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Not good form - System let grandmother slip through the cracks

Jacqueline Levers ? missing paperwork meant she received no warning that cancer had reappeared.
Jacqueline Levers ? missing paperwork meant she received no warning that cancer had reappeared.

By BELINDA SCOTT

TO err is human, and Jacqueline Levers would certainly have forgiven one mistake. But Jacqueline Levers was the victim of at least three mistakes in the health system and she had no chance to forgive those who made them, because a few months later, she was dead. The 67-year-old Coffs Harbour mother and grandmother died on the last day of the old year, on December 31, 2003. Six months earlier, she had been the belle of the dance floor. Described by her daughters as a strong, vibrant person and their best friend as well as a wonderful mother to her five children, the youngest of whom is still in his 20s, Mrs Levers had many friends and was enjoying life to the full. A good dancer, the highlight of Mrs Levers' week was the Sunday night dance, where she was keen to be the first to take the dance floor with her partner. Although she had had breast cancer seven years earlier, she had just had a check-up and received an all-clear report when she became ill and was admitted to the Coffs Harbour Health Campus for a gall bladder operation in June last year. The removal of her gall bladder, carried out using keyhole surgery, went well and Mrs Levers was home within a few days. Nobody noticed that mistakes had been made that were to have devastating consequences. The duty surgeon listed on Mrs Levers' admittance form when she entered the emergency department was not the surgeon who operated on her, but the name was never changed on the form. And no discharge report was done when she left the hospital, apparently because of an annual changeover of staff. Because of the first error, the histopathology report on Jacqueline Levers, which showed the presence of cancer cells in her gall bladder, was sent to a surgeon who had never seen Mrs Levers and who apparently put the report aside. Because there was no discharge report, the absence of the pathology report was not noticed and no recommendations for further treatment were sent to Mrs Levers' GP. The operating surgeon never received the report he should have been expecting and did not notice the report's absence when Mrs Levers made her post-operative visit. Although her GP apparently recorded its absence in her case notes, the report was never followed up. Mrs Levers' daughter, Janice Riddel, said her mother felt something was wrong when she made her post-operative visits, because she had told her surgeon she was worried about lumps on her scar, but he had reassured her these were simply scar tissue. Four months later Jacqueline Levers became very ill. Within weeks, she was diagnosed with liver cancer and within months she was dead. She died at home, surrounded by her loving family, but her death left some unanswered questions. Her daughters, Janice Riddel and Karen Beavis, spent months trying to find answers to their questions, but the answers did not reassure them. "We decided to go public because the health system is in strife and mistakes are being made,' Janice Riddel said. "We have a first-class country . . . and Australia deserves a first-class health system. "We need to send a very strong message to our politicians that health . . . needs to be looked at very seriously. "By speaking out, hopefully we may be able to prevent other families going through the nightmare we have been through this past nine months." Mrs Riddel and Mrs Beavis said they did not have a problem with Health Campus staff and their mother had always received excellent care from the nursing staff while she had been in the hospital. They have also been impressed with the hospital's willingness to talk to them, to investigate the case, and put remedial measures in place.



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