DRUG-ABUSING PUBLIC HOSPITAL DOCTOR'S MISBEHAVIOUR REPEATEDLY IGNORED. FINALLY HE KILLS A PATIENT BY NEGLIGENCE

A coroner has found no evidence that an Adelaide doctor who smoked 10 cones of cannabis a day was to blame for the death of a patient, even though he could not remember treating her. Wayne Chivell concluded that Stuart Mauro's treatment of Ruth Sorenson, 69, was "seriously inadequate" and a gross departure from a reasonable standard of care. But he found no evidence that the ability of the doctor, who was also caught stealing valium, was impaired.

Dr Mauro told his psychiatrist he had a 10-cones-a-day cannabis habit and was taking anti-depressants and valium at the time he treated Sorenson at the emergency department of the Queen Elizabeth Hospital in Adelaide in July 2002. The inquest heard he failed to diagnose Sorenson's bowel obstruction, and discharged her with painkillers, thinking she probably had gastroenteritis. Sorenson collapsed and died 16 hours later.

Dr Mauro was later sacked from the hospital over the valium theft. Five months before the woman's death, a medical board committee received a report from Dr Mauro's psychiatrist, who was concerned about his drug use but thought he could "probably work effectively, at least in a reasonably controlled environment".

Mr Chivell said it was "a matter of concern" that the board committee took no action about Dr Mauro and did not refer incidents to the medical board. Even if the hospital had investigated Dr Mauro's history, Mr Chivell concluded, "they had no information before them to indicate that Dr Mauro was impaired" because they would not have received any relevant information from the medical board. The inquest also revealed that the medical board did not investigate a 2000 complaint that Dr Mauro appeared to be under the influence of drugs and behaved inappropriately while treating patients for an Adelaide locum service. Mr Chivell said "one might have thought" the board would have considered whether to investigate Dr Mauro's health after it also heard that Dr Mauro's employment in NSW had triggered a complaint to the NSW Medical Board.

Mr Chivell said he was not authorised to make any recommendations about the medical board's behaviour, instead drawing it to the attention of South Australian Health Minister Lea Stevens. She yesterday requested an urgent report from the board. Board chief executive Joe Hooper declined to comment.

A committee dealing with drug-dependent doctors saw Dr Mauro in February 2001 after the locum service complaint. Mr Chivell found that committee psychiatrist Ross Kalucy did not follow up the meeting with Dr Mauro's psychiatrist, although he testified that he did. He also found that Dr Mauro's psychiatrist's recommendation in 2001 that he practise under close clinical supervision was ignored. Restrictions on Dr Mauro's right to practise were removed in December 2003.

Dr Mauro told the inquest his treatment of Soreson had been done a "little bit quickly" and he was experienced enough to have known better. A post-mortem examination found that Sorenson's death could have been prevented if basic tests had been done and the seriousness of her condition recognised.

Source

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