Brain surgery led to suicide

THE Coroner has found a Lismore man took his own life because of a mood disorder brought on by brain surgery and medication to treat Parkinson's disease.

Deputy State Coroner Hugh Dillon compiled the report into the death of Kenneth 'Ken' Mawby, who died in Lismore on January 5, 2009, aged 59.

Mr Mawby underwent deep brain stimulation that involves implanting a 'brain pacemaker' at Wesley Hospital, Brisbane on November 19, 2008.

The device aims to mitigate or reduce the symptoms of Parkinson's disease, including tremors, by sending electrical impulses into specific areas of the brain.

The dental prosthetist and keen guitarist, described as "a gentle, kind, mild-mannered man", was married to Cheri Mawby and had two adult sons, Paris and Adam.

After the procedure, Mr Mawby was showing signs of distress in hospital, including mood swings, incontinence, bouts of euphoria, restlessness and confusion.

However, he was hastily discharged on December 1, 2008 and died while waiting to see his treating neurologist, Professor Peter Silburn.

After returning home to Lismore, Mr Mawby's mood fluctuated between manic, agitated and out of control to calm and settled at times.

His behavioural issues culminated in an argument with his wife on January 5, 2009.

Mr Mawby, acting in an uncharacteristic manner, kicked a rubbish bin and shook his wife by the shoulders when she refused to hand over car keys.

He stormed out and his wife found him dead shortly after in their garage.

The inquest found there was poor post-operative communication and care and inadequate record-keeping by Prof Silburn leading to Mr Mawby's death.

Despite this, and regardless of "attempting to mislead the court" by implicating another medical professional, Mr Dillon said it would be unfair to recommend Prof Silburn to the Health Ombudsman.

Mr Mawby's mood disorder persisted from two days after his surgery to the date of his death due in "insignificant but unquantifiable measure" to the DBS device stimulation and prescribed medication.

Inquest Recommendations

Asia-Pacific Centre for Neuro-Modulation/St Andrew's War Memorial Hospital (where DBS is now performed) amend Model of Care Flow Chart so treating neurologists approve discharges.

DBS nurses to ensure thorough follow-up of discharged patients through various means.

Neurosciences Queensland develop checklist for St Andrew's to be completed by the DBS nurses before patient discharge.

Neurosciences Queensland and St Andrew's establish a system to ensure that a copy of the completed checklist be provided to the hospital for inclusion in its patient records.

A discharge card with all necessary follow-up information be developed and given to patients.

 

Improvements Made

Prof Silburn and Neurosciences Queensland have evidentially improved practices.

Specialist DBS nurses employed by Neurosciences Queensland.

24-hour helpline and several nurses available for technical questions about the DBS device.

Psychological assessments undertaken pre-admission.

A pre-admission information package developed and given to patients.



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