevertheless, the total volume of fluid infused before departure to Monash medical Centre was six litres of crystalloid, two litres of Haemocell and almost five units of blood.[181] Along with ephedrine for blood pressure support, in the circumstances this amounts to a reasonable level of resuscitation and does not fall below the standard expected of a competent anaesthetist.

Allegation (b): Failed appropriately to manage Mrs Siriwan's continuing blood loss

Dr Williams was not aware that some bleeding had been observed by Nurse McManus from the uterine packing before Mrs Siriwan left theatre.[182] He remained under the impression that the bleeding had been stopped and it was reasonable for him to maintain this belief while no further bleeding was reported to him or Dr Lichter by the nurses caring for Mrs Siriwan. The nursing staff did however observe and record ongoing bleeding but did not tell Dr Williams.[183]

The nurses in the recovery unit did not appear to recognise the significance of the ongoing bleeding, probably because Dr Lichter had not left sufficiently specific post-operative observation orders. His order was for 'RPOA and intensive nursing'.[184] There was no mention of observing for and reporting blood loss or of feeling the level of the uterine fundus, both indicators of the success of the packing in stemming the bleeding. The fact that not one of the many nurses attending Mrs Siriwan felt her uterus indicated a lack of understanding on their part of the nature of her problem (uterine atony and bleeding) or its treatment (the use of a pack to prevent bleeding and the need to assess its effectiveness).

1. We accept that Dr Williams responded appropriately during the examination under anaesthetic, in taking blood for cross-matching, marking it urgent and up to the point of infusing crystalloid and colloid fluids.
2. Dr Williams admits that the sudden loss of blood observed by Dr Lichter and nurse McManus was a significant event. He maintains that he was not made aware of it by either of them, although he himself observed blood in a bottle by the patient's side. He was critical of others not informing him, in circumstances where Dr Simmons points out the importance of an anaesthetist gaining some estimate of blood loss and then taking steps to restore it. Dr Williams failed to initiate any inquiries about the extent of blood loss himself.
3. Although Dr Lichter may have assured Dr Williams he had in fact stopped the bleeding, after the examination under anaesthetic, the most important indicator of Mrs Siriwan's state of health were her vital signs. It is the anaesthetist's role here, to monitor these. In this case, we accept those signs indicated an ongoing haemodynamic instability, thus a matter Dr Williams should have been acutely aware of. It ought to have been evident to Dr Williams that Mrs Siriwan was continuing to bleed and should have prompted him to contact Dr Lichter. He was the medical practitioner responsible at that point in time. He should have paid greater attention to ensure that Mrs Siriwan was stable and recovering. Where this was clearly not the case, he should have personally assessed her condition with regard to blood pressure, pulse rate and responsiveness and monitored her and taken steps to treat her ongoing instability, rather than solely relying on Dr Lichter's communication to him.
4. Whilst Dr Williams had ordered blood, it was slow to arrive. He did nothing himself to chase it up. He made no inquiries about the availability of O negative blood which he admits could have been used. Nor did he ensure that when the fluids arrived, they were given as quickly as possible. As the anaesthetist, it was Dr Williams' responsibility as the doctor in charge of Mrs Siriwan's care for these matters, to manage those matters. Instead he left it to others and sought to blame them.
5. We agree with the Board and do not accept Dr Williams' submissions that the total volume of fluid infused before departure, with the ephedrine for blood pressure support, amounts to a reasonable level of resuscitation and does not fall below the standard expected of a competent anaesthetist. This flies in the face of Mrs Siriwan's vital signs recorded, which clearly indicated she was in urgent need of additional blood, blood products and fluids to support her circulating volume.
6. We accepted Dr Simmons' evidence that a competent anaesthetist would anticipate and address a patient's blood loss and loss of clotting factors, even before getting pathology results. In his opinion, one litre of crystalloid was not enough. His evidence was that at 9:15am her signs of blood pressure of 90 systolic and a heart rate of 109 indicates that the patient needed further fluid resuscitation. Further, at 9:30am, by reason of her large blood loss, inadequate fluid replacement and the fact that the source of the bleeding had not been identified with no real indication as to how long it was going to be before the bleeding was dealt with, indicated, according to Dr Simmons' evidence which we accepted, that she required further aggressive fluid replacement by Dr Williams.
7. We accepted his evidence that a competent anaesthetist assessing her situation, would identify the possibility that there could be a coagulation problem and anticipate the need for clotting products such as fresh frozen plasma even prior to obtaining the results of testing for a coagulation, and even evaluating the loss of red blood cells using a Haemacue at the bedside.
8. Dr Williams failed to assess and/or adequately address Mrs Siriwan's blood loss and haemodynamic instability and failed to appropriately manage her continuing blood loss. We are satisfied allegations (a) and (b) are made out. His failure in these areas, represents such a significant departure from what would be regarded as reasonable conduct by his professional peers of good repute, that it constitutes unprofessional conduct of a serious nature.

9. Allegation (c) is that Dr Williams failed to address Mrs Siriwan's coagulopathy.

In the period between 10.40 hours and 12.20 hours on 31 March 2004, you made no attempt to reverse Mrs Siriwan's coagulopathy, a condition which should have been apparent to you.

1. The Board submitted, relying on Dr White's evidence, that because of the very large blood loss that had occurred, it was likely Mrs Siriwan would require a post-operative blood transfusion, regardless of the success of the examination under anaesthetic.
2. The Board relied on the expert evidence of Dr Simmons to submit that it was clear it was likely that a coagulopathy would develop, just by reason of the large amounts of blood lost and the dilution of the clotting factors caused by replacement of volume with fluid which did not contain clotting factors.
3. The Board further submitted that :

During the course of the EUA, Dr Williams became aware that Dr Lichter was concerned that a coagulopathy might be developing. The nurses description of the physical appearance of the expelled blood during the procedure was consistent with coagulopathy. Dr Williams filled in the requests for pathology concerning the urgent provision of blood and the clotting studies. Dr Simmons said that he would expect a competent anaesthetist to be anticipating and taking steps to address blood loss and loss of clotting factors, even prior to obtaining the results of testing for a coagulopathy.[185]

It is clear that in the early stages of her care for her, Dr Williams did not anticipate the need to order clotting factors. Indeed, even when the existence of a coagulopathy became apparent, at no stage did he order any clotting factors for Mrs Siriwan. In the circumstances, this failure amounted to unprofessional conduct. By reason of the grave consequences which this failure could have had for his patient, the conduct is serious in nature.

1. About this allegation, Dr Williams made the following submissions :

Dr Williams did consider the issue of a coagulopathy developing, but by the time he diagnosed it, it was too late to organise appropriate blood products for treating to commence at South Eastern Private Hospital. Significantly, a lack of communication between Dr Lichter and others delayed Dr Williams' level of concern about an evolving coagulopathy.

It is submitted that had Dr Williams been told earlier of the changing consistency and colour of the blood observed to gush from the patient in the operating theatre (discussed above ...) he would have been alerted earlier to the possibility of a coagulopathy developing. Dr Lichter however, was fully cognisant of the possibility: '... by the time she was put into stirrups and there was extra bleeding ... at that time the amount of blood loss would suggest that a coagulopathy was certainly a possibility anyway.[186]

In light of his concern, Dr Lichter contacted Dr Levin, the haematologist, whilst still in the operating theatre. Dr Williams was not privy to the discussion[187] and Dr Lichter agreed that he did not provide any further information to Dr Williams regarding his suspicions or observations,[188] other than to request that blood be taken for clotting studies. Dr Williams took the appropriate sample for testing, but the specific tests for the clotting studies were telephoned to the laboratory by Dr Levin at 1027 hours and 1039 hours[189] after the procedure had been completed, so Dr Williams was not alerted to specifically which tests were being conducted.

Dr Levin said the patient's condition was not fully communicated to him by Dr Lichter and had he known the extent of blood loss and the ongoing bleeding, he would have suggested that clotting factors be given prior to the knowledge of any clotting test results.[190] Having sought an expert haematologist's advice, Dr Lichter failed to communicate to Dr Williams the information necessary for him to provide the appropriate treatment.

Having formed the belief that the bleeding had stopped, Dr Williams concluded that a coagulopathy was not a likely complication.[191] He also knew that Dr Lichter had spoken to the haematologist and if a problem was detected he believed Dr Levin would contact Dr Lichter as a follow-up to their earlier conversation or that Dr Lichter himself would follow-up the test results. In the event of a disorder, communication to Dr Williams would be straightforward. Dr Simmons' opinion was that he believed it was appropriate for the obstetrician to communicate any plan of management to the anaesthetist, '... certainly having sought out a haematologist which was of interest to everyone in the room[192].

Dr Levin did not notify their treating doctor when the laboratory staff at South Eastern Private Hospital spoke to him about their initial observation that the blood would not clot at around 1100 hours[193]. Dr Lichter did not follow up the test results and Dr Levin only communicated them to the hospital at some time after midday[194] and even then he did not communicate the vastly abnormal results directly to either Drs Williams or Lichter. Nurse Nacey's evidence was that she took the test results by speaking to 'someone from pathology ... the patient had been placed in the ambulance by then ...[195]. She passed the results on to Dr Lichter but Dr Williams did not become aware of them until he was at Monash Medical Centre.[196]

When Dr Williams was alerted to the fact that Mrs Siriwan was continuing to bleed at approximately 1130 hours he came to the realisation that she had probably developed a coagulopathy. He immediately told Dr Lichter (Dr Lichter places the conversation at 1145 hours) that a hysterectomy at South Eastern Private Hospital was not the best option, but that she should be transferred to a facility with an intensive care unit[197], an opinion that was reasonable in Dr Simmons' view[198].

Knowing that the hospital had called a MICA ambulance, he reasonably believed that Mrs Siriwan's transfer was imminent and by the time the necessary blood products would be available to address her coagulopathy, the transfer would have taken place[199]. Further, Dr Williams believed that if Mrs Siriwan was transferred to a major hospital the blood products required would be available on-site.

Dr Levin said the products would take at least an hour to be packaged, transported and thawed for infusion;[200]Dr Williams held a reasonable belief that the transfer would occur within less than this time. The only reason this did not occur was because of Dr Lichter's indecisiveness which caused a delay of more than an hour between the decision to transfer and the ambulance leaving South Eastern Private Hospital ...

1. Whilst it may be that Dr Williams did consider a developing coagulopathy, by the time he diagnosed it, he considered it to be too late to organise the appropriate blood products.
2. If Dr Williams had considered a developing coagulopathy, as he says, and which Dr Simmons suggests any competent anaesthetist would have, and given all the signs, should have, where Dr Williams' conduct falls short, is his lack of early and appropriate response to the possibility. As an anaesthetist he was or ought to have been aware that the units of blood which he had ordered would not have replaced her lost clotting factors. We agree with the Board's submissions that it ought to have been obvious to him as an experienced anaesthetist that he needed to plan for and treat a possible coagulopathy rather than wait for a definitive "diagnosis" to be made.
3. We do not accept that Dr Williams can excuse his behaviour by blaming others for not communicating with him, whether it be about the amount of loss of blood or its colour and texture. We accepted Dr Simmons' evidence to the effect that an anaesthetist should satisfy himself or herself about those matters. In any event, Dr Williams knew a sample of blood had been sent for clotting testing purposes. His conduct falls so far short of what would reasonably be expected by his peers such as to constitute unprofessional conduct of a serious nature.
4. We are satisfied that his failure to make any attempt to reverse her coagulopathy is unprofessional conduct of a serious nature.
5. The final allegation against Dr Williams is that he failed to appropriately manage Mrs Siriwan's deteriorating condition before and during transfer from the South Eastern Private Hospital to the Monash Medical Centre. The particulars are in 3 parts as follows :

(i) In the period between 10.40 hours and 12.20 hours on 31 March 2004 (sic), you did not stay with Mrs Siriwan, did not manage her condition by means of aggressive resuscitation, and you did not ensure adequate oxygenation for Mrs Siriwan by insertion of an endotrached tube.

(ii) At about 12.00 hours you, with Dr Maurice Lichter, decided to transfer Mrs Siriwan to Monash Medical Centre, a decision which was inappropriate, given that Mrs Siriwan's condition was not stable and she was in extremis.

(iii) In the period from 12.55 hours until 13.05 hours, Mrs Siriwan was in transit from the South Eastern Private Hospital to the Monash Medical Centre, during which time she arrested. You, who accompanied Mrs Siriwan in transit, did not commence any measures for basic or advanced life support.

1. Dr Williams initially remained with Mrs Siriwan in the recovery unit for about 20 minutes. Whilst he was contactable at all times, he actually left the recovery room and went to the tea room. The evidence of nursing staff, which we accepted, was that they did have to go out to the tea room and call him back in. He administered ephedrine to increase her blood pressure, he says, may be five or six times before she was finally placed in the ambulance. He was present when the first unit of blood was started. After the blood transfusion commenced, he responded to a request to provide an epidural to another patient from about 11:10am to 11:30am.
2. He maintains that he did all that was reasonably necessary to support her airway prior to her transfer. In particular, he submits that -

Mrs Siriwan was receiving oxygen via a Hudson face mask at all times whilst in the recovery unit. Dr Williams did not insert an endotracheal tube because it was his clinical judgment that it was not necessary; he knew that if required it would take about 30 seconds to insert.[201] Her oxygen saturations were consistently acceptable at 97%-99%[202] and only dipped briefly when she expelled her Guedel airway which was quickly reinserted.[203]

1. Mrs Siriwan continued to breathe spontaneously until she suffered a cardiac arrest in the ambulance. Dr Williams pointed out that her problem was not her airway; it was her continued blood loss that led to an adequate circulating blood volume to oxygenate her tissues.[204]
2. The reality is that Dr Williams left his patient in the recovery room when he ought not to have left at all because Mrs Siriwan was not stable. At no time did she achieve stability when she was in the recovery unit and had Dr Williams paid any sufficient attention to Mrs Siriwan during this time, this would have been obvious to him.
3. Dr Williams contends that his failure to insert an endotracheal tube was legitimate. This contention is in stark contrast to the evidence of Dr Simmons set out at page 6 of his report and given during the hearing :

In preparation for transferring a patient I would intubate them and put them on a sort of mechanical ventilation device ... because it protects the airway and it ensures adequate ventilation and oxygenation in a transport environment.[205]

1. Whilst Dr Williams had said he thought he contacted Dr Lichter at about 11:30am, when he became aware of bleeding in Mrs Siriwan, he agreed when it was put to him that Dr Lichter might have rung him. Dr Lichter denied being contacted by Dr Williams at any time.
2. Given Dr Williams' prevarication on this point, we preferred Dr Lichter's evidence that he was never contacted. This failure was serious. Given her very worrying vital signs, he ought to have contacted Dr Lichter, as early as 10:40am and certainly by 11:00am as the Board contended.
3. In making this finding, we note Dr Lichter's evidence and Dr Caldwell's evidence. Dr Lichter said that every one of the entries on the post-anaesthetic record should have resulted in a communication with Dr Lichter.[206] Dr Caldwell said that given Mrs Siriwan's vital signs after 10:40am : "If I hadn't been there and the anaesthetist had seen this I would expect the anaesthetist to call me"[207].
4. Further, we accepted Dr Simmons' evidence that Dr Williams' failure to contact Dr Lichter in respect of her ongoing bleeding was a departure from accepted standards.[208]
5. We are satisfied that between 10:40 and 12:20 Dr Williams did not stay with Mrs Siriwan and manage her condition by means of aggressive resuscitation, nor did he ensure adequate oxygenation.
6. A decision was made at about 12:00 noon to transfer Mrs Siriwan. It was inappropriate, given that her condition was not stable and she was in extremis. Dr Williams maintains that he suggested a transfer at 11:30am. We do not accept this evidence. The weight of the evidence suggests that his first contact with Dr Lichter was when Dr Lichter returned, which was approximately 11:45am.
7. We have already found that Dr Williams refused to carry out an anaesthetic upon Dr Lichter's return, when at that point it was Dr Lichter's preference to perform a hysterectomy. As we have referred to earlier, the difficulty at that point in time was the state Mrs Siriwan was in. From his own evidence, it appears that Dr Williams did not fully appreciate as he should have, given her vital signs, her parlous state. He opined in the hearing that if Dr Lichter had "said to me that the patient would die unless she had a hysterectomy then I would have agreed".[209] Given his specialist training, his own observations should have informed him of her very serious condition.
8. Dr Williams seemed to excuse himself from any responsibility for the decision, seeing it all as Dr Lichter's role, and excusing himself from any involvement. We do not agree. Excusing himself was inappropriate and constitutes unprofessional conduct of a serious nature.
9. Dr Williams conceded that he provided Mrs Siriwan with no clinical care to speak of in the period after Dr Lichter arrived, despite realising that by reason of her significant blood loss, Mrs Siriwan's life was "in great danger".[210] In all the circumstances, this conduct we found difficult to understand. He gave us the impression that once the decision to transfer Mrs Siriwan had been made, he simply washed his hands of any responsibility for her care. His conduct was inexcusable. While the transfer was being arranged, it was the principal responsibility of Dr Williams to look after her treatment and to ensure that she was as well readied for the trip as could reasonably be arranged. He did not order further blood, or liaise with the haematologist, did not expedite the transfusion, order further blood products or re-engage with the decision to transfer her. Dr Williams' lack of any attention to her treatment during this period was seriously unprofessional.
10. The decision that Dr Williams was to accompany Mrs Siriwan in the ambulance was made just before its departure. He agrees that by the time the transfer was underway, her condition was "terrible".
11. The allegation is that while in transit, Dr Williams did not commence any measures for basic or advanced life support.
12. Dr Williams could not recall whether Mrs Siriwan had any "airway assistance" inserted before she entered the ambulance . It was clear however that he did not intubate her.
13. He declined the presence of a trained ambulance paramedic in the back with him. In making sure that there was adequate fluid taken in the ambulance, the evidence is clear that all Dr Williams did was observe that at the commencement of the transfer, there was a unit of blood being transfused. He made no attempt to ascertain whether there was any additional blood available, despite knowing it had been ordered[211], nor had he taken any steps to ascertain the availability of O negative blood. He took neither crystalloid nor colloid fluids with him in the ambulance. He was unaware that an esky had been put in the back of the ambulance which contained 4 units of cross-matched blood for use in resuscitating Mrs Siriwan.
14. Dr Simmons gave evidence about what he would have done if he were going to transport her. He would have intubated her and put her on some sort of mechanical ventilation device.[212] He also said that because monitoring can be difficult in an ambulance, he would have at least attempted to put an arterial line in[213] and made sure that there was adequate fluid "and it would be the blood that's available, so take the red cell volume and make sure that I can rapidly infuse that as needed during transport".[214] He also said that he would take some crystalloid and some colloid fluid with him "so several litres of fluid".[215]
15. The evidence is also clear, and we rely on Ms Bobetic's evidence, that when Mrs Siriwan went into cardiac arrest, Dr Williams did not begin cardiac compressions because she was hypervolemic and/or under-transfused. In his opinion, it would have been futile. He even recalled Ms Bobetic's surprise at his inaction.
16. Dr Simmons was critical of Dr Williams for not attempting CPR in the ambulance. His evidence was that Dr Williams should have provided cardiopulmonary resuscitation -

Effectively you've got a patient for whom a decision has been made to transfer to another facility for definitive intervention, you're in an appropriate transport vehicle, you've got an assistant, it's a short journey, there's absolutely nothing to be lost by cardiopulmonary resuscitation.[216]

He pointed out that even after 10 minutes of no resuscitation, the team at Monash were able to get some sort of rhythm.[217] He described Dr Williams' failure in this regard as a significant departure from accepted standards.[218]

1. We accept Dr Simmons' opinion and are satisfied Dr Williams' failure to attempt resuscitation for Mrs Siriwan en route amounts to unprofessional conduct of a serious nature. This failure was indefensible. It reduced the chances of her surviving the trip and subsequent operation. Why it is serious is that his conduct amounted to an abrogation of his responsibilities as the professional entrusted with endeavouring to keep Mrs Siriwan alive during the 8-9 minute trip.

1. With respect to Dr Lichter, having considered all the submissions made, we find that with respect to each of the allegations made by the Board in relation to his professional conduct, Dr Lichter has engaged in unprofessional conduct of a serious nature.
2. With respect to Dr Williams, having considered all the submissions made, we find that with respect to each of the allegations made by the Board in relation to his professional conduct, Dr Williams has engaged in unprofessional conduct of a serious nature.
3. Given these findings, it remains for the Tribunal to consider what orders should be made under s 45A(2) of the Medical Practice Act. The parties still need to be heard in relation to those matters. For these reasons the proceeding is listed for a Directions Hearing.

[1] S 169 of the HPR Act operates so that conduct which occurred before the commencement of the HPR Act can only be the subject of findings and determinations under the MP Act.

[2] See D Marsden and A Henry, 'Postpartum Haemorrhage: When the Oxytocics fail' (2006) 8(4) O&G 30: Exhibit C

[3] Statement of Catherine Joustra, Exhibit W, at p 332

[4] Statement of Maureen Nacey, Exhibit Z, at p344.

[5] Evidence of Dr Lichter, Transcript, at p 841; 931

[6] Statement of Nurse McManus, Exhibit Y, at p392

[7] Evidence of Dr Williams, Transcript at p 681-682

[8] Evidence of Dr Williams, transcript at p 680

[9] Evidence of Dr Williams, Transcript at p 680

[10] Evidence of Dr Lichter, Transcript at p944

[11] See eg D Danso and PW Reginald, 'Internal Uterine Tamponade', Exhibit 1

[12] Statement of Dr White, 29 March 2005, Exhibit U, at p105; transcript at p 32

[13] Evidence of Dr Lichter, Transcript, at p867-868

[15] Evidence of Dr White, Transcript, at p32

[16] Operation Notes, Exhibit V, TB 211

[17] Evidence of Dr Lichter, Transcript, at p842

[18] Evidence of MacManus, Transcript at p97

[20] Evidence of Dr Caldwell, Transcript at p 557

[21] Evidence of Dr Lichter, Transcript at p 875

[22] Evidence of Dr Lichter, Transcript at p 871

[23] Evidence of Dr Lichter, Transcript at p 875. See also p851

[24] Evidence of Dr Lichter, Transcript at p 872

[25] Evidence of Dr Lichter, Transcript at p 877

[26] Evidence of Dr Lichter, Transcript at p 998

[27] Evidence of Dr Lichter, transcript at p 1004

[28] Evidence of Dr Lichter, transcript at p1009

[29] Evidence of Dr Lichter, Transcript at p880

[30] Evidence of Dr Lichter, Transcript at p854

[31] Evidence of Dr Lichter, Transcript at p880

[35] See Evidence of Dr Williams, Transcript, at p760

[36] See Evidence of Dr Williams, Transcript, at p761

[37] Evidence of Dr Williams, Transcript at p766

[38] Evidence of Dr Williams, Transcript at p760

[39] Evidence of Dr Williams, Transcript at p767

[40] Evidence of Dr Williams, Transcript at p 768-769, 778

[41] Health Care Complaints Commission v Litchfield [1997] NSWSC 297; (1997) 41 NSWLR 630 at 638

[42] Pillai v Messiter (No 2) (1989) 16 NSWLR 197 at 200

[43] [2004] VCAT 1044 at [33]

[44] [2005] VCAT 1058 at [7]

[45] Dr Williams' evidence is consistent with Dr Lichter's assertion that at 10.40 hours Dr Williams advised him that the arrival of the blood was imminent. See Dr Williams' evidence at T720 & 728 in particular. See also Williams T680, T693, t714.

[46] An explanation for Dr Levin's failure to contact either Dr Williams or Lichter may be that he was under a misapprehension that a staff member at SEPH laboratory had rung Dr Williams and advised him of the coagulopathy results [Levin T221] a communication which Dr Williams denies occurred.

[47] Evidence of Dr White, transcript at p57

[48] Evidence of Dr White, Transcript p22-23

[49] Evidence of Dr White, Transcript p29-30

[50] Evidence of Dr Caldwell, Transcript at p558

[51] Evidence of Dr Caldwell, Transcript at p572

[52] Evidence of Dr Caldwell, Transcript at p572

[53] Whose evidence must be qualified by her admission that she have never packed a uterus before.

[54] Although Dr Lichter gave evidence that he may possibly have been in the Recovery Room at the time the blood arrived and was put up - which if accurate would place him with the patient up to around 11.05 am - the balance of the evidence demonstrates that this is unlikely to be correct : See the evidence of Nurse Southern CB326; Nurse Nacey T84 & T123; Williams T797

[55] D Danso and PW Reginald, 'Internal Uterine Tamponade', Exhibit 1, at p266

[56] D Danso and PW Reginald, 'Internal Uterine Tamponade', Exhibit 1, at p266

[57] D Danso and PW Reginald, 'Internal Uterine Tamponade', Exhibit 1, at p266

[58] Evidence of Dr White, Transcript, at p35-36, 44

[59] Evidence of Dr White Transcript, at p32

[60] Evidence of Dr White, Transcript, at p43

[61] Evidence of Dr White, Transcript at p34

[62] Evidence of Dr White, Transcript at 43 and also at p13 on 23 October 2009

[63] Evidence of Dr Caldwell, Transcript at p572

[64] Evidence of Dr White, Transcript at p 37; Dr White made similar observations at Transcript p30 on 23 October 2009

[65] Evidence of Dr White, transcript at p30 on 23 October 2009

[66] Evidence of Dr Caldwell, Transcript at p573

[67] Evidence of Dr Caldwell, Transcript at p573

1. [68] In addition it should be noted that prior to Dr Lichter leaving the Recovery Room he had observed Mrs Siriwan's uterus to be tight and that she was not bleeding [T950] and that upon his return to the Recovery Room at around 11.45am he also found - despite Mrs Siriwan's parlous state and that she had obviously been bleeding - the uterus to be tight [Lichter T854] indicating that monitoring of the fundus height prior to then would not have yielded any meaningful observations which indicated bleeding. [Tribunal's note: Dr Lichter was confused on this point. The fundus may have remained tight as it was filling with blood, the important point to note was whether or not it was increasing in height indicating ongoing bleeding].

[69] Evidence of Dr White, Transcript, at p33-34

[70] Evidence of Dr White, Transcript, at p44

[71] Evidence of Dr White, Transcript, at 74

[72] Evidence of Dr Caldwell, Transcript at p568-571

[73] Evidence of Dr Caldwell, Transcript at 568-569

1. [74] It is further submitted that Mr Caldwell ultimately conceded in cross examination by Counsel for Dr Lichter and when re-examined by Counsel assisting the Board that packing was a reasonable alternative to have used in the circumstances of this case [Caldwell T633, T658].

[75] Evidence of Dr White, Transcript, at p40

[76] Evidence of Dr White, Transcript, at p35

[77] Evidence of Dr Caldwell, Transcript, at p 567

[78] See statement of Barbara MacManus Exhibit Y

[79] Evidence of Barbara MacManus at p95

[80] Evidence of Dr Caldwell, Transcript at p 562; Evidence of Dr Simmons, Transcript at p 430

[81] Evidence of Dr White, Transcript at p30

[82] Evidence of Dr White, Transcript at p74

[83] Evidence of Dr White, Transcript, at p51

[84] Evidence of Dr White, Transcript, at p51-52

[86] Report of Dr Simmons, Exhibit BB at p6

[87] Evidence of Dr Lichter, Transcript, at p953

[88] Evidence of Dr Simmons, Transcript, at p405-406

[89] Evidence of Dr Simmons, Transcript, at p407

[90] Evidence of Dr Simmons, Transcript, at p407

[91] Evidence of Dr Simmons, Transcript at p408

[92] Evidence of Dr Simmons, Transcript, at p416

[93] Evidence of Dr Simmons, Transcript, at p410

[94] Evidence of Dr Simmons, Transcript, at p406

[95] Evidence of Dr Simmons, Transcript, at p411

[96] Evidence of Dr Simmons, Transcript, at p411

[97] Evidence of Dr Simmons, Transcript, at p406

[98] Evidence of Dr Simmons, Transcript, at p451

[99] Evidence of Dr Simmons, Transcript, at p412

[100] Evidence of Dr Simmons, Transcript, at p413-14

[101] Evidence of Dr Simmons, Transcript, at p415

[102] Evidence of Dr Simmons, Transcript, at p415

[103] Evidence of Dr Simmons, Transcript, at p 416; Evidence of Dr Caldwell, transcript at p556-557

[104] Evidence of Dr Simmons, Transcript, at p418

[105] Evidence of Dr Simmons, Transcript at 419-419

[106] Evidence of Dr Simmons, Transcript, at p421

[107] Evidence of Dr Simmons, Transcript, at p423-424

[108] Evidence of Dr Caldwell, Transcript, at p558

[109] Evidence of Dr Simmons, Transcript, at p425

[110] Evidence of Dr Simmons, Transcript, at p431

[111] Evidence of Dr Simmons, Transcript, at p425

[112] Evidence of Dr Simmons, Transcript, at p426

[113] Evidence of Dr Simmons, Transcript, at p426

[114] Evidence of Dr Simmons, Transcript, at p427

[115] Evidence of Dr Simmons, Transcript, at p427

[116] Evidence of Dr Simmons, Transcript, at p413

[117] Evidence of Dr Simmons, Transcript, at p413-414

[118] Evidence of Dr Simmons, Transcript, at p427-428

[119] Evidence of Dr Simmons, Transcript, at p438

[120] Evidence of Dr Simmons, Transcript, at p438-439

[121] Evidence of Dr Simmons, Transcript, at p439

[122] Evidence of Dr Simmons, Transcript, at p454

[123] Report of Dr Simmons, Exhibit BB

[124] Report of Dr Simmons, Exhibit BB

[125] Evidence of Dr Simmons, Transcript, at p437

[126] Evidence of Dr Simmons, Transcript, at p437

[127] Evidence of Dr Simmons, Transcript, at p441

[128] Evidence of Dr Simmons, Transcript, at p439

[129] Report of Dr Simmons, Exhibit BB

[131] Evidence of Dr Simmons, Transcript at p454

[132] Evidence of Dr Simmons, Transcript, at p456-458

[133] Evidence of Dr Simmons, Transcript, at p456

[134] Evidence of Dr Simmons, Transcript, at p459

[135] Evidence of Dr Simmons, Transcript, at p434

[136] Evidence of Dr Simmons, Transcript, at p446-447

[137] Evidence of Dr Simmons, Transcript, at p452

[138] Evidence of Dr Simmons, Transcript, at p452

[139] Evidence of Dr Simmons, Transcript, at p444

[140] Evidence of Dr Simmons, Transcript at p446-447

[141] Evidence of Dr Simmons, Transcript at p447

[142] Evidence of Dr Simmons, Transcript, at p445

[143] Evidence of Dr White, Transcript, at p46

[144] Evidence of Dr Simmons, Transcript, at p443

[145] Evidence of Dr Simmons, Transcript, at p432 and 443

[146] Evidence of Dr Simmons, Transcript, at p443-444

[147] Evidence of Dr Simmons, Transcript, at p460

[148] Report of Dr Simmons, Ex BB at p5

[149] Evidence of Dr Lichter, Transcript, at p884

[150] Evidence of Dr Lichter, Transcript, at p886

[157] Fluid balance chart, Exhibit CC, page 206 TB.

[164] Statement of Nurse Hayes, TB p 365

[170] Exhibit K, handwritten notes following statement of Fran Catacouzinos, TB p 356

[178] Exhibit K, statement of Nurse Fran Catacouzinos, TB p351, paragraph 17

[183] Exhibit L, Post-operative charts, TB pp354-355

[189] Exhibit Q, statement of Dr Mark Levin, TB p 329

[202] Exhibit L, Recovery Notes, TB p354, 355

[203] Exhibit K, Statement of Fran Catacouzinos, TB351 para 17; T146; T777-778

[206] Evidence of Dr Caldwell, Transcript at p576-577

[207] Evidence of Dr Caldwell, Transcript at p576-577

[208] Evidence of Dr Simmons. Transcript at p487

[209] Evidence of Dr Williams, Transcript at p694

[210] Evidence of Dr Williams, Transcript at p 737

[211] Evidence of Dr Williams, Transcript at p691

[212] Evidence of Dr Simmons, Transcript at p480

[213] Evidence of Dr Simmons, Transcript at p480

[214] Evidence of Dr Simmons, Transcript at p481

[215] Evidence of Dr Simmons, Transcript at p481

[216] Evidence of Dr Simmons, Transcript, at p485

[217] Evidence of Dr Simmons, Transcript at p486

[218] Evidence of Dr Simmons, Transcript at p488