By Natalie Akoorie
Local Democracy Reporting Editor
An inquest will be held into the death of a Whanganui woman 11 years ago at Waikato Hospital, just hours after a cancer procedure that was meant to extend her life.
The Ministry of Justice has confirmed Coroner Alexander Ho will hold an inquest into the sudden death of Carmen Walker, who lost so much blood following the operation in August 2010 that she died hours later in intensive care.
The decision to hold an inquest comes after the pathologist who conducted Walker's autopsy changed his conclusion on the cause of her death earlier this year, prompting the Solicitor-General to order a new inquiry into the controversial case.
News of the inquest coincides with the reading of a petition in Parliament today [Thursday] calling for a full inquiry into the case, launched by a whistleblower doctor who witnessed the procedure and alleged that systemic failures at Waikato District Health Board contributed to Walker's death and were "covered up".
Walker, of Whanganui, was 78 when she died at Waikato Hospital on August 3, 2010 following an isolated limb infusion [ILI], where high doses of chemotherapy were washed through her lower leg to treat Stage 4 melanoma that had spread from her right ankle.
The treatment was supposed to extend the life of Walker, who was otherwise fit and active.
At the time pathologist Dr Ian Beer concluded the grandmother died of cardiogenic shock, where the heart suddenly can't pump enough blood around the body, often caused by a severe heart attack.
Former Coroner Gordon Matenga based his April 2011 findings for Walker's death on Beer's autopsy and the surgeon's notes, listing cardiogenic shock as the cause of death.
A Waikato DHB internal review of the event, dated January 2013, found no definitive cause for the death.
But in May Beer took the unusual step of writing to Chief Coroner, Judge Deborah Marshall, telling her he wanted to change his finding to hypovolaemic shock due to blood loss and asked that a coronial inquest be opened.
He changed his mind after reading the expert opinion of Royal Adelaide Hospital Associate Professor Susan Neuhaus, and ILI expert, who told the Health and Disability Commissioner's investigation into Walker's death she believed an unrecognised tourniquet leak resulted in the rapid blood loss that caused Walker's death, and that this was a "severe departure from the expected standards for ILI".
Beer admitted he did not have all of Walker's patient notes when he made his finding, and he was not informed by the Health and Disability Commissioner of Neuhaus' later opinion, only discovering it when he read the HDC investigation file in April.
The HDC investigation found in December 2013 that aspects of the care given to Walker were "suboptimal" but because the DHB was no longer performing the isolated limb infusion procedure, then commissioner Anthony Hill took no further action.
Dr Adam Greenbaum, who was observing the procedure that day and complained to the Medical Council and HDC that Walker's death was avoidable and some of the circumstances had been covered up, said he was delighted an inquest would go ahead.
Greenbaum, who together with Walker's family is also petitioning Parliament for an inquiry into the case including Waikato DHB's handling of it and the HDC investigation, said it was vitally important Walker's death be re-examined.
"I'm hoping that this inquest will give closure to the Walker family by producing the truth of what happened to their mother," Greenbaum said.
"The biggest issue is not that mistakes were made, but that they were repeatedly denied in the face of all evidence to the contrary," he said.
"I very much hope the legacy of Carmen Walker's death will be improvements in safeguards for patients who die in a manner that requires referral to a Coroner.
"In particular I hope the Coroner will make recommendations that every pathologist must not conduct an autopsy without the entirety of any patient's records available to them, and that Coroners without medical training will have to be advised by medically trained assessors.
"From what happened to Carmen, these seem to be the minimum safeguards Kiwis should be assured of having from a public service whose function is to identify opportunities to prevent future avoidable deaths in New Zealand."
Son Craig Walker said he was pleased there would be an inquest but disappointed it had taken 11 years to get one.
"We want answers to our questions and heads need to roll over this if it has been covered up."
Waikato DHB said it would not comment now the matter was before a coroner.
Coroner Ho has estimated the inquest will take five days in Hamilton and a date will be set after he consults Walker's family and other interested parties.