The Aftermath of June Long's Iatrogenic Death

In June 1994, June Long was admitted to hospital following an asthma attack. 14 hours later, on 29 June, she was dead; not from asthma but from clinical incompetence. Three doctors, in one of Australia's largest public hospitals, misdiagnosed her condition and maltreated her. When the 'alarm bells were ringing' specialists were not called in until the crisis had occurred. Four inept nurses added to the fiasco.

The hospital covered up the cause of death and clinicians knowingly and intentionally issued a false death certificate. At no time was the family alerted to her deteriorating condition and subsequent death until 1 1/2 hours after she was dead. The Alfred Hospital, Prahran, classed her death as 'routine'.

Having failed in their statutory duty to report the death to the Coroner, hospital clinicians lied to June Long's family and, if that wasn't enough, could not locate her body when the family and the undertaker arrived. Hospital clinicians told the family that they had conducted an autopsy. On the day of the funeral that was discovered to be untrue. The family alerted the Coroner. The day after burial the Victorian Department of Justice requested permission for exhumation. The Victorian acting Minister for Health, Robert Knowles, announced that there would be a government inquiry.

In August 1994, the Victorian Minister for Health, Marie Tehan, pre-empting the coronial inquiry, stated to the media that "...an internal peer review by the Alfred Hospital into the treatment of June Long before she died has not uncovered any errors. I have spoken to the Alfred Hospital about it and they have assessed all their protocols in that matter and are comfortable that the clinical decisions that were made were the right ones in the circumstances". The Minister further stated that she was "at ease with the government inquiry finding". Government inquiry? There wasn't one - rather an exercise in public servants spending a lot of public money covering-up unacceptable levels of public safety.

Medical records were lost, never to be found. Medical records were tampered with. ICD coding was lacking and knowingly false. Medical records were withheld from the State Coroner's Office and the family. Six clinicians refused to provide depositions to the Coroner. Some of these had spoken to the media about the death but did not have the fortitude to elaborate in front of the Coroner to assist him in his investigation. Accordingly the Alfred Hospital made no effort to apologise to June Long's family.

During the March 1996 Inquest the Coroner expressed concern at the lack of medical information provided for an Inquest. The Alfred Hospital was exceedingly obstructive. Statements provided by clinicians were inadequate having been orchestrated and controlled by Alfred Hospital lawyers in an attempt to control the evidence. The hospital refused to hand over its file and withheld its audit of the death claiming it was protected by legislation. The fact that the Minister for Health had already put the inquiry in the public domain when she discussed it with the media in 1994 was conveniently disregarded.

In August 1996, after a 2 year coronial investigation, the State Coroner of Victoria, Graeme Johnstone, found Melbourne's Alfred Hospital contributed to the death of June Long "by not ensuring a protocol was in place to provide advice and/or review by a Respiratory Unit Registrar/Specialist on admission to that unit". She was treated by an intern with five month's experience, and a registrar - not a respiratory specialist. The intern was left "without adequate supervision for a potentially complex case. The chance of a successful outcome in Mrs Long's case would have been greater had she been managed by a clinician with respiratory experience". The intern's lack of experience was "understandable" and it was "the system that needed addressing".

The Coroner found "although there was no intensive care unit bed available at the hospital when Mrs Long became critically ill, the real issue was her earlier treatment in the Alfred Hospital's respiratory unit".

The Inquest heard: "The lessons from this death are twofold:

  1. Oxygen-induced hypoventilation is a danger in the conservative management of respiratory failure. It needs to be considered, sought and actively treated.
  2. There is a tendency to place too much comfort in satisfactory oximetry measurements."

The Coroner found several clinicians involved in treating Mrs Long "did not make a complete record of the events". Thus, the Coroner suggested, "the problems associated with a failure to take accurate notes be emphasised through the relevant medical colleges".

"The Department of Human Services should issue a warning to all hospitals and medical colleges to take special note of the case", Coroner Johnstone stated.

The Long family's dogged pursuit for answers was justified.