D Lane v Northern NSW Local Health District; E Lane v Northern NSW Local Health District [2013] NSWDC 12

District Court New South Wales

Medium Neutral Citation: D Lane v Northern NSW Local Health District; E Lane v Northern NSW Local Health District [2013] NSWDC 12 Hearing dates: 11, 14, 15, 16, 17, 18 May, 19, 20, 21, 22 June 2012 Decision date: 15 February 2013 Jurisdiction: Civil Before: Williams DCJ Decision: Verdict for the defendant. Plaintiffs to pay defendant's costs. Catchwords: Professional negligence - medical negligence - psychiatric injury caused by death of parent - peer professional conduct - Civil Liability Act - end of life considerations. Legislation Cited: Civil Liability Act ss5O, 30, 31, 32. Cases Cited: Aon Risk Services v.ANU [2009] HCA 27 Wyong Shire Council v Shirt [1980] HCA 12 Northbridge v Central Sydney Area Health Service [2000] NSWSC 1241 Messiha v South East Health [2004] NSWSC 1061 Airedale NHS Trust v Bland [1993] AC 789 Rogers v Whitaker [1992] 175 CLR 479 Texts Cited: Gould Medical Dictionary 4th Ed Category: Principal judgment Parties: Deirdre Mary LANE Elizabeth Helen LANE Representation: Counsel: P:- Self represented D:- Mr Richard J A Sergi Solicitors: Self represented Curwoods Legal Services Pty Ltd File Number(s): 66/10 & 67/10 Publication restriction: Nil

Judgment 1Where do family relationships go so wrong as to be the cause of so much damage and cost to themselves and to the wider community? This is a case study of such a problem and a problem that is becoming increasingly prevalent in our legal system, involving the commencement and continuation of litigation that should really not have been allowed to go on as long as it has. This judgment, in the matters of D Lane & E Lane v. The Northern NSW Local Health District, formerly known as the North Coast Area Health Service will, I have no doubt, not set at rest the various reasons that have led to the actions being instigated in the first place. 2There are two separate actions in negligence before me. The first plaintiff is Deirdre Mary Lane and the second is Elizabeth Helen Lane. By consent the maters have been heard together. Both actions have been pleaded in exactly the same way. At the time of the hearing of this matter both plaintiff's were self-represented. Both gave evidence. 3Without intending any disrespect, during the course of this judgment I will refer to the first plaintiff as Deirdre and to the second plaintiff as Elizabeth. These proceedings are proceedings in negligence against the defendant claiming psychiatric injury as a result of their mother's death which they allege was caused by her negligent treatment whilst a patient in the Casino District Memorial Hospital (CDMH) and the Lismore Base Hospital (LBH). 4Other persons who either gave evidence or might be mentioned during the course of this judgment are:- Dr Laird who was a visiting medical officer at the Lismore Base Hospital gave evidence; Dr Burrell who was a treating doctor at the Lismore Base Hospital gave evidence; Dr Coupe who was the medical registrar at Lismore Base Hospital gave evidence; Dr Seneviratne, a treating doctor at the Lismore Base Hospital gave evidence; Ms Kostal a speech pathologist at Lismore Base Hospital gave evidence; Ms Wiebke Lucks a speech pathologist at Casino Hospital gave evidence; Ms Jill Rhodes a social worker at the Lismore Base Hospital gave evidence; Dr Jurian Beek, the family general practitioner from Casino gave evidence; Mr Leo Lane, the plaintiff's father, who I will refer to as Mr Lane gave evidence; Mrs Helen Lane, the plaintiff's deceased mother who I will refer to as Mrs Lane or Helen; Dr Knox, a general practitioner who treated Mrs Lane; Dr Boyce a specialist treating neurologist; Dr Fairfull-Smith, a specialist treating geriatrician; Robin Gordon, a neuropsychologist; the Aged Care Assessment Team (ACAT); Dr Pearson, the medico legal psychiatrist for the plaintiff's and Dr Petroff, a medico legal psychiatrist who saw both plaintiff's for the defendant gave evidence; Professor Ehrlich, a medico legal expert for the plaintiffs gave evidence; Dr Obeid a geriatrician medico legal expert for the defendant gave evidence; and Dr Raftos, an emergency medicine specialist for the defendant gave evidence. Additionally both Mrs Lane, Deirdre and Elizabeth consulted a number other medical practitioners and health care professionals at different times and they will be referred to as and when they appear. 5This unfortunate case has its genesis in an event that occurred to Mrs Lane on the 10 March 2007 after which she was taken by ambulance to Casino Hospital and then transferred to Lismore Base Hospital for further treatment where she remained for some 12 days. She was then returned to Casino Hospital where she died on 24 March 2007. 6The plaintiff's claim was filed 1 day before the limitation period expired. The statements of claim had been drafted by their then solicitors, who have since ceased to act. The matter has had a somewhat chequered history having been set down for trial on a number of occasions and then adjourned. The proceedings were commenced in the Newcastle registry of the District Court then transferred to Lismore. The proceedings were listed for trial at the sittings commencing on the 24 October 2011 but the plaintiffs were not ready to proceed and it was re-listed for trial at the next sittings on the 20 February 2012. The matters were again not ready to proceed at those sittings and were further adjourned to the sittings on 7 May 2012 before me. 7Deirdre and Elizabeth made an application to further adjourn the matter on the 7 May, as they were still not ready. Having regard to the listing history to date, the High Courts decision in Aon Risk Services v. ANU and because I felt that no matter how much time the plaintiffs had to prepare the matter there would always be some reason to delay the proceedings, particularly having regard to the way in which the claim was framed, I refused the application and directed that the matter proceed. It was also in everybody's interest that their recollections of events not be delayed any further given the relevant events occurred five years before. 8The proceedings commenced on Friday 11 May at the Lismore District Court by the calling of Deirdre and Elizabeth's father Mr Leo Lane. His evidence took all day. On Monday 14 May Deirdre gave evidence and was cross-examined over that day and the next. On Wednesday 16 May Dr Seneviratne was called and Dr Petroff gave evidence via a telephone link. On Thursday 17 May, Dr Laird gave evidence as did Ms Kostal. On Friday 18 May, Ms Lucks gave evidence as did Dr Burrell and Ms Rhodes. The matter was to proceed the following week in Lismore but for various reasons it could not and it was consequently adjourned to the 19 June in Sydney. On that day Elizabeth gave evidence and was cross-examined. On Wednesday 20, Dr Pearson gave evidence via a telephone link up and Professor Ehrlich gave oral evidence. On Thursday 21 June, Dr Beek gave evidence by telephone link up and Dr Coupe gave oral evidence and on Friday 22 June, Dr Obeid and Dr Raftos gave evidence. The matter was adjourned to allow the plaintiffs to submit for tender additional documents and for written submissions. Additional documents were received from both plaintiffs. Some were rejected and some admitted. The defendant was to provide written submissions first, then the plaintiffs, with the opportunity of a reply by the defendant. The time-table set on 22 June inevitably came undone and consequently it was not until 10 December 2012 that all submissions were completed. 9In all, the plaintiffs submissions were 144 pages long, the defendants some 53 pages. A flavour of the plaintiffs submissions can be obtained from their "Introduction" par 10 where, amongst other things they suggest the medical staff "allowed, in reality forced,(Mrs Lane) to die". At par 32 it is alleged that the defendant was recklessly indifferent to Mrs Lane's life "having the intent to cause her death. Under the Crimes Act 1900 18(1)(a), this is murder." At TP 90 on 17 May, the accusation was made to Dr Laird while giving evidence that "He killed my mother." 10I should say at the very outset that I totally and un-reservedly reject each and every one of those propositions. Whilst the outburst on 17 May is understandable given the obvious emotional state of the plaintiffs at the time of the cross examination of Dr Laird, the statements contained within their introduction are without any merit or any evidence and would not have been made had they been legally represented. 11I propose to deal with this matter by examining Mrs Lane's medical history chronologically in order to give a proper understanding of her pre-morbid health leading up to the event that placed her firstly in Casino and then Lismore Hospital and finally back at Casino. 12There is no doubt and its not disputed, that the hospitals had a duty of care towards Mrs Lane and toward any one who may have been affected by their treatment of Mrs Lane while she was in their care. Whilst the statement of claim does not link the alleged negligence of the hospitals to any damage sustained by the plaintiff's, there is no lack of understanding on the part of the defendant as to what the plaintiffs' claim is. They each say that they have sustained psychiatric injury occasioned by the hospitals negligent treatment of their mother causing, among other things, a loss of earning capacity and a diminution of their amenity and enjoyment of life. 13I propose first to deal with the issue of liability and then move on to the question of damages. The question of damages is as complicated as is the background to the issue in regard to liability. Deirdre and Elizabeth are but two of seven children of Mr and Mrs Lane. It is quite clear on the material before me, that prior to and subsequent to Mrs Lane's death, there was substantial friction within the family in regard to Mrs Lane's pre-morbid care and in regard to her treatment in hospital before her death. 14A large amount of material has been tendered by the plaintiffs in this case much of which, I regret to say, is quite irrelevant to the issue that confronts the court. The plaintiffs made submissions to the commission of enquiry conducted by Peter Garling SC (now Justice Garling of the Supreme Court of NSW). In the course of those submissions they expressed their concerns at the treatment that their mother had received whilst a patient at the two hospitals in question. They also approached the State Coroners office in regard to the death certificate that had been issued in regard to their mother and have tendered correspondence in regard to that application, which resulted in a somewhat different death certificate being issued by the relevant medical practitioner. In fact Deirdre's evidence in chief before me was given by way of reading the submission she made to the Commission of Enquiry and that document has been marked for identification in these proceedings as MFI 'A'. Substantial parts of that document were objected to and were ruled inadmissible. 15Whilst its fair to say that Deirdre and Elizabeth have presented a united front during the course of this lengthy trial, such was not always the case in regard to Mrs Lane's care prior to her death. 16The particulars of negligence as pleaded are set out below. I will address each particular specifically at the end of the judgement but will endeavour to cover these matters generally during the course of the examination of the medical and hospital records and the evidence in the trial. 17Particulars of negligence:- (1) Failing to consider or properly consider and implement treatment for Helen in accordance with New South Wales Health End of Life Care and Decision Making Guidelines as revised in June, 2006. (2) Failing to investigate or investigate and treat Helen's condition of pneumonia or similar condition by the administration of antibiotics or other appropriate drug. (3) Failing to ambulate Helen as a consequence of a decision to bedfast her such that this caused a deterioration in Helen's condition so as to contribute to her death. (4) Failing to provide any or any proper nutrition to Helen so as to prevent the development of anorexia and starvation which contributed to her death. (5) Failing to acknowledge Helen's request for nutrition and treatment so as to contribute to her death. (6) Failing to investigate or properly investigate Helen's pre-hospital seizure. (7) Failing to prepare or properly prepare a management plan for Helen. (8) Incorrectly diagnosing Helen as having suffered hypoxic brain injury. (9) Failing to provide appropriate treatment on the assumed basis that Helen had a poor quality of life pre-morbidly when this was not the case. (10) Failing to obtain accurate pre-hospital admission medical treatment and pre-existing conditions from Helen's treating doctors by either contacting such doctors and by requesting their records and obtaining such information from Helen's primary care giver, Deirdre Lane. (11) Administering or continuing to administer to Helen morphine when it was apparent that Helen was having an adverse reaction to the drug including the development of a chest infection with subsequent development of pneumonia. (12) Administering and/or continuing to administer to Helen morphine when such drug impeded Helen's ability to communicate her wishes in respect to treatment. (13) Administering and/or continuing to administer morphine to Helen when such drug was having an adverse effect upon Helen and her wellbeing. (14) Failing to obtain or properly obtain specialist neurological or geriatric opinion as to Helen's condition so as to properly prepare an appropriate management plan for Helen. (15) Failing to continue to administer to Helen antibiotics when she was in need of such medications as she was developing an infection. MRS LANE'S PRE-MORBID HEALTH HISTORY 18Amongst the documents tendered by the defendant are the clinical notes from Dr Beek's practice over many years, he being Mrs Lane's general practitioner and the family's general practitioner. Dr Beek gave evidence. 19It is also perhaps apposite to note at this point the concession made by Deidre Lane on the last day of the hearing of this matter at TP 117. She said to Dr Raftos:- Now Doctor, Elizabeth and I agree that Mrs Lane may have had a form of dementia and that dementia tends to progress and is not curable. We accept that Mrs Lane had disabilities but that she still had reasonable mobility albeit with some support. We agree that a neurological event occurred on 10/03/07, a seizure, of whatever unknown cause, and we know there was no specific terminal diagnosis. 20The earliest relevant medical record is a report of 31January 1994 from a Dr Prince, an ear nose and throat surgeon, in regard to Mrs Lane which indicates she presented with decreasing hearing in the last 3 to 4 years and although suffering from a sensorineural hearing loss did not at that stage want a hearing aid. I refer to this document because Mrs Lane's ability to hear has been a cause of concern to the plaintiffs, particularly in regard to the way she was treated whilst in hospital. It's probably a fair summation to say that Mrs Lane's hearing did not improve over the years. She had also been treated by way of operation for varicose veins in 1999. 21In 2001 Mrs Lane had a hysterectomy that had ongoing problems. 22On the 13 September 2002 she presented to her GP with what appeared to be a severe cold but the doctor has noted "has strong alternate medical views and came with daughter". 23On 8 October 2002 the doctor noted amongst other things that Mrs Lane was "generally anxious". 24On 12 August 2003, Deidre applied for a Carer's Pension in respect of her mother. This form (ex12) required the ticking of boxes to indicate the status of the person concerned who required care. That form indicates that, at least from Deidre's point of view, her mother was even then considerably in need of help. 25On 18 August 2003 the doctor noted "multiple emotional home problems - presents with daughter who does most of the talking on behalf of mother - draining day at home - lots of disputes - ? sibling rivalry". 26On 22 January 2004 (DTB2 P349) Dr Brendan O'Sullivan, a gynaecologist, reported to Dr Beek that:- Physically Helen is now frail with marked abdominal distension and faecal loading associated with obstipation and constipation. At the time of her visit she had a level of faecal impaction associated recurrence of the low recto seal. My feeling is that she is too much under the direction of her daughter Deirdre who manipulates situation and management. I recommended a combination of Epsom salts, lactulose and suppositories but doubt that she will be unable to implement any of this while Deirdre is driving things. I can only sympathise with the other family members at the hands of this overbearing woman. 27I note that Dr O'Sullivan had been treating Mrs Lane at least since 1994 so that his observations, particularly as to Mrs Lane's frailty and the inter-action between Mrs lane and Deidre, are not those of a one off visit. It is also an observation supported in documents pertaining to the treatment of Elizabeth referred to later in this judgement. 28It is clear from the general medical records that Mrs Lane was, by this stage of her life, not enjoying the best physical health, apparently a consequence of her earlier hysterectomy. 29On 22 November 2004 there is a Casino Medical Centre note that there was a discussion with Leo Lane. Leo voices concerns Helens ongoing health concerns. Leo states he feels she is showing some early signs of dementia. He states that Dr Beek had attended a referral for Helen to be reviewed by Dr Fairfull-Smith but this did not go ahead as his daughter Deirdre felt it not necessary. 30On 27 May 2005 there is a letter from Dr Janet Knox, a GP at Byron Bay, requesting Dr Boyce, a neurologist, to provide an expert opinion. In the letter Dr Knox says inter alia :- Helen recently presented to this practice with her daughter Deirdre, with a progressive history of decreasing mobility, rigidity, and 'anxiety attacks ' Deirdre describes the attacks as being triggered by a stressful event, her limbs become flexed and rigid, she has difficulty breathing, stares into space and has been incoherent in speech. ... She has no history or family history of neurological problems. Her past history includes hysterectomy 4 years ago for ? prolapse O/E shuffling gait, blank face, positive glabellar tap, cogwheel rigidity, hyperreflexia. Abdo - distended and tender. I am concerned that this lady has Parkinson's disease and would appreciate your opinion regarding diagnosis and ongoing management. 31Dr Boyce wrote back to Dr Knox on 1 June 2005 as follows:- "Mrs Lane is 74 years of age. She has had a lot of trouble with her abdomen and trouble with a hysterectomy. Her major problem at the moment is mobility. She also has severe attacks of anxiety. Speaking to the lady it was clear that she has some degree of dementia. She was disorientated in time and place. She wasn't able to add 16 and 13. She couldn't tell me the name of the town she was in. She had a dyspraxia of right and left and finger agnosia. I agree with your findings ...I have had a longer talk with her daughter... I have suggested that she contact her lawyer about her mother's testamentory capacity". 32On 15 June 2005 Dr Boyce referred Mrs Lane to Dr Fairfull-Smith in the following terms:- "The lady wasn't able to give a coherent history. Her major problem was mobility and attacks of anxiety. Clearly the lady has a Parkinsonian type gait and has rigidity to facilitation bilaterally. She has staring affect. She is totally disorientated in time and place. She wasn't able to calculate. I found a dyspraxia of right/left function and finger agnosia. I couldn't get what I felt was a coherent mini mental status. ...I felt that she had a Parkinsonian dementia i.e. a concurrent onset of a dementing process and Parkinsonism within about twelve months. Her CT brain shows widened subarachnoid spaces and increased size of the third and lateral ventricles particularly with decrease in size of the temporal lobes. 33Dr Fairfull-Smith is the director of rehabilitation and geriatric services for St Vincent's Hospital, Lismore. He provided a report to Dr Boyce on 6 October 2005. Amongst other things in that report Dr Fairfull-Smith says:- "Thank you for referring Helen who was seen on 25 August 2005 accompanied by her husband and daughter Deirdre. The most likely diagnosis is corticoid basal degeneration in view of the severity of aphasia, the difficulties initiating actions. This is undoubtedly a dementing process". 34Under the heading "examination" the doctor noted that:- "She needed hearing amplification above her hearing aids to get her to understand adequately. In spite of this it became apparent that she has a significant and severe aphasia being unable to name simple common objects. She could sometimes follow a single command but not a two stage one. She has apraxia being unable to demonstrate or even use a pair of scissors or sign her name. She had difficulty comprehending no matter how information was presented. In naming animals she could only name one and had great difficulty understanding the concept. Getting her to do drawings she was very concrete and literal with a 3D box, writing draw before being shown that she had to copy the box and then just drew a square. With the clock face she placed 12 several times. Also she wrote clock and mis-spelt it. She was very slow in doing all these tasks. A brief physical examination did not show any postural hypertension, primitive reflexes mildly increased tone bilaterally. I will refer her to the dementia outreach service to see if the family wish any further information on this unfortunate condition. I note that doctor was well aware of Mrs Lane's hearing difficulties. 35On 19 October 2005 she was seen by a neuro-psychologist Robyn Gordon. In a report to Dr Knox and Dr Fairfull-Smith of 26 October 2005 she said:- "I attempted an assessment of Helen on 19 October 2005. She was accompanied by her daughter Deirdre who sat in on the assessment. I also had the opportunity to speak briefly with her husband". 36Under a heading "results" she wrote:- " 1. Helen appears to have a severe aphasic disorder with both expressive and receptive difficulties. 2. Helen demonstrated apraxia both in her attempts at obeying instructions and her attempts at basic design. 3. She appeared to have difficulty initiating actions or responses, consistent with anecdotal evidence. 4. Helen's memory was impaired at a very basic level. 5. Attention abilities were grossly impaired. 6. She seemed to be readily confused. 7. Occasional preservative responses were noted in her speech". 37Under the heading "impression" she records:- "Unfortunately it does appear that Helen is suffering from a quite severe dementia; diagnosis of corticoid basal degeneration would appear to be supported in this case. While it is likely that Helen's high anxiety would be a contributing factor, it is not felt to be the prime cause of her current presentation. Helen requires a high level of care and supervision in her daily living. Helen would be unable to make any informed, considered decisions. Helen is also unable to mange her finances. Helen is probably best managed by use of set routines and prompting". 38Whilst there is some debate as to who requested the ACAT to become involved with Mrs Lane's care, Deidre acknowledged at TD3 p12 that both she and her father were anxious for the ACAT team to get involved in her mother's care because of the burden Helen's illness was placing on her and her father. 39Mrs Lane was seen by the St Vincent's Hospital ACAT over different periods of time but more relevantly from the 25 August 2005. An ACAT clinical note of that date indicates that she is deaf and has been very deaf for 8-10 years. It was noted that she feeds herself and shuffles and has poor memory and a CT scan showed cerebral atrophy. It was also noted that she was easily distracted. 40An ACAT clinical note of 7 October 2005 said:- Elizabeth Lane presented at the office with allegations of elder abuse by her sister Deirdre to her mother Helen. Elizabeth alleges that Helen is anxious and frightened at times when Deirdre is around - thinks she wasn't receiving ideal medical and nutritional care. 41On 12 April 2006 her GP notes:- "Review. Long talk. Problems 1. long standing anxiety 2. challenging domestic situation -very assertive daughters-conflicting domestic aims between two daughters 3. critical son. P/h of medical trauma ...indecipherable. 5. belief in alternative therapies 6. denial of dementing process by the family siblings 7. will progress to need n/h care note p/h of chronic anxiety. domestic situation problems difficult to change. suggest use of alpraxalone. note no weight loss". 42On the 28 April 2006 there is, what I presume to be, an ACAT file note in respect of Mrs Lane which says:- "Phone call from Elizabeth Lane. Elizabeth again outlined the differences of opinion with Deirdre about the care provided to her mother. I informed Elizabeth that her father Leo, who has no cognitive impairment, is involved with Helen's case is able to monitor Helen's case". 43An ACAT note of the 9 May 2006 says:- the family conflict continues to rage. 44In August 2006 there is a GP notation of "↑anxiety". 45A further note on 13 July 2006 says there was a home visit to Leo and Deirdre. "Leo notes that improvement in his wife's condition coincided with service from SCCC. Reported family conflict has quietened down so that the household is less fraught". 46However on 18 July 2006 there was phone call from Elizabeth Lane who was again concerned that her mother had been denied a hearing aid by her father despite Elizabeth's opinion she would benefit from it. She was advised to discuss the situation with her mothers GP. 47On 14 September 2006 there was a home visit to Leo and Deirdre and Helen was seen but only briefly. It was explained to them the levels of residential community and respite care and it was reiterated that Helen was a high care patient. 48On 25 October 2006 there was a phone call from Dr Beek in Casino who was receiving pressure from both Elizabeth and Deirdre to contact ACAT. The ACAT already had a referral and they had been in touch with Leo to confirm the referral. It was noted that Elizabeth is now alleging that Deirdre is an alcoholic and that she would like to make a guardianship application. 49On 13 November 2006 there was a home visit by registered nurse who met with Leo, Deirdre and Helen. She noted that Helen required considerable care now, was quite frail and had difficulty mobilising and appeared to be in considerable pain. 50On 15 November 2006 there was an ACAT home visit at Leo's request and a psychologist, Mr Bradley Ward, met with Leo and Elizabeth. The note says:- "Elizabeth had lots of questions re the best way to care for Helen. I named out loud that I would not be drawn into taking sides re hers or Deirdre's views on Helen's care. My answers were only in generalities, as I hardly knew Helen. I concluded with reinforcing ultimate decisions re Helen's care sit with Leo, not with the daughters. Leo is aware of this. 51The ACAT assessment conducted on the 23 November 2006 indicated that:- Mrs Lane required full assistance for showering dressing and grooming. She was mobile but very unsteady. She needed assistance on standing. She was a high falls risk. There were no continence problems but required assistance with toilet and assistance with post toileting hygiene. She had expressive and receptive aphasia which combined with poor hearing and slow mentation made communication difficult at times. Patience and understanding needed. Helen responds well to reassurance. She is an anxious lady and this is an important consideration in her care. At Plaintiffs submissions par 157, (PS par 157) the plaintiffs suggest that this document in effect should have been part of anyone obtaining an accurate history of Mrs Lane's premorbid condition. 52"Aphasia" is the "loss or impairment of the reception or use of language caused by a lesion of the cerebrum." (Gould Medical Dictionary 4th Ed). I cannot see that this document would have made any difference or would have been relevant to Mrs Lane's treatment after the incident of 10 March 2007. All the relevant practitioners well knew of Mrs Lane's communication problems. I cannot see any evidence of her being treated other than with patience and where possible, given her condition, reassurance. All these issues were noted on her admission in one form or another. 53On 29 November 2006 there is report from the Richmond Valley ACAT which says:- I met with Helen, her husband Leo and daughter Deirdre. As you are aware, Deirdre is providing considerable care for her mother. There is minimal help currently, with St Michaels providing some personal care one day per week. Helen also has infrequent social outings with St Michaels. I have approved Helen for an extended aged care at home package as well as high level respite and permanent care. 54On 31 Jan 2007 Mrs Lane was prescribed Amoxycillin and anti-biotic, apparently because of concerns for her recurring UTI. On 23 Feb 2007 Deidre noted that her mother was more unsteady and seemed more frail and had deteriorated very quickly. 55On 8 February 2007 there was a home visit to Leo Lane from the Dementia Outreach Service of St Vincent's Hospital because the "SCCC" had pulled service out apparently due to occupational health and safety issues. The note says "Eldest son John visited and drew up family care plan that Deidre and Elizabeth have agreed to - they are currently working together much better. ... Leo is much more relaxed when family tension is lowered". The note concludes "Saw Helen - severely demented". 56On 27 Feb 2007 Deidre told the surgery that her mother had been deemed "High risk" by the ACAT. 57On 1 March 2007 Mrs Lane was prescribed Augmentin Duo Forte and on 9 March 2007 further pathology tests were ordered by Dr Beek. The results came back after Mrs Lane had collapsed on 10 March 2007 but were negative, confirming later testing at Lismore Hospital. 58On 10 March 2007 Mrs Lane experienced some type of cerebral incident and was taken by ambulance to Casino Hospital.