1
00:01:33,180 --> 00:01:34,224
Yeah?

2
00:01:38,446 --> 00:01:39,447
On my way.

3
00:01:55,680 --> 00:01:58,987
She"s tachycardic,
up from an hour ago, on Fibral.

4
00:01:58,988 --> 00:02:00,815
Respiration 22 and
pressure is down.

5
00:02:00,816 --> 00:02:01,947
That's why we called.

6
00:02:02,426 --> 00:02:04,124
Hello, Lisa. Hello.

7
00:02:05,516 --> 00:02:07,169
My name is Elizabeth Taylor.

8
00:02:07,170 --> 00:02:08,692
I'm the consultant surgeon.

9
00:02:08,693 --> 00:02:11,478
This is my registrar,
Richard Whitehead.

10
00:02:11,479 --> 00:02:13,567
Lisa, do you know where you are?

11
00:02:13,568 --> 00:02:14,917
Can you hear us all right?

12
00:02:16,005 --> 00:02:17,528
Does it hurt when you breathe?

13
00:02:18,007 --> 00:02:20,182
She's had no increase
of pain at McBurney's,

14
00:02:20,183 --> 00:02:21,966
so it doesn't look
like appendix.

15
00:02:21,967 --> 00:02:24,708
But she has had ten milligrams
of morphine since 9:30

16
00:02:24,709 --> 00:02:27,189
and ten megs of Maxolon.

17
00:02:27,190 --> 00:02:28,799
The history?

18
00:02:28,800 --> 00:02:31,933
Um, it was one day
of cramping abdominal pain.

19
00:02:31,934 --> 00:02:34,284
Tender abdomen
with guarding at the left iliac.

20
00:02:34,589 --> 00:02:37,373
Was given trimethoprim,
diclofenac and paracetamol,

21
00:02:37,374 --> 00:02:39,070
and then sent away.

22
00:02:39,071 --> 00:02:40,681
Fuck. They sent her home.

23
00:02:40,682 --> 00:02:43,901
She came back three
days later in a lot of pain,

24
00:02:43,902 --> 00:02:45,294
elevated pulse.

25
00:02:45,295 --> 00:02:47,819
She was put on IV fluids
and then transferred here.

26
00:02:48,211 --> 00:02:50,038
Decreased urine
output for two days.

27
00:02:50,039 --> 00:02:52,954
Imaging suggests there's
possible bowel involvement,

28
00:02:52,955 --> 00:02:55,913
and notes there is also
an IUCD in the sit...

29
00:02:59,004 --> 00:03:01,484
Okay. Sorry, Lisa.

30
00:03:01,485 --> 00:03:02,617
Sorry, Lisa.

31
00:03:07,230 --> 00:03:08,536
Well?

32
00:03:09,145 --> 00:03:11,277
Uh, clearly
intra-abdominal catastrophe,

33
00:03:11,278 --> 00:03:12,974
so immediate surgery to assess

34
00:03:12,975 --> 00:03:14,889
for perforated
bowel or appendix.

35
00:03:14,890 --> 00:03:16,195
Extensive fluids,

36
00:03:16,196 --> 00:03:18,414
transfer to theatre
for laparoscopy, right?

37
00:03:18,415 --> 00:03:21,243
I agree with immediate
urgent laparoscopy.

38
00:03:21,244 --> 00:03:24,072
Radiology suggests
necrosis of the bowel

39
00:03:24,073 --> 00:03:27,249
and abscess not amenable
to percutaneous drainage.

40
00:03:27,250 --> 00:03:29,251
She needs an operation.

41
00:03:29,252 --> 00:03:31,601
Three units
packed red blood cells,

42
00:03:31,602 --> 00:03:32,733
cross-matched.

43
00:03:32,734 --> 00:03:33,951
Prep for theatre.

44
00:03:33,952 --> 00:03:36,519
Call Dr. Colton to consent her.

45
00:03:36,520 --> 00:03:37,913
Lisa, we'll see you soon.

46
00:03:39,915 --> 00:03:41,263
All right!

47
00:03:41,264 --> 00:03:44,746
We will go in today using
the Hasson technique.

48
00:03:47,183 --> 00:03:48,270
Alex.

49
00:03:48,271 --> 00:03:51,055
We are... good to go.

50
00:03:51,056 --> 00:03:52,622
Knife.

51
00:03:52,623 --> 00:03:54,320
Knife.

52
00:03:54,321 --> 00:03:57,018
All right,
we make a ten mil incision

53
00:03:57,019 --> 00:03:59,107
just above the umbilicus,

54
00:03:59,108 --> 00:04:03,590
right through the subcutaneous
tissue into the fascia.

55
00:04:03,591 --> 00:04:04,722
Kocher.

56
00:04:08,248 --> 00:04:09,552
S-Bends.

57
00:04:09,553 --> 00:04:11,162
S-Bends.

58
00:04:11,163 --> 00:04:12,990
Thank you, Robin.
Holding.

59
00:04:12,991 --> 00:04:14,166
Thank you.

60
00:04:16,734 --> 00:04:17,778
Knife.

61
00:04:17,779 --> 00:04:19,911
Now, just a few...

62
00:04:20,956 --> 00:04:22,479
fibres at a time.

63
00:04:24,742 --> 00:04:26,570
And there's the peritoneum.

64
00:04:28,311 --> 00:04:29,486
Stitch.

65
00:04:32,489 --> 00:04:33,533
Here you go.

66
00:04:33,534 --> 00:04:34,578
Okay.

67
00:04:43,283 --> 00:04:45,196
Clip.

68
00:04:45,197 --> 00:04:46,764
- Ready?
- Cut.

69
00:04:48,244 --> 00:04:50,071
This one's out.

70
00:04:50,072 --> 00:04:51,333
Thank you, Robin.

71
00:04:51,334 --> 00:04:54,728
Thank you.
Now, we use traction.

72
00:04:54,729 --> 00:04:56,207
Why?

73
00:04:56,208 --> 00:04:58,862
To avoid damaging
the underlying structures

74
00:04:58,863 --> 00:05:01,125
when we penetrate the peritoneal
sheath into the abdomen.

75
00:05:01,126 --> 00:05:02,693
Good, Richard.

76
00:05:05,392 --> 00:05:07,915
- All right. Port, please, Robin.
- Port.

77
00:05:07,916 --> 00:05:10,047
All right, we'll be inserting

78
00:05:10,048 --> 00:05:11,614
three trocars into Lisa today.

79
00:05:11,615 --> 00:05:12,660
Here we go.

80
00:05:16,577 --> 00:05:18,405
Uh, reducer.
Please, Robin.

81
00:05:21,799 --> 00:05:23,626
Give her
the gas port there, Richard.

82
00:05:23,627 --> 00:05:24,933
Thank you.

83
00:05:27,718 --> 00:05:28,980
That's set up.

84
00:05:29,329 --> 00:05:31,330
- Gas on.
- Thank you.

85
00:05:31,331 --> 00:05:32,722
All right, maestro.

86
00:05:32,723 --> 00:05:33,897
Yes?

87
00:05:33,898 --> 00:05:35,290
Gas, please.

88
00:05:35,291 --> 00:05:36,509
Gas is on.

89
00:05:36,510 --> 00:05:37,814
Light is on.

90
00:05:37,815 --> 00:05:39,251
There it comes.

91
00:05:44,996 --> 00:05:46,955
There we are, Richard.
You guide it.

92
00:05:49,044 --> 00:05:50,653
There we go.

93
00:05:50,654 --> 00:05:52,134
Marsh?

94
00:05:55,746 --> 00:05:57,138
Hmm.

95
00:05:57,139 --> 00:05:59,227
Well...
uh, it's extensive pus.

96
00:05:59,228 --> 00:06:01,491
Indeed.
Sepsis it is.

97
00:06:02,449 --> 00:06:05,365
All right, I'm inserting
the second trocar now.

98
00:06:08,933 --> 00:06:10,456
Yeah, that's good.
Thank you, Richard.

99
00:06:10,457 --> 00:06:13,416
Hold it right there, I need
direct visualization, please.

100
00:06:15,287 --> 00:06:16,418
Put it back in a little bit.

101
00:06:16,419 --> 00:06:18,115
There...

102
00:06:18,116 --> 00:06:19,161
Okay.

103
00:06:24,819 --> 00:06:26,515
Thank you.

104
00:06:26,516 --> 00:06:28,604
All right, what's going
on with the gas?

105
00:06:28,605 --> 00:06:30,127
How much pressure?

106
00:06:30,128 --> 00:06:31,346
I need ten.

107
00:06:31,347 --> 00:06:32,566
We need more flow,

108
00:06:33,044 --> 00:06:34,567
more separation of the organs.

109
00:06:34,568 --> 00:06:36,177
Flow rate is at six.

110
00:06:36,178 --> 00:06:37,439
But we're not at ten yet.

111
00:06:37,440 --> 00:06:39,006
The tank was full.

112
00:06:39,007 --> 00:06:41,530
Mei-Lynn, can you
increase the flow, please?

113
00:06:41,531 --> 00:06:43,097
Copy that.

114
00:06:43,098 --> 00:06:45,752
Richard, do you want
to put in the last trocar?

115
00:06:45,753 --> 00:06:47,275
Yeah.

116
00:06:47,276 --> 00:06:48,363
Thank you, Robin.

117
00:06:48,364 --> 00:06:50,105
Let's find you a spot.

118
00:06:51,802 --> 00:06:52,889
Here we are.

119
00:06:52,890 --> 00:06:53,935
Thank you.

120
00:07:03,248 --> 00:07:05,206
Honey, you've got
plenty of room Richard,

121
00:07:05,207 --> 00:07:06,817
you've got plenty of room.

122
00:07:07,949 --> 00:07:08,950
You can see?

123
00:07:10,125 --> 00:07:11,126
Yeah.

124
00:07:13,520 --> 00:07:16,435
All right, Richard.
Time's ticking. Let's go.

125
00:07:18,089 --> 00:07:20,178
Let's go.
Give it some welly.

126
00:07:20,483 --> 00:07:21,528
Sorry.

127
00:07:26,489 --> 00:07:28,925
Fuck!
Quick, we need to open.

128
00:07:28,926 --> 00:07:31,145
- We're converting.
- We're converting.

129
00:07:31,146 --> 00:07:32,712
I need the B tray

130
00:07:32,713 --> 00:07:33,843
and arterial
instruments, please.

131
00:07:33,844 --> 00:07:35,018
B tray, please.

132
00:07:35,019 --> 00:07:35,758
Pull the trocars out, Richard.

133
00:07:35,759 --> 00:07:37,194
Sorry.

134
00:07:37,195 --> 00:07:38,848
Someone call
Mei-Lynn back in right now.

135
00:07:38,849 --> 00:07:40,284
- Someone call Mei-Lynn!
- B tray, please!

136
00:07:40,285 --> 00:07:41,764
Alex, talk to me.

137
00:07:41,765 --> 00:07:43,853
Systolic 90.
Pressure is falling now.

138
00:07:43,854 --> 00:07:45,464
Of course it's fucking falling.

139
00:07:45,465 --> 00:07:47,988
I need the B tray!

140
00:07:47,989 --> 00:07:49,511
B, B, quick, quick, quick!

141
00:07:49,512 --> 00:07:51,295
Calm, calm.

142
00:07:51,296 --> 00:07:52,383
Please, everybody, quiet.

143
00:07:52,384 --> 00:07:53,994
Diathermy?

144
00:07:53,995 --> 00:07:56,823
Uh, no. I don't
have time. I'll do it myself.

145
00:07:56,824 --> 00:07:58,520
Richard, hold that.

146
00:07:58,521 --> 00:07:59,565
Alex?

147
00:07:59,566 --> 00:08:01,915
Heart rate is 160.

148
00:08:01,916 --> 00:08:03,482
Pushing midribonol now.

149
00:08:03,483 --> 00:08:04,744
Hold that, Richard.

150
00:08:04,745 --> 00:08:06,833
Here we go. All right.
I'm going in, Alex.

151
00:08:10,751 --> 00:08:12,186
- Fuck!
- Suction.

152
00:08:12,187 --> 00:08:13,404
Suction.

153
00:08:13,405 --> 00:08:15,668
Retractors.
I'll hold it. Retractors.

154
00:08:15,669 --> 00:08:17,800
- Yeah, we need...
- Nice, Robin.

155
00:08:17,801 --> 00:08:19,498
- Good. You got it?
- I got this.

156
00:08:19,499 --> 00:08:20,542
Get the big one.

157
00:08:20,543 --> 00:08:21,936
Pull it, Richard. Pull it.

158
00:08:24,373 --> 00:08:25,982
- Yeah, Richard.
- I got it. I got it.

159
00:08:25,983 --> 00:08:28,464
- Packs.
- Packs.

160
00:08:39,083 --> 00:08:40,883
- Careful with the ureter.
- Mm-hmm.

161
00:08:41,999 --> 00:08:44,044
Suction...
I can't find it.

162
00:08:44,045 --> 00:08:45,741
Find it.

163
00:08:45,742 --> 00:08:47,917
It's not the IVC,

164
00:08:47,918 --> 00:08:49,440
it's the lumbar artery.

165
00:08:49,441 --> 00:08:51,226
Put your finger on it.

166
00:08:51,618 --> 00:08:52,748
Pressure.

167
00:08:52,749 --> 00:08:54,271
- Sorry.
- Feel it?

168
00:08:54,272 --> 00:08:55,490
Right there.
It's pumping.

169
00:08:55,491 --> 00:08:56,883
- Feel it?
- Mm.

170
00:08:56,884 --> 00:08:59,059
Keep your
finger on it. Clamp.

171
00:08:59,060 --> 00:09:00,365
Thank you.

172
00:09:05,545 --> 00:09:07,067
Got it? Okay.

173
00:09:07,068 --> 00:09:08,722
One more here.
One more here.

174
00:09:10,375 --> 00:09:11,376
Stitches.

175
00:09:12,464 --> 00:09:13,769
Five-0, please.

176
00:09:13,770 --> 00:09:15,119
Stitch.

177
00:09:40,928 --> 00:09:41,929
Okay.

178
00:09:43,147 --> 00:09:45,105
The torrential bleeding
from the vena cava

179
00:09:45,106 --> 00:09:46,586
is controlled with clamps...

180
00:09:47,630 --> 00:09:50,110
and we move
in order of urgency.

181
00:09:50,111 --> 00:09:52,068
Richard has control

182
00:09:52,069 --> 00:09:54,332
of the posterior
tear with his finger.

183
00:09:55,246 --> 00:09:58,684
The most urgent
is the lumbar vessel

184
00:09:58,685 --> 00:10:00,468
due to the volume of bleeding,

185
00:10:00,469 --> 00:10:03,515
and I am focused
on that right now.

186
00:10:07,607 --> 00:10:09,304
There's a rent in the IVC...

187
00:10:12,089 --> 00:10:13,395
which is clamped,

188
00:10:14,570 --> 00:10:17,442
and severe lumbar
bleeding in the psoas,

189
00:10:18,705 --> 00:10:21,663
which is posterior...

190
00:10:21,664 --> 00:10:23,971
and deep.

191
00:10:25,059 --> 00:10:27,104
Currently sewing five-0 prolene.

192
00:10:33,589 --> 00:10:34,937
Looking much better now.

193
00:10:34,938 --> 00:10:37,201
- Okay.
- Pressure is coming up.

194
00:10:38,507 --> 00:10:40,682
Now for the original operation.

195
00:10:40,683 --> 00:10:43,554
Let's wash out this pelvis,
pop in a drain,

196
00:10:43,555 --> 00:10:45,470
take out the appendix
for good measure.

197
00:10:46,558 --> 00:10:47,820
Yeah. Okay.

198
00:10:47,821 --> 00:10:49,778
Uh, I'm... Elizabeth, I'm sorry.

199
00:10:49,779 --> 00:10:52,303
Hey, just close.

200
00:10:57,134 --> 00:10:59,310
- Josie.
- I need you on this retractor.

201
00:10:59,963 --> 00:11:00,964
Yeah.

202
00:11:03,575 --> 00:11:04,576
Okay, uh...

203
00:11:05,708 --> 00:11:06,708
Okay, splash me.

204
00:11:08,102 --> 00:11:10,142
- Thank you.
- I'll take suction. Thank you.

205
00:11:13,150 --> 00:11:14,673
Fuck.

206
00:11:14,674 --> 00:11:16,588
- Yeah, well...
- Suction.

207
00:11:20,941 --> 00:11:22,116
Uh, yes, let me.

208
00:11:22,856 --> 00:11:24,378
Thank you, that's it.

209
00:11:24,379 --> 00:11:25,727
Suction.

210
00:11:41,570 --> 00:11:43,484
Unfortunately,
I've got to reschedule

211
00:11:43,485 --> 00:11:44,921
my next surgery.

212
00:11:49,360 --> 00:11:51,274
Go tell Lisa's
parents it went well.

213
00:11:51,275 --> 00:11:52,667
Uh, don't you want...

214
00:11:52,668 --> 00:11:53,755
She's out of the woods.

215
00:11:53,756 --> 00:11:55,191
But surely you could explain...

216
00:11:55,192 --> 00:11:57,628
Richard, it went well.

217
00:11:57,629 --> 00:11:59,326
She's in recovery.

218
00:11:59,327 --> 00:12:01,068
They can talk to her in ICU.

219
00:12:03,244 --> 00:12:04,593
You're good with families.

220
00:12:05,463 --> 00:12:06,682
Thank you, Richard.

221
00:12:19,086 --> 00:12:20,869
Um,
Mr. and Mrs. Williams,

222
00:12:20,870 --> 00:12:23,567
I am Richard Whitehead,
the registrar.

223
00:12:23,568 --> 00:12:25,439
I'm with Mrs. Taylor.

224
00:12:25,440 --> 00:12:27,571
Lisa's doing well.
She's in recovery now.

225
00:12:27,572 --> 00:12:29,705
I just want to apologize
about the delay.

226
00:13:06,176 --> 00:13:07,960
Just nice, deep breaths, Lisa.

227
00:13:07,961 --> 00:13:10,137
Just easy breaths.
Yeah.

228
00:13:11,181 --> 00:13:12,226
That's it.

229
00:13:17,927 --> 00:13:19,015
How's she doing?

230
00:13:19,668 --> 00:13:20,929
Uh, she's stable.

231
00:13:20,930 --> 00:13:23,150
A bit agitated about the mask.

232
00:13:33,595 --> 00:13:34,857
Hi, Lisa.

233
00:13:51,613 --> 00:13:52,832
It went well.

234
00:14:52,021 --> 00:14:54,545
Robin, did you get a taxi?

235
00:14:56,417 --> 00:14:57,809
Uh, yeah.

236
00:14:58,854 --> 00:15:00,333
Clear night.

237
00:15:00,334 --> 00:15:01,856
Um, yeah. It is.

238
00:15:01,857 --> 00:15:03,292
It's beautiful.

239
00:15:03,293 --> 00:15:05,252
Want some chicken?

240
00:15:08,472 --> 00:15:10,386
Got a double shift tomorrow.

241
00:15:10,387 --> 00:15:11,649
- That's shit.
- Mm.

242
00:15:12,999 --> 00:15:14,639
- I'll talk to Alastair...
- Mm-mm.

243
00:15:15,436 --> 00:15:16,958
Please don't.

244
00:15:16,959 --> 00:15:18,960
You can't do things like that.

245
00:15:18,961 --> 00:15:20,180
It might ruin things.

246
00:15:25,272 --> 00:15:26,273
You good?

247
00:15:30,190 --> 00:15:31,973
Yeah.

248
00:15:31,974 --> 00:15:32,975
Yup.

249
00:16:26,289 --> 00:16:27,725
Fuck!

250
00:16:53,925 --> 00:16:54,969
All good?

251
00:16:54,970 --> 00:16:57,015
Yeah, of course.
Uh, five by three.

252
00:16:57,016 --> 00:16:58,278
Walk beside me, Richard.

253
00:17:01,585 --> 00:17:03,195
How are you doing?

254
00:17:03,196 --> 00:17:04,805
I'm all right.

255
00:17:04,806 --> 00:17:07,590
Good. How did you hear?

256
00:17:07,591 --> 00:17:08,636
Hear what?

257
00:17:13,728 --> 00:17:16,164
Richard, we lost
the sepsis this morning.

258
00:17:16,165 --> 00:17:18,124
I was texted on the way in.

259
00:17:19,864 --> 00:17:22,040
She... What?
So she was what, in the ICU?

260
00:17:22,041 --> 00:17:23,390
Yes, in ICU.

261
00:17:24,434 --> 00:17:25,869
Ah, I didn't know.

262
00:17:25,870 --> 00:17:27,132
Yes, it's a bad outcome.

263
00:17:27,133 --> 00:17:28,482
It's very disappointing.

264
00:17:29,918 --> 00:17:30,918
Okay?

265
00:17:30,919 --> 00:17:32,094
Yeah, of course. Yeah.

266
00:17:34,140 --> 00:17:35,749
The sepsis was too advanced,

267
00:17:35,750 --> 00:17:38,448
and she was likely
never going to make it.

268
00:17:42,496 --> 00:17:44,540
The trocar... did that...
Was that...

269
00:17:44,541 --> 00:17:46,413
This was advanced sepsis,
wasn't it?

270
00:17:46,935 --> 00:17:48,153
You saw that yourself.

271
00:17:48,154 --> 00:17:51,765
So we'll never know
to what degree if any,

272
00:17:51,766 --> 00:17:53,897
the extra time
in surgery contributed.

273
00:17:53,898 --> 00:17:55,508
Yeah... I suppose
the complication...

274
00:17:55,509 --> 00:17:56,857
The complication
may have contributed,

275
00:17:56,858 --> 00:17:58,119
but we'll never know how much.

276
00:17:58,120 --> 00:17:59,164
Right?

277
00:17:59,165 --> 00:18:01,080
So certainly didn't help.

278
00:18:01,863 --> 00:18:03,952
Look, all we can do
now is move on.

279
00:18:05,127 --> 00:18:06,606
Get past it. Get better.

280
00:18:06,607 --> 00:18:07,651
Learn.

281
00:18:10,089 --> 00:18:11,264
Morning, Liz.

282
00:18:13,179 --> 00:18:14,483
Good morning, Alastair.

283
00:18:14,484 --> 00:18:16,920
Have you seen the staff
photo on the website?

284
00:18:16,921 --> 00:18:19,401
Yes. It looked like
a group of prisoners

285
00:18:19,402 --> 00:18:21,099
about to be taken out and shot.

286
00:18:21,100 --> 00:18:22,144
Ah.

287
00:18:23,363 --> 00:18:24,775
Well, maybe
it was the black and white.

288
00:18:24,799 --> 00:18:26,366
What can I do for you, Alastair?

289
00:18:27,193 --> 00:18:29,019
Can we have a quick word?

290
00:18:29,020 --> 00:18:30,673
Of course.

291
00:18:30,674 --> 00:18:31,979
I'll catch up.

292
00:18:31,980 --> 00:18:34,112
- Yeah, okay.
- Thanks, Richard.

293
00:18:34,113 --> 00:18:35,114
No worries.

294
00:18:36,289 --> 00:18:37,332
I'm sorry.

295
00:18:37,333 --> 00:18:38,987
Um, hi, David isn't it?

296
00:18:39,205 --> 00:18:41,120
- Yes.
- Great, I've got...

297
00:18:42,164 --> 00:18:43,425
Anyway, Alastair?

298
00:18:43,426 --> 00:18:45,601
Liz,
the family of Lisa Williams,

299
00:18:45,602 --> 00:18:47,908
who died this morning,
are asking to see you.

300
00:18:47,909 --> 00:18:49,127
They're here now.

301
00:18:49,128 --> 00:18:50,345
Oh.

302
00:18:50,346 --> 00:18:53,218
I should warn you,
they're very distraught.

303
00:18:53,219 --> 00:18:56,221
They were under the impression
that when she was admitted,

304
00:18:56,222 --> 00:18:57,570
yes, it was an emergency,

305
00:18:57,571 --> 00:19:00,790
but an appendix
or something like that.

306
00:19:00,791 --> 00:19:02,836
They feel very caught off guard,

307
00:19:02,837 --> 00:19:04,751
and they say
they're very unsatisfied

308
00:19:04,752 --> 00:19:06,927
with the explanation from ICU.

309
00:19:06,928 --> 00:19:08,537
Who spoke to them from ICU?

310
00:19:08,538 --> 00:19:09,712
Ben Matthews.

311
00:19:09,713 --> 00:19:11,237
Ben was the intensivist.

312
00:19:13,064 --> 00:19:14,500
Andrew.

313
00:19:14,501 --> 00:19:16,242
Elizabeth, how are you?

314
00:19:17,373 --> 00:19:19,375
Well, I'm happy
to speak with them.

315
00:19:22,248 --> 00:19:24,553
And what are you going to say?

316
00:19:24,554 --> 00:19:27,034
I'm going to tell them
what happened in surgery.

317
00:19:27,035 --> 00:19:28,644
I wasn't there in ICU.

318
00:19:28,645 --> 00:19:29,994
Okay.

319
00:19:31,170 --> 00:19:33,172
What really happened, Liz?

320
00:19:34,651 --> 00:19:36,523
Well, you've obviously
read the notes.

321
00:19:38,960 --> 00:19:41,309
Uncontrolled
insertion of a trocar

322
00:19:41,310 --> 00:19:43,268
leading to internal damage...

323
00:19:43,269 --> 00:19:46,227
Which was unrelated
to the galloping infection

324
00:19:46,228 --> 00:19:49,057
that led to her fatal
deterioration in ICU.

325
00:19:50,450 --> 00:19:51,537
"Unrelated"?

326
00:19:51,538 --> 00:19:53,234
Yes, that's what I said.

327
00:19:53,235 --> 00:19:54,757
Okay...

328
00:19:54,758 --> 00:19:56,063
But you know what
you're going to say.

329
00:19:56,064 --> 00:19:57,195
You've got it in hand.

330
00:19:57,196 --> 00:19:58,239
I think well in hand.

331
00:19:58,240 --> 00:20:00,589
- Okay.
- Thank you, Andrew.

332
00:20:00,590 --> 00:20:01,895
Actually, I just
wanted to ask you

333
00:20:01,896 --> 00:20:03,244
if you're coming
to the conference,

334
00:20:03,245 --> 00:20:05,899
the Surgical Safety
and Measurements Jamboree?

335
00:20:05,900 --> 00:20:08,815
Yes, Andrew. I will take
that one for the team.

336
00:20:08,816 --> 00:20:11,296
Actually, I want the whole team
to be there. Richard, Robin.

337
00:20:11,297 --> 00:20:12,471
I think it's important.

338
00:20:12,472 --> 00:20:14,821
It's... It's quite interesting.

339
00:20:14,822 --> 00:20:16,039
Interesting?

340
00:20:16,040 --> 00:20:17,476
Well... it is about
publishing results.

341
00:20:17,477 --> 00:20:19,521
That's our new reality.

342
00:20:19,522 --> 00:20:23,221
Our surgical results are going
to be published in the paper.

343
00:20:23,222 --> 00:20:25,963
Mortality, complications.

344
00:20:26,703 --> 00:20:28,444
<i>My</i> results, you mean.

345
00:20:30,490 --> 00:20:32,187
True, your results.

346
00:20:33,188 --> 00:20:35,058
Everything under your watch.

347
00:20:35,059 --> 00:20:37,278
But I don't think it's, uh...

348
00:20:37,279 --> 00:20:39,280
I don't think
it's necessarily a bad idea.

349
00:20:39,281 --> 00:20:42,152
It will incentivize us to
avoid very sick patients

350
00:20:42,153 --> 00:20:43,590
and it will affect training.

351
00:20:44,460 --> 00:20:46,854
Liz, the family are waiting
in the Whanau room.

352
00:20:47,898 --> 00:20:49,421
Thank you.

353
00:20:49,422 --> 00:20:50,683
Andrew.

354
00:20:50,684 --> 00:20:51,728
Elizabeth.

355
00:21:48,176 --> 00:21:50,091
I'm so sorry for your loss.

356
00:21:53,399 --> 00:21:54,443
Well...

357
00:21:55,575 --> 00:21:58,360
This is what happened to Lisa.

358
00:21:59,840 --> 00:22:02,625
Lisa was very sick
when she came to hospital.

359
00:22:05,062 --> 00:22:08,805
Some of her reproductive
organs had become infected.

360
00:22:10,024 --> 00:22:12,939
We believe this was
because of her IUCD.

361
00:22:12,940 --> 00:22:15,899
That stands for "Intrauterine
Contraceptive Device."

362
00:22:18,554 --> 00:22:20,163
Uh...

363
00:22:20,164 --> 00:22:24,559
We needed to do what
is called a "laparoscopy."

364
00:22:24,560 --> 00:22:26,996
That's a kind of keyhole surgery

365
00:22:26,997 --> 00:22:29,085
where we make a small hole

366
00:22:29,086 --> 00:22:32,045
and... and use a small
camera to look inside Lisa

367
00:22:32,046 --> 00:22:36,136
and see... um...
what's wrong with her.

368
00:22:36,137 --> 00:22:39,052
And we could see
that she was very sick,

369
00:22:39,053 --> 00:22:41,620
that many of her abdominal
organs had become infected,

370
00:22:41,621 --> 00:22:45,667
and that she needed a...

371
00:22:45,668 --> 00:22:48,714
a proper operation to
help her get better.

372
00:22:48,715 --> 00:22:51,631
And I can give you the details
of that if you'd like.

373
00:23:00,161 --> 00:23:02,381
I mean, we just don't
know what happened.

374
00:23:04,687 --> 00:23:07,297
We... We want to know more.

375
00:23:17,091 --> 00:23:18,788
Uh...

376
00:23:20,355 --> 00:23:22,965
There was a complication
during the surgery.

377
00:23:22,966 --> 00:23:27,536
We had to make a larger
incision than initially planned.

378
00:23:28,537 --> 00:23:29,930
What complication?

379
00:23:31,061 --> 00:23:34,021
As I said,
her IUCD had become infected.

380
00:23:34,674 --> 00:23:37,589
And, um, we don't
know why at this point.

381
00:23:37,590 --> 00:23:40,418
But there are many
reasons it could have happened.

382
00:23:40,419 --> 00:23:44,334
Lisa was moved to intensive
care after the surgery,

383
00:23:44,335 --> 00:23:46,946
and I was not directly
involved in that.

384
00:23:46,947 --> 00:23:49,079
We just thought,
"Oh, it's her..."

385
00:23:50,733 --> 00:23:53,387
We just thought
her appendix had burst,

386
00:23:53,388 --> 00:23:55,998
which is why it was so bad.

387
00:23:55,999 --> 00:23:57,348
I'm sorry.

388
00:23:58,741 --> 00:24:00,742
I know this must be very hard,

389
00:24:00,743 --> 00:24:03,310
but it was not to do
with her appendix.

390
00:24:03,311 --> 00:24:06,139
Lisa had trouble
breathing in ICU.

391
00:24:06,140 --> 00:24:08,968
The infection was
too much for her body,

392
00:24:08,969 --> 00:24:12,146
and this led to
her cardiac arrest.

393
00:24:16,759 --> 00:24:18,369
She's in the morgue.

394
00:24:20,067 --> 00:24:23,723
Our daughter is in the morgue.

395
00:24:32,993 --> 00:24:34,473
Wh... What's your name?

396
00:24:38,738 --> 00:24:41,741
Elizabeth Taylor is my name.

397
00:25:56,816 --> 00:25:58,294
<i>Welcome, everybody,</i>

398
00:25:58,295 --> 00:26:02,342
<i>to this week's MandM.</i>

399
00:26:02,343 --> 00:26:06,086
<i>So we'll start with
the Lisa Williams case.</i>

400
00:26:06,869 --> 00:26:12,831
Anaesthesia, nursing,
as well as surgery.

401
00:26:12,832 --> 00:26:14,311
Glad to see you.

402
00:26:15,835 --> 00:26:17,705
Uh, excuse me.
Where's Dr. Matthews?

403
00:26:17,706 --> 00:26:19,707
Well, Dr. Matthews
is an apology.

404
00:26:19,708 --> 00:26:21,404
Dr. Matthews
was the intensivist

405
00:26:21,405 --> 00:26:22,841
on Lisa Williams,

406
00:26:22,842 --> 00:26:24,625
- the main case today.
- Well...

407
00:26:24,626 --> 00:26:27,976
I'd like to call for this
meeting to be adjourned.

408
00:26:27,977 --> 00:26:29,804
Oh... Why, Liz?

409
00:26:29,805 --> 00:26:32,633
Without Dr. Matthews,
what's the point?

410
00:26:32,634 --> 00:26:33,852
Well, the point is that

411
00:26:33,853 --> 00:26:36,419
this is a morbidity
and mortality meeting,

412
00:26:36,420 --> 00:26:39,597
and in it, we're going to
be discussing in particular

413
00:26:39,598 --> 00:26:41,207
surgery and mortality.

414
00:26:41,208 --> 00:26:44,210
The mortality in this case is
not related to the surgery.

415
00:26:44,211 --> 00:26:46,516
It's related to her
advanced sepsis,

416
00:26:46,517 --> 00:26:49,258
and the nearly 12 hours
of intensive care

417
00:26:49,259 --> 00:26:51,391
that failed to save
her afterwards.

418
00:26:51,392 --> 00:26:52,958
No, this is just an MandM.

419
00:26:52,959 --> 00:26:54,787
We're not apportioning blame.

420
00:26:55,439 --> 00:26:56,483
Um... Blame?

421
00:26:56,484 --> 00:26:57,789
No...

422
00:26:57,790 --> 00:26:59,791
I want to know what happened.

423
00:26:59,792 --> 00:27:01,706
Family want more information.

424
00:27:01,707 --> 00:27:02,968
What information?

425
00:27:02,969 --> 00:27:04,665
I've spoken to them already.

426
00:27:04,666 --> 00:27:06,841
Well, let's just say
their acceptance

427
00:27:06,842 --> 00:27:09,365
of their daughter's death
is not yet settled.

428
00:27:09,366 --> 00:27:11,630
Okay, this is so fucking stupid.

429
00:27:13,109 --> 00:27:15,981
Why would that be stupid, Liz?

430
00:27:15,982 --> 00:27:18,637
It's stupid, Andrew, because...

431
00:27:20,726 --> 00:27:22,204
We can go through our notes,

432
00:27:22,205 --> 00:27:24,424
you can talk to my team
till you're blue in the face.

433
00:27:24,425 --> 00:27:28,471
But we can't possibly know
what happened with this girl

434
00:27:28,472 --> 00:27:30,343
without ICU
and their nurses here,

435
00:27:30,344 --> 00:27:31,910
because they took over her care

436
00:27:31,911 --> 00:27:34,521
and she <i>died</i> on their watch.

437
00:27:34,522 --> 00:27:37,089
Lisa Williams' parents
have questions about errors

438
00:27:37,090 --> 00:27:40,135
made by the surgical staff,
not ICU.

439
00:27:40,136 --> 00:27:43,661
They want to know about
complications in the surgery,

440
00:27:43,662 --> 00:27:47,403
your surgery,
because you told them

441
00:27:47,404 --> 00:27:51,191
there were complications
for Liz... apparently.

442
00:27:52,409 --> 00:27:54,455
I mean, for Lisa.

443
00:27:56,109 --> 00:27:57,763
Am I right?

444
00:27:59,939 --> 00:28:02,114
Or...

445
00:28:02,115 --> 00:28:03,594
am I being stupid?

446
00:28:05,771 --> 00:28:08,686
Right.
Let me just summarize.

447
00:28:08,687 --> 00:28:12,298
- Anaesthesia started at 1:40.
- Yes, it did.

448
00:28:12,299 --> 00:28:14,953
- And the surgery at 1:50.
- Correct.

449
00:28:14,954 --> 00:28:16,737
And the gas port was inserted

450
00:28:16,738 --> 00:28:21,047
into the abdomen and,
uh, insufflation commenced.

451
00:28:21,656 --> 00:28:22,657
Robin?

452
00:28:24,311 --> 00:28:26,138
Yes. Yes, that is correct.

453
00:28:26,139 --> 00:28:28,270
And you say here in your notes

454
00:28:28,271 --> 00:28:32,100
that Mrs. Taylor verbalized
that there was no gas.

455
00:28:32,101 --> 00:28:33,536
Insufficient gas.

456
00:28:33,537 --> 00:28:35,060
I-I said in my notes

457
00:28:35,061 --> 00:28:39,586
that, um, Mrs. Taylor said
there was insufficient gas flow.

458
00:28:39,587 --> 00:28:41,023
What did she mean?

459
00:28:43,286 --> 00:28:44,896
What...

460
00:28:44,897 --> 00:28:47,768
She meant there's insufficient
pressure of gas in the abdomen

461
00:28:47,769 --> 00:28:49,727
that lifts the peritoneal sac

462
00:28:49,728 --> 00:28:51,685
away from internal structures

463
00:28:51,686 --> 00:28:54,906
that could be damaged
by insertion of instruments.

464
00:28:54,907 --> 00:28:57,430
And what was the pressure
at that point?

465
00:28:57,431 --> 00:28:59,258
How much gas was in her abdomen?

466
00:28:59,259 --> 00:29:01,086
I mean, frankly speaking,

467
00:29:01,087 --> 00:29:03,045
was it safe to go
sticking things in her?

468
00:29:03,959 --> 00:29:05,525
Well, I don't know, Doctor.

469
00:29:05,526 --> 00:29:07,048
Ah! You don't know?

470
00:29:07,049 --> 00:29:08,746
She can't know!

471
00:29:08,747 --> 00:29:11,792
The indicator on the insufflator
reads "enough" or "not enough."

472
00:29:11,793 --> 00:29:13,968
When the belly is inflated,
the gas slows down

473
00:29:13,969 --> 00:29:15,883
as the pressure
doesn't let it in there.

474
00:29:15,884 --> 00:29:18,973
The theoretical pressure needed
inside the cavity is ten, sure,

475
00:29:18,974 --> 00:29:22,150
but there's no actual
gauge that measures that.

476
00:29:22,151 --> 00:29:25,632
It just says the flow rate
is or is not high enough

477
00:29:25,633 --> 00:29:27,068
to inflate at that level.

478
00:29:27,069 --> 00:29:28,635
- Okay.
- Okay or not.

479
00:29:28,636 --> 00:29:31,464
We had direct visualization
of the organ space.

480
00:29:31,465 --> 00:29:32,682
Okay.

481
00:29:32,683 --> 00:29:34,815
And at whatever
actual pressure it was,

482
00:29:34,816 --> 00:29:36,817
in my clinical judgment,

483
00:29:36,818 --> 00:29:38,166
there was sufficient pressure...

484
00:29:38,167 --> 00:29:40,125
To insert the last trocar?

485
00:29:40,126 --> 00:29:41,430
Yes, Jason.

486
00:29:41,431 --> 00:29:44,172
Jesus, Jason.
There's no definitive timing.

487
00:29:44,173 --> 00:29:46,131
That's what you do.

488
00:29:46,132 --> 00:29:47,960
You use your clinical judgment.

489
00:29:49,091 --> 00:29:52,006
So, who inserted
the last trocar, Liz?

490
00:29:52,007 --> 00:29:54,314
Who put it... the trocar in?

491
00:29:58,231 --> 00:29:59,232
Uh...

492
00:30:01,408 --> 00:30:02,843
I did.

493
00:30:02,844 --> 00:30:05,715
You inserted the last trocar

494
00:30:05,716 --> 00:30:08,153
that caused
the damage to this girl,

495
00:30:08,154 --> 00:30:11,243
which was a rent in
the inferior vena cava,

496
00:30:11,244 --> 00:30:13,506
cut in the posterior
abdominal wall,

497
00:30:13,507 --> 00:30:14,855
a tear in the lumbar artery...

498
00:30:14,856 --> 00:30:18,772
Yes, yes, which we repaired,
of course.

499
00:30:18,773 --> 00:30:19,947
Okay, good.

500
00:30:19,948 --> 00:30:21,645
Good. Yes.

501
00:30:24,344 --> 00:30:25,345
Okay.

502
00:30:27,521 --> 00:30:30,871
Look, it was more
complicated than that.

503
00:30:30,872 --> 00:30:35,267
I instructed my registrar,
Richard Whitehead,

504
00:30:35,268 --> 00:30:38,879
to make the incision
and insert the last trocar,

505
00:30:38,880 --> 00:30:40,272
and he did.

506
00:30:40,273 --> 00:30:43,188
Oh, so <i>Richard</i> inserted
the last trocar.

507
00:30:43,189 --> 00:30:44,667
I'm the team leader.

508
00:30:44,668 --> 00:30:45,931
I'm the lead surgeon.

509
00:30:46,627 --> 00:30:48,323
It's my theatre.

510
00:30:48,324 --> 00:30:49,803
Under my instruction,

511
00:30:49,804 --> 00:30:52,198
Richard inserted
the last trocar,

512
00:30:53,721 --> 00:30:55,375
which failed to penetrate.

513
00:30:56,680 --> 00:30:58,986
I told him to push harder.

514
00:30:58,987 --> 00:31:00,727
Told Richard...

515
00:31:00,728 --> 00:31:03,122
I said to give it some welly.

516
00:31:05,037 --> 00:31:06,081
"Welly."

517
00:31:12,653 --> 00:31:13,654
That's right.

518
00:31:27,929 --> 00:31:31,932
Would you look at
this gorgeous creature?

519
00:31:31,933 --> 00:31:33,326
You're a dog mother.

520
00:31:34,805 --> 00:31:37,372
Have you ever seen
anything so photogenic?

521
00:31:37,373 --> 00:31:39,853
- He's like your child.
- Mmm.

522
00:31:39,854 --> 00:31:41,290
He's great company.

523
00:31:42,944 --> 00:31:44,336
What's new?

524
00:31:45,947 --> 00:31:47,817
You know, it's...

525
00:31:47,818 --> 00:31:49,733
It's complicated.

526
00:31:50,517 --> 00:31:52,387
I met a really smart guy.

527
00:31:52,388 --> 00:31:54,695
And your marriage?

528
00:31:55,696 --> 00:31:56,958
It's over.

529
00:31:59,743 --> 00:32:01,440
- Yeah.
- I'm sorry.

530
00:32:01,441 --> 00:32:03,008
Yeah, I know.
It's shit, really.

531
00:32:08,274 --> 00:32:10,885
I had a shit week too.

532
00:32:12,452 --> 00:32:13,539
Yeah.

533
00:32:13,540 --> 00:32:14,888
Complicated, as you say.

534
00:32:14,889 --> 00:32:15,934
Mm.

535
00:32:20,547 --> 00:32:22,156
Um...

536
00:32:22,157 --> 00:32:24,985
So I really hate to ask, Liz,

537
00:32:24,986 --> 00:32:26,987
but is there any
way that Atticus

538
00:32:26,988 --> 00:32:28,729
could stay with you
for a little while?

539
00:32:30,383 --> 00:32:32,036
- The dog?
- Yeah.

540
00:32:32,037 --> 00:32:33,559
It's just because I'm...

541
00:32:33,560 --> 00:32:35,387
I'm moving into his apartment,

542
00:32:35,388 --> 00:32:38,781
and-and you know,
it's no good for a big dog.

543
00:32:38,782 --> 00:32:40,783
There's elevators and stuff.

544
00:32:40,784 --> 00:32:45,484
And Stephen won't take him
because he's punishing me, so...

545
00:32:45,485 --> 00:32:47,269
But it would just
be for a short term.

546
00:32:48,096 --> 00:32:50,010
Jess, no. I really don't...

547
00:32:50,011 --> 00:32:51,533
I really don't think I can.

548
00:32:51,534 --> 00:32:53,535
Atticus is so old, Liz.

549
00:32:53,536 --> 00:32:55,189
He's totally house trained.

550
00:32:55,190 --> 00:32:58,105
All he does is just lie around
in the sun all day and sleep,

551
00:32:58,106 --> 00:32:59,193
and he'll be your best buddy.

552
00:32:59,194 --> 00:33:00,325
I am never home.

553
00:33:00,326 --> 00:33:01,674
Oh, God. Fuck.
Don't worry about it.

554
00:33:01,675 --> 00:33:03,982
We're never home either.
He's totally used to it.

555
00:33:14,818 --> 00:33:16,516
Robin, where are you?

556
00:33:17,647 --> 00:33:19,127
I want you to come over.

557
00:33:20,476 --> 00:33:21,869
Do you want to?

558
00:33:23,305 --> 00:33:24,437
Um.

559
00:33:25,873 --> 00:33:28,701
Hey, I'm sorry I've been
so distracted by everything,

560
00:33:28,702 --> 00:33:31,009
you know,
all the shitty fucking shit.

561
00:33:32,880 --> 00:33:36,752
Jessica is making
me take her dog.

562
00:33:38,451 --> 00:33:39,756
<i>It's such...</i>

563
00:33:40,583 --> 00:33:42,020
Uh... Okay.

564
00:33:44,718 --> 00:33:46,240
Bye for now.

565
00:33:46,241 --> 00:33:47,329
Call me.

566
00:36:08,601 --> 00:36:10,341
You have been
invisible to your patients

567
00:36:10,342 --> 00:36:13,257
and your performance levels
have been equally invisible

568
00:36:13,258 --> 00:36:14,693
until now,

569
00:36:14,694 --> 00:36:16,477
because we are
going to be publishing

570
00:36:16,478 --> 00:36:18,740
surgical outcomes publicly.

571
00:36:18,741 --> 00:36:20,656
This, of course, raises
profound questions,

572
00:36:21,353 --> 00:36:23,963
because once publication starts,

573
00:36:23,964 --> 00:36:27,009
patients and potential patients

574
00:36:27,010 --> 00:36:29,535
will assess your track records
and compare you to others.

575
00:36:30,231 --> 00:36:32,711
Of course, they won't know
that the surgeon down the road,

576
00:36:32,712 --> 00:36:34,843
who has much better statistics,

577
00:36:34,844 --> 00:36:36,584
only qualified six months ago,

578
00:36:36,585 --> 00:36:40,240
and has operated on
a grand total of seven young,

579
00:36:40,241 --> 00:36:41,981
non-smoking white patients,

580
00:36:41,982 --> 00:36:44,940
whilst you have
been in the trenches,

581
00:36:44,941 --> 00:36:48,640
operating on the morbidly obese,
the diabetic,

582
00:36:48,641 --> 00:36:51,077
elderly brown folk
with histories of falls

583
00:36:51,078 --> 00:36:53,122
and gout
and respiratory disease.

584
00:36:53,123 --> 00:36:55,690
You will be compared
surgeon to surgeon,

585
00:36:55,691 --> 00:36:58,258
and every case of everyone
who has ever died

586
00:36:58,259 --> 00:36:59,564
underneath your scalpel

587
00:36:59,565 --> 00:37:01,653
will be on full public display.

588
00:37:01,654 --> 00:37:05,223
Every surgical site,
infection, every nicked aorta.

589
00:37:06,398 --> 00:37:08,616
Will some surgeons
be forced to retire?

590
00:37:08,617 --> 00:37:10,139
Maybe.

591
00:37:10,140 --> 00:37:11,532
Probably.

592
00:37:11,533 --> 00:37:13,708
Will some surgeons
be treated unfairly?

593
00:37:13,709 --> 00:37:15,275
Yes, most likely.

594
00:37:15,276 --> 00:37:16,798
Why, then, should we allow this,

595
00:37:16,799 --> 00:37:17,974
even encourage it?

596
00:37:18,888 --> 00:37:21,586
Transparency
and informed consent.

597
00:37:21,587 --> 00:37:23,544
And I'm talking about
real consent,

598
00:37:23,545 --> 00:37:26,417
not just a scribble
on a piece of paper

599
00:37:26,418 --> 00:37:27,940
moments before operating.

600
00:37:27,941 --> 00:37:29,463
In the broader context,
a surgeon...

601
00:37:29,464 --> 00:37:31,160
Sorry. I'm sorry.

602
00:37:31,161 --> 00:37:32,249
Yes?

603
00:37:32,250 --> 00:37:33,815
Liz Taylor.

604
00:37:33,816 --> 00:37:36,209
Yes, Mrs. Taylor?

605
00:37:36,210 --> 00:37:38,256
This will turn
surgery upside down.

606
00:37:38,952 --> 00:37:40,169
It is inevitable

607
00:37:40,170 --> 00:37:42,911
that good surgeons
will be treated unfairly.

608
00:37:42,912 --> 00:37:44,392
You just said so yourself.

609
00:37:45,437 --> 00:37:47,394
And it sounds like
you accept this.

610
00:37:47,395 --> 00:37:49,875
Well, isn't being
transparent about your results

611
00:37:49,876 --> 00:37:52,138
what a good surgeon does,

612
00:37:52,139 --> 00:37:54,445
so that your patients are
able to give informed consent?

613
00:37:54,446 --> 00:37:56,447
Okay, look, sorry if I'm...

614
00:37:56,448 --> 00:37:58,231
Maybe I'm coming off
like a tendentious bitch...

615
00:37:58,232 --> 00:38:00,278
but this is important to us.

616
00:38:00,974 --> 00:38:03,802
Publishing results
is a bad idea.

617
00:38:03,803 --> 00:38:06,153
We will avoid
very sick patients.

618
00:38:07,241 --> 00:38:10,112
Why risk adding someone who
will likely die to my numbers?

619
00:38:10,113 --> 00:38:11,680
Why should I take that risk?

620
00:38:12,377 --> 00:38:14,291
Changes everything.

621
00:38:14,292 --> 00:38:16,815
Which surgeon will
give their registrar a go,

622
00:38:16,816 --> 00:38:18,382
if when it all
turns to shambles,

623
00:38:18,383 --> 00:38:19,992
it goes on their record?

624
00:38:19,993 --> 00:38:21,299
Liz.

625
00:38:22,561 --> 00:38:25,606
That's... That's a good point.

626
00:38:25,607 --> 00:38:26,912
Lots of good points.

627
00:38:26,913 --> 00:38:29,871
But what we're talking
about here is resources.

628
00:38:29,872 --> 00:38:31,308
No! We're talking about numbers.

629
00:38:31,309 --> 00:38:33,440
- Well...
- I'm talking about numbers.

630
00:38:33,441 --> 00:38:36,443
We're talking about
ranking people

631
00:38:36,444 --> 00:38:39,272
best to worst in league tables

632
00:38:39,273 --> 00:38:43,190
using data that is
insufficient and partial.

633
00:38:43,886 --> 00:38:46,367
And surgeons will
be hung out to dry.

634
00:38:50,197 --> 00:38:51,240
Whoa!

635
00:38:51,241 --> 00:38:52,981
It appears we have entered

636
00:38:52,982 --> 00:38:55,810
the QandA portion of our session

637
00:38:55,811 --> 00:38:57,464
slightly ahead of time.

638
00:38:57,465 --> 00:38:59,640
I just don't think
we can be idiots about this,

639
00:38:59,641 --> 00:39:02,077
and do it just because
other countries do.

640
00:39:02,078 --> 00:39:04,994
How many cardiac surgeons
can we afford to lose?

641
00:39:06,256 --> 00:39:07,496
Do you know how many we've got?

642
00:39:07,997 --> 00:39:09,999
- Twenty-nine! It's not enough.
- Liz.

643
00:39:11,218 --> 00:39:12,219
Thank you.

644
00:39:13,655 --> 00:39:15,395
Twenty-nine.

645
00:39:15,396 --> 00:39:17,005
And according to him,

646
00:39:17,006 --> 00:39:18,398
half are going to
have to retire soon.

647
00:39:18,399 --> 00:39:21,009
Yeah, okay.
That's a good point.

648
00:39:21,010 --> 00:39:22,271
But let's...

649
00:39:22,272 --> 00:39:23,317
Doctor.

650
00:40:43,136 --> 00:40:45,354
Very gripping stuff.

651
00:40:45,355 --> 00:40:46,443
Wasn't it.

652
00:40:46,444 --> 00:40:48,620
Interesting, provocative.

653
00:40:49,185 --> 00:40:50,447
People will be crucified.

654
00:40:50,448 --> 00:40:53,145
Yeah, some surgeons
need to reassess.

655
00:40:53,146 --> 00:40:54,625
You're not worried
about your data.

656
00:40:54,626 --> 00:40:56,497
The other specialties
are nervous.

657
00:40:57,150 --> 00:40:58,455
We're years behind
the world on this,

658
00:40:58,456 --> 00:40:59,892
and it's not thought through.

659
00:41:01,023 --> 00:41:02,546
You're not nervous, eh?

660
00:41:02,547 --> 00:41:04,157
'Cause you're brilliant.

661
00:41:05,550 --> 00:41:07,246
You're absolutely brilliant.

662
00:41:07,247 --> 00:41:08,901
But, um...

663
00:41:09,989 --> 00:41:12,817
Elizabeth, unfortunately,
it falls to my lot

664
00:41:12,818 --> 00:41:14,949
to tell you that
there's been a...

665
00:41:14,950 --> 00:41:16,604
formal complaint.

666
00:41:18,301 --> 00:41:19,345
A complaint?

667
00:41:19,346 --> 00:41:21,479
Formal complaint.
Lisa's parents.

668
00:41:24,569 --> 00:41:26,571
When were you going
to tell me about this?

669
00:41:28,007 --> 00:41:29,922
Well, I'm telling you now.

670
00:41:37,059 --> 00:41:38,060
Piece of shit.

671
00:41:47,069 --> 00:41:48,070
Hey.

672
00:41:49,245 --> 00:41:50,246
Hi.

673
00:41:51,291 --> 00:41:52,292
Leave you to it.

674
00:41:54,642 --> 00:41:56,470
I called you last night.

675
00:41:58,080 --> 00:41:59,081
Yeah.

676
00:42:00,822 --> 00:42:02,954
I can feel you disappearing.

677
00:42:02,955 --> 00:42:05,523
Yeah, I just want to
get the fuck out of here.

678
00:42:08,047 --> 00:42:11,005
So, what did Andrew want?

679
00:42:11,006 --> 00:42:12,790
Saw he cornered you.

680
00:42:12,791 --> 00:42:15,880
Apparently,
there's been a complaint

681
00:42:15,881 --> 00:42:17,186
about the surgery.

682
00:42:18,187 --> 00:42:20,580
Like a...
Like a formal complaint?

683
00:42:20,581 --> 00:42:22,496
I haven't read it.

684
00:42:23,628 --> 00:42:25,672
Haven't seen it
in writing, but yes.

685
00:42:25,673 --> 00:42:28,370
And, um, he wanted
to rub it in my face.

686
00:42:28,371 --> 00:42:29,503
Well, that's shit.

687
00:42:30,417 --> 00:42:31,635
Well.

688
00:42:31,636 --> 00:42:32,680
Yeah.

689
00:42:33,463 --> 00:42:34,813
Can't handle you.

690
00:42:48,914 --> 00:42:50,002
Did you...

691
00:42:51,525 --> 00:42:54,093
Did you know Richard left
when you were speaking?

692
00:42:55,442 --> 00:42:56,573
Richard?

693
00:42:56,574 --> 00:42:57,575
Yeah.

694
00:42:58,488 --> 00:42:59,489
No.

695
00:43:01,622 --> 00:43:03,623
He was pretty upset.

696
00:43:03,624 --> 00:43:06,844
Richard is a sensitive type.

697
00:43:06,845 --> 00:43:09,281
He needs to learn
to love the hook.

698
00:43:09,282 --> 00:43:10,630
Well, uh...

699
00:43:10,631 --> 00:43:12,023
I don't blame him, Liz.

700
00:43:12,024 --> 00:43:13,264
It was... It was pretty public.

701
00:43:14,592 --> 00:43:15,635
What's public?

702
00:43:15,636 --> 00:43:17,769
The things you say out loud...

703
00:43:19,814 --> 00:43:21,816
Registrars in shambles.

704
00:43:25,515 --> 00:43:27,039
Oh, Jesus Christ.

705
00:43:28,170 --> 00:43:29,824
What's wrong with people?

706
00:45:00,741 --> 00:45:01,872
Andrew.

707
00:45:01,873 --> 00:45:02,917
Seen this?

708
00:45:21,066 --> 00:45:22,067
Fuck!

709
00:45:35,080 --> 00:45:36,516
Unbelievable.

710
00:46:03,499 --> 00:46:04,499
Hey.

711
00:46:04,500 --> 00:46:06,588
Uh, sorry to interrupt.

712
00:46:06,589 --> 00:46:08,940
Oh, no, you're not interrupting.

713
00:46:13,074 --> 00:46:14,901
What can I do for you, Richard?

714
00:46:14,902 --> 00:46:17,730
I, uh...
I think it's ridiculous.

715
00:46:17,731 --> 00:46:20,081
That's ridiculous and wrong.

716
00:46:20,821 --> 00:46:22,039
You'll be all right.

717
00:46:22,040 --> 00:46:24,432
Just keep your head
down and work.

718
00:46:24,433 --> 00:46:26,261
Don't start looking unlucky.

719
00:46:27,872 --> 00:46:29,569
What does your father
say about it?

720
00:46:30,135 --> 00:46:33,528
I haven't told him anything yet.

721
00:46:33,529 --> 00:46:35,748
Isn't that something
you'd talk to him about?

722
00:46:35,749 --> 00:46:37,402
You talk about work, don't you?

723
00:46:37,403 --> 00:46:39,970
But the thing is, like,
he's just been appointed

724
00:46:39,971 --> 00:46:41,799
to the head of surgery
in Dunedin.

725
00:46:43,191 --> 00:46:44,148
Yeah.

726
00:46:44,149 --> 00:46:45,497
I'm just not sure

727
00:46:45,498 --> 00:46:47,586
what position it would
put him in if I told him.

728
00:46:47,587 --> 00:46:49,197
- You know?
- Oh?

729
00:46:51,156 --> 00:46:52,157
Yeah.

730
00:46:54,942 --> 00:46:56,770
Not actually sure
what he would say.

731
00:47:01,819 --> 00:47:04,038
He'd probably say
you're better than this.

732
00:47:05,387 --> 00:47:06,953
Probably, but...

733
00:47:06,954 --> 00:47:09,216
What if I'm not, though?

734
00:47:09,217 --> 00:47:11,131
Come on, Richard.

735
00:47:11,132 --> 00:47:12,306
You don't understand.

736
00:47:12,307 --> 00:47:14,787
Look, I have been
having dreams about her.

737
00:47:14,788 --> 00:47:15,833
Richard...

738
00:47:17,747 --> 00:47:20,358
We did everything in our power,

739
00:47:20,359 --> 00:47:22,187
inside and outside theatre.

740
00:47:24,319 --> 00:47:26,147
Mistakes may always happen.

741
00:47:28,715 --> 00:47:30,630
They're scary dreams, Liz.

742
00:47:36,201 --> 00:47:38,289
They're just dreams.

743
00:47:38,290 --> 00:47:40,988
Just dreams.

744
00:47:43,948 --> 00:47:44,949
Yeah.

745
00:47:51,520 --> 00:47:54,131
Maybe you'd be interested in
some confidential counselling

746
00:47:54,132 --> 00:47:55,524
or something like that.

747
00:47:56,786 --> 00:47:58,484
Can I set that up for you?

748
00:48:00,355 --> 00:48:01,704
I...

749
00:48:04,055 --> 00:48:05,316
I want you to know that,

750
00:48:05,317 --> 00:48:08,623
I know what you've done for me.

751
00:48:08,624 --> 00:48:09,930
I did nothing, Richard.

752
00:48:11,366 --> 00:48:13,628
It was my mistake.

753
00:48:13,629 --> 00:48:15,761
I trusted your judgment,
I was wrong.

754
00:48:15,762 --> 00:48:16,936
It's called training.

755
00:48:16,937 --> 00:48:18,199
It has risks.

756
00:48:20,071 --> 00:48:22,159
I took the decision to do it.

757
00:48:22,160 --> 00:48:23,247
That was me...

758
00:48:23,248 --> 00:48:24,379
No, I did.

759
00:48:25,815 --> 00:48:26,904
I did.

760
00:48:27,905 --> 00:48:28,906
Me.

761
00:48:31,952 --> 00:48:33,345
Leave it with me.

762
00:48:35,434 --> 00:48:38,349
You can. You can just
leave it with me.

763
00:48:38,350 --> 00:48:40,352
Really, I can take it.

764
00:48:46,271 --> 00:48:47,924
Why don't you get
something, hmm?

765
00:48:47,925 --> 00:48:49,360
Get something to eat.

766
00:48:49,361 --> 00:48:50,449
Uh...

767
00:48:51,145 --> 00:48:52,842
Uh, no, no.

768
00:48:55,323 --> 00:48:57,977
Okay, well...

769
00:48:59,066 --> 00:49:00,720
I've got to get going.

770
00:49:01,242 --> 00:49:03,113
So...

771
00:49:03,114 --> 00:49:05,898
To be continued? Yeah.

772
00:49:05,899 --> 00:49:07,248
Well, when are we...

773
00:49:09,033 --> 00:49:10,121
When what?

774
00:49:11,861 --> 00:49:13,385
When will it be continued?

775
00:49:15,909 --> 00:49:16,954
Tomorrow sometime.

776
00:49:19,304 --> 00:49:21,784
I told her parents
that she was okay,

777
00:49:22,829 --> 00:49:23,872
that it went well.

778
00:49:23,873 --> 00:49:24,962
You said that.

779
00:49:27,442 --> 00:49:28,704
Yes, I did.

780
00:49:30,054 --> 00:49:31,577
Yes, she was.

781
00:49:34,972 --> 00:49:36,930
Stop telling yourself
a different story.

782
00:49:41,587 --> 00:49:43,415
Jesus!
Fuck, Richard.

783
00:50:36,511 --> 00:50:37,859
Gonna go fishing this weekend.

784
00:50:37,860 --> 00:50:39,078
You want to come?

785
00:50:39,079 --> 00:50:40,384
- Me?
- You'd enjoy it.

786
00:50:40,385 --> 00:50:42,038
I don't fish.

787
00:50:42,039 --> 00:50:43,430
Well, you could try.

788
00:50:43,431 --> 00:50:45,519
You could learn.

789
00:50:45,520 --> 00:50:46,868
Everything is always there.

790
00:50:46,869 --> 00:50:49,567
You go away, take a rest,
come back.

791
00:50:49,568 --> 00:50:51,438
Is the patient consented?

792
00:50:51,439 --> 00:50:52,745
Yes.

793
00:50:53,441 --> 00:50:55,486
- It's cancelled.
- What, really?

794
00:50:55,487 --> 00:50:57,327
I don't know, they just told
me it's cancelled.

795
00:51:02,059 --> 00:51:03,060
Fuck!

796
00:51:08,630 --> 00:51:09,804
Oh...

797
00:51:09,805 --> 00:51:11,284
What happened?

798
00:51:11,285 --> 00:51:12,894
Oh, I'm sorry about that.

799
00:51:12,895 --> 00:51:14,244
He, he ate something in
the middle of the night,

800
00:51:14,245 --> 00:51:15,723
forgot about it,

801
00:51:15,724 --> 00:51:17,726
and then remembered
all of a sudden during consent.

802
00:51:18,249 --> 00:51:19,467
Oh.

803
00:51:20,033 --> 00:51:21,512
You're going through a bit

804
00:51:21,513 --> 00:51:23,036
over there, I gather.

805
00:51:24,603 --> 00:51:26,125
It'll blow over.

806
00:51:26,126 --> 00:51:28,041
It's a cracked system, Liz.

807
00:51:32,611 --> 00:51:35,092
Look, how well known
is my complaint?

808
00:51:36,745 --> 00:51:38,921
Well, it's about, can't lie.

809
00:51:41,010 --> 00:51:42,794
But as you say, it'll blow over.

810
00:51:47,452 --> 00:51:48,975
Did he really eat something?

811
00:51:51,456 --> 00:51:52,631
So I'm told.

812
00:51:54,415 --> 00:51:57,244
Some spag bowl from the fridge
in the middle of the night.

813
00:51:58,332 --> 00:52:00,681
And there's really
nothing else...

814
00:52:00,682 --> 00:52:02,944
Nothing else that I
can use you for today.

815
00:52:02,945 --> 00:52:05,644
So, um,
I'm sorry to waste your time.

816
00:53:15,453 --> 00:53:16,454
Excuse me?

817
00:53:17,498 --> 00:53:18,585
Are you Mrs. Taylor?

818
00:53:18,586 --> 00:53:19,717
I am.

819
00:53:19,718 --> 00:53:21,240
I have a registered
letter for you.

820
00:53:21,241 --> 00:53:22,286
Oh?

821
00:53:29,118 --> 00:53:30,555
What the fuck?

822
00:53:30,685 --> 00:53:31,816
Fuck is this?

823
00:53:43,524 --> 00:53:46,178
<i>Hi, this is Robin's phone...</i>

824
00:53:47,441 --> 00:53:49,137
Robin.

825
00:53:49,138 --> 00:53:50,748
So they've, uh,

826
00:53:50,749 --> 00:53:52,315
"temporarily restricted

827
00:53:52,316 --> 00:53:55,405
my practice of laparoscopy
and laparotomy."

828
00:53:55,406 --> 00:53:57,016
Suspended me.

829
00:53:57,712 --> 00:53:59,278
It's fucking...

830
00:53:59,279 --> 00:54:03,282
It's just
ass-covering cowardice.

831
00:54:03,283 --> 00:54:05,110
It's unbelievable.

832
00:54:05,111 --> 00:54:06,765
Unbelievable! Anyway.

833
00:54:08,984 --> 00:54:09,985
Call me.

834
00:55:47,735 --> 00:55:49,301
Hello again.

835
00:55:49,302 --> 00:55:51,434
Mrs. Taylor...

836
00:55:51,435 --> 00:55:53,436
from the conference.

837
00:55:53,437 --> 00:55:54,786
Please sit down.

838
00:55:57,136 --> 00:56:00,182
You're here to talk about
the publishing of data?

839
00:56:01,445 --> 00:56:02,489
I am, yes.

840
00:56:03,534 --> 00:56:04,622
Look...

841
00:56:05,623 --> 00:56:07,798
there's no easy way to say this,

842
00:56:07,799 --> 00:56:11,192
but our priority
isn't to shelter

843
00:56:11,193 --> 00:56:13,412
surgeons from criticism.

844
00:56:13,413 --> 00:56:15,936
Our priority is deciding
what's good for everybody,

845
00:56:15,937 --> 00:56:17,721
most importantly, the public,

846
00:56:17,722 --> 00:56:19,418
our patients.

847
00:56:19,419 --> 00:56:21,202
I understand that
the methodology

848
00:56:21,203 --> 00:56:22,856
may not yet be perfect,

849
00:56:22,857 --> 00:56:25,250
but I believe transparency
is a good thing.

850
00:56:25,251 --> 00:56:27,470
And we can improve
the methodology over time.

851
00:56:27,471 --> 00:56:29,036
The decisions
that we have to make

852
00:56:29,037 --> 00:56:31,299
in theatre in
fractions of seconds

853
00:56:31,300 --> 00:56:34,955
are boiled down to
"they lived" or "they died."

854
00:56:34,956 --> 00:56:38,916
No context, no case histories,

855
00:56:38,917 --> 00:56:40,178
just "they lived"
or "they died."

856
00:56:40,179 --> 00:56:41,963
That's not transparency.

857
00:56:43,225 --> 00:56:45,140
It's looking for
someone to blame.

858
00:56:48,405 --> 00:56:50,754
I understand what you're saying.

859
00:56:50,755 --> 00:56:52,103
- Do you?
- Yes.

860
00:56:52,104 --> 00:56:56,455
But once we pass
this first storm,

861
00:56:56,456 --> 00:56:59,937
hopefully then we can
focus on worthy things,

862
00:56:59,938 --> 00:57:01,591
such as risk adjustment.

863
00:57:01,592 --> 00:57:03,202
Risk adjustment?

864
00:57:04,638 --> 00:57:06,987
Have you heard of Z51.5?

865
00:57:06,988 --> 00:57:09,903
That's a code for palliative
care in the UK system.

866
00:57:09,904 --> 00:57:13,429
A Z51.5 doesn't go on
anyone's stats because it says

867
00:57:13,430 --> 00:57:15,387
that the patient was already
dying when they came in.

868
00:57:15,388 --> 00:57:17,476
Patients died quietly.

869
00:57:17,477 --> 00:57:19,391
No chemo, no scalpels,

870
00:57:19,392 --> 00:57:22,046
just morphine and flowers.

871
00:57:22,047 --> 00:57:24,788
Would my sepsis have qualified?

872
00:57:24,789 --> 00:57:25,919
Do you understand?

873
00:57:25,920 --> 00:57:27,574
Should I have not intervened?

874
00:57:29,358 --> 00:57:33,319
Maybe, it's better for
the patients that way.

875
00:57:34,494 --> 00:57:38,758
Maybe, because at times
it's best not to operate.

876
00:57:38,759 --> 00:57:40,978
Let them die with dignity.

877
00:57:40,979 --> 00:57:42,675
And maybe the publishing of data

878
00:57:42,676 --> 00:57:46,463
will mean that more people
die with less intervention.

879
00:57:47,681 --> 00:57:50,161
You know what's best
for patients, do you?

880
00:57:50,162 --> 00:57:51,990
Sitting here at your keyboard?

881
00:57:54,209 --> 00:57:56,994
I know your reputation,
Mrs. Taylor.

882
00:57:56,995 --> 00:57:58,517
You're the best at what you do.

883
00:57:58,518 --> 00:57:59,997
One of.

884
00:57:59,998 --> 00:58:02,914
But is what you do always
best for the patients?

885
00:58:05,046 --> 00:58:07,308
I'm sorry that sounds tough.
I know.

886
00:58:07,309 --> 00:58:10,268
But hospitals hide
these things, don't they?

887
00:58:10,269 --> 00:58:12,662
Staff learn to hide things,

888
00:58:12,663 --> 00:58:14,402
and patients never know
anything went wrong.

889
00:58:14,403 --> 00:58:16,884
And the ones hurt the most
are the families left behind.

890
00:58:18,190 --> 00:58:20,453
We must hold ourselves
to a higher standard.

891
00:58:22,760 --> 00:58:24,064
I have a standard.

892
00:58:24,065 --> 00:58:26,023
It's the Hippocratic Oath.

893
00:58:26,024 --> 00:58:27,765
And I'm not trying
to hide anything.

894
00:58:48,394 --> 00:58:50,614
- Hey!
- Well, hi.

895
00:58:51,223 --> 00:58:52,919
How are you?

896
00:58:52,920 --> 00:58:54,051
You good?

897
00:58:55,880 --> 00:58:57,359
Did you forget
some of your stuff?

898
00:58:58,578 --> 00:59:00,100
No, I, um...

899
00:59:00,101 --> 00:59:02,974
I just... I came to get it.

900
00:59:07,631 --> 00:59:08,893
Well...

901
00:59:09,937 --> 00:59:10,938
Why?

902
00:59:15,595 --> 00:59:17,683
I can't be inside this, Liz.

903
00:59:17,684 --> 00:59:19,206
You'll be Dr A,

904
00:59:19,207 --> 00:59:20,556
Richard will be Dr B,

905
00:59:20,557 --> 00:59:22,688
and the nurses
will be there by name,

906
00:59:22,689 --> 00:59:23,863
and one of us will go down.

907
00:59:23,864 --> 00:59:24,995
That's just noise.

908
00:59:24,996 --> 00:59:26,911
No, it's not noise.

909
00:59:27,302 --> 00:59:28,999
I need my job, Liz.

910
00:59:29,000 --> 00:59:30,567
Robin.

911
00:59:31,524 --> 00:59:33,003
Robin, I can protect you.

912
00:59:33,004 --> 00:59:34,135
You can't.

913
00:59:38,357 --> 00:59:39,445
I'm done.

914
00:59:42,622 --> 00:59:43,622
There it is.

915
00:59:51,849 --> 00:59:53,719
- I'm sorry.
- No, I'm sorry.

916
00:59:53,720 --> 00:59:54,765
Just go.

917
01:00:19,267 --> 01:00:20,268
Fuck.

918
01:03:50,696 --> 01:03:52,654
Oh, fuck off, Richard.

919
01:04:43,314 --> 01:04:46,099
Oh, fuck! Oh, fuck!

920
01:04:51,017 --> 01:04:53,802
Atticus!

921
01:04:55,152 --> 01:04:57,023
Oh fuck! Atticus, here boy!

922
01:05:08,992 --> 01:05:11,515
He's quiet. I didn't see him.

923
01:05:11,516 --> 01:05:14,300
I forgot. I forgot the dog.

924
01:05:14,301 --> 01:05:16,173
- Right.
- I forgot him.

925
01:05:18,218 --> 01:05:20,176
- I forgot he was there.
- Okay.

926
01:05:20,177 --> 01:05:22,179
I'm just going to
check his heart, okay?

927
01:05:24,137 --> 01:05:26,443
Shhh.

928
01:05:44,853 --> 01:05:46,071
Yeah.

929
01:05:46,072 --> 01:05:48,161
He's not doing so good.

930
01:05:49,510 --> 01:05:50,598
Um...

931
01:05:52,078 --> 01:05:54,124
I think it's time
to say goodbye.

932
01:05:59,042 --> 01:06:00,390
Right now?

933
01:06:00,391 --> 01:06:01,740
- Right now?
- Yeah.

934
01:06:02,349 --> 01:06:03,784
Okay.

935
01:06:03,785 --> 01:06:06,397
Right. Right.

936
01:06:08,225 --> 01:06:09,878
- You ready?
- Mm-mm.

937
01:06:30,116 --> 01:06:31,899
You can...
You can put your hand on him.

938
01:06:31,900 --> 01:06:33,424
You can help him out.

939
01:06:42,389 --> 01:06:44,129
Good dog.

940
01:06:47,699 --> 01:06:49,004
Yeah.

941
01:06:49,005 --> 01:06:51,049
I'm going to put
the needle in now, okay?

942
01:06:51,050 --> 01:06:53,051
Mm.

943
01:06:53,052 --> 01:06:54,706
All right. Here we go.

944
01:07:15,640 --> 01:07:16,989
Check his heart.

945
01:07:25,606 --> 01:07:26,825
He's gone now.

946
01:07:34,702 --> 01:07:36,356
Would you like him cremated?

947
01:07:43,320 --> 01:07:44,886
He's not mine.

948
01:07:46,018 --> 01:07:48,586
He's not... my dog.

949
01:07:51,893 --> 01:07:53,895
He's not my dog.

950
01:08:02,469 --> 01:08:06,081
You killed my dog.

951
01:08:06,082 --> 01:08:07,604
I'm sorry.

952
01:08:07,605 --> 01:08:09,649
What is wrong with you?

953
01:08:09,650 --> 01:08:11,477
He's gone.

954
01:08:11,478 --> 01:08:13,262
I'm sorry.

955
01:08:13,263 --> 01:08:14,915
I'm so fucking sorry.

956
01:08:16,614 --> 01:08:18,398
I'm so fucking sorry.

957
01:08:39,027 --> 01:08:41,639
I'm so, I'm so sorry.

958
01:09:20,243 --> 01:09:21,373
Jesus.

959
01:09:35,649 --> 01:09:37,650
Hello, this is
Mrs. Elizabeth Taylor.

960
01:09:37,651 --> 01:09:39,522
I'm trying to
reach my registrar,

961
01:09:39,523 --> 01:09:40,915
Richard Whitehead.

962
01:09:41,568 --> 01:09:43,266
<i>Could I get his address, please?</i>

963
01:10:17,300 --> 01:10:18,300
Richard?

964
01:10:21,260 --> 01:10:22,696
Richard, pick up.

965
01:10:48,418 --> 01:10:50,549
Richard!

966
01:10:50,550 --> 01:10:51,638
Richard!

967
01:10:54,032 --> 01:10:55,163
Richard!

968
01:10:58,036 --> 01:10:59,037
Jesus.

969
01:11:00,038 --> 01:11:01,299
Fuck! Fuck!

970
01:11:01,300 --> 01:11:03,040
Fucking stupid, stupid.

971
01:11:03,041 --> 01:11:07,262
Fuck. Fuck. Fuck.

972
01:11:07,263 --> 01:11:08,828
Richard? Richard!

973
01:11:08,829 --> 01:11:10,874
Oh, Richard? Richard!

974
01:11:10,875 --> 01:11:12,267
Richard.

975
01:11:12,268 --> 01:11:13,746
Oh, no, no, no.

976
01:11:13,747 --> 01:11:16,183
No, Richard!

977
01:11:18,578 --> 01:11:22,321
You didn't.

978
01:11:23,757 --> 01:11:25,410
You didn't.

979
01:11:25,411 --> 01:11:27,065
Please!

980
01:11:28,719 --> 01:11:29,720
Fuck.

981
01:11:32,200 --> 01:11:34,463
Why?

982
01:12:24,557 --> 01:12:25,993
Right.

983
01:12:27,995 --> 01:12:31,258
You were there I'm told,
first responder.

984
01:12:31,259 --> 01:12:32,782
- I was, yes.
- I'm sorry.

985
01:12:32,783 --> 01:12:35,567
Thank you.
Stupid, stupid bugger.

986
01:12:35,568 --> 01:12:36,873
Yeah, sadly so.

987
01:12:36,874 --> 01:12:39,092
But listen, the staff
don't know at present,

988
01:12:39,093 --> 01:12:41,138
so do you think
you've got this in hand?

989
01:12:41,139 --> 01:12:42,314
I... Yes, of course.

990
01:12:43,620 --> 01:12:45,403
- I will, of course.
- What a business.

991
01:12:45,404 --> 01:12:47,797
For the hospital,
for the department,

992
01:12:47,798 --> 01:12:49,712
for everybody.

993
01:12:49,713 --> 01:12:52,149
So, I think you and I should
keep a lid on the gossip

994
01:12:52,150 --> 01:12:54,412
and speculation
before it even starts.

995
01:12:54,413 --> 01:12:57,415
And, yeah, we've got to
keep control of the situation.

996
01:12:57,416 --> 01:12:58,504
Right.

997
01:13:00,288 --> 01:13:02,202
Well, what...
What can I do, Andrew?

998
01:13:02,203 --> 01:13:03,335
What can I do?

999
01:13:08,253 --> 01:13:10,603
Well, I think you probably
know what this is about.

1000
01:13:11,909 --> 01:13:13,213
Right.

1001
01:13:13,214 --> 01:13:16,521
Yeah, it's not an uncommon
phenomenon, burnout.

1002
01:13:16,522 --> 01:13:18,697
But I think for the majority
of the staff here,

1003
01:13:18,698 --> 01:13:19,916
this will be the first time.

1004
01:13:19,917 --> 01:13:22,093
So we need to
show a united front.

1005
01:13:24,487 --> 01:13:25,531
Andrew...

1006
01:13:27,881 --> 01:13:29,970
Richard was not "burnt out."

1007
01:13:31,972 --> 01:13:35,584
Elizabeth, we need
one version of the truth,

1008
01:13:35,585 --> 01:13:37,194
for everybody's sake.

1009
01:13:37,195 --> 01:13:39,110
How... How does
that work, exactly?

1010
01:13:42,200 --> 01:13:45,637
Well, did you know my father
was a surgeon in Korea?

1011
01:13:45,638 --> 01:13:47,247
He was a POW.

1012
01:13:47,248 --> 01:13:49,902
And when he dealt
with limb trauma,

1013
01:13:49,903 --> 01:13:53,210
he would take them to
latrines for their examinations,

1014
01:13:53,211 --> 01:13:55,125
where there were
millions of flies.

1015
01:13:55,126 --> 01:13:56,256
You know what that means?

1016
01:13:56,257 --> 01:13:57,344
Maggots.

1017
01:13:57,345 --> 01:13:59,259
But maggots do
their job very well.

1018
01:13:59,260 --> 01:14:00,826
They debris dead flesh,

1019
01:14:00,827 --> 01:14:02,741
they clean the wounds,

1020
01:14:02,742 --> 01:14:04,917
they never sleep,
they never take a break.

1021
01:14:04,918 --> 01:14:08,444
They're vigilant, consistent,
persistent, trustworthy...

1022
01:14:10,446 --> 01:14:11,795
Unlike some people.

1023
01:14:14,188 --> 01:14:16,146
What's the point?

1024
01:14:16,147 --> 01:14:17,627
What are you getting at?

1025
01:14:21,282 --> 01:14:23,501
Do you remember
you called me "stupid"

1026
01:14:23,502 --> 01:14:27,940
at the Mortality
and Morbidity meeting?

1027
01:14:27,941 --> 01:14:30,944
You really were incredibly rude.

1028
01:14:34,557 --> 01:14:35,993
That's what this is about?

1029
01:14:38,386 --> 01:14:39,909
No...

1030
01:14:39,910 --> 01:14:41,345
No?

1031
01:14:41,346 --> 01:14:44,696
No, this hospital has invested
huge amount in you.

1032
01:14:44,697 --> 01:14:46,785
You're a very
valuable commodity.

1033
01:14:46,786 --> 01:14:49,048
You are brilliant,
but you are not easy.

1034
01:14:49,049 --> 01:14:50,486
You're emotional.

1035
01:14:51,574 --> 01:14:53,226
Yeah, emotional.

1036
01:14:53,227 --> 01:14:55,141
I know it's not
fashionable to say it,

1037
01:14:55,142 --> 01:14:57,579
but I'm not sure
women are suited

1038
01:14:57,580 --> 01:14:59,145
to a career in medicine,

1039
01:14:59,146 --> 01:15:00,931
particularly unmarried women.

1040
01:15:02,193 --> 01:15:04,411
But when I have a vested
interest in someone,

1041
01:15:04,412 --> 01:15:08,285
I act irrespective of the risk.

1042
01:15:08,286 --> 01:15:10,027
So it is decided.

1043
01:15:11,289 --> 01:15:13,073
What has?
What's been decided?

1044
01:15:15,032 --> 01:15:16,033
Honestly?

1045
01:15:17,382 --> 01:15:19,383
Sometimes, Elizabeth,
I could just, you know...

1046
01:15:19,384 --> 01:15:21,212
take you or leave you.

1047
01:15:22,996 --> 01:15:23,996
I see.

1048
01:15:25,085 --> 01:15:26,565
No, I don't think you do see.

1049
01:15:27,697 --> 01:15:29,437
You've been given
a second chance.

1050
01:15:30,613 --> 01:15:33,136
You're going to be back
on call after a week's leave.

1051
01:15:33,137 --> 01:15:34,441
That's what we've decided.

1052
01:15:34,442 --> 01:15:35,878
Then we're going
to publish an article

1053
01:15:35,879 --> 01:15:37,967
in the <i>New Zealand
Journal for Medicine</i>

1054
01:15:37,968 --> 01:15:39,272
and you're going
to sign up to it.

1055
01:15:39,273 --> 01:15:41,187
It'll be about suicide, burnout

1056
01:15:41,188 --> 01:15:45,757
and, uh, Richard's
effect on your data.

1057
01:15:45,758 --> 01:15:47,977
Richard will be shown
as what he was...

1058
01:15:47,978 --> 01:15:50,588
young, ineffective,
out of his depths,

1059
01:15:50,589 --> 01:15:53,765
and that he skewed the data.

1060
01:15:53,766 --> 01:15:55,550
You know, we took
too much care of him.

1061
01:15:55,551 --> 01:15:57,116
<i>You</i> took too much care of him.

1062
01:15:57,117 --> 01:15:58,901
And it's a tragedy
for the hospital,

1063
01:15:58,902 --> 01:16:00,467
for the community,

1064
01:16:00,468 --> 01:16:03,035
and it led to his suicide.

1065
01:16:03,036 --> 01:16:05,124
So, uh...

1066
01:16:05,125 --> 01:16:06,604
you know, the staff
will get counselling,

1067
01:16:06,605 --> 01:16:07,692
there'll be a vigil,

1068
01:16:07,693 --> 01:16:11,828
and then business as usual.

1069
01:16:17,660 --> 01:16:20,358
And I want you
to sign up to it all.

1070
01:16:23,970 --> 01:16:28,453
It's called
"cleaning the wound," Elizabeth.

1071
01:16:32,239 --> 01:16:33,589
Like a maggot.

1072
01:16:35,329 --> 01:16:37,767
Those wonderful maggots.

1073
01:17:03,531 --> 01:17:05,229
Liz? Liz.

1074
01:17:09,233 --> 01:17:10,321
I'm sorry.

1075
01:17:12,105 --> 01:17:13,106
I'm sorry.

1076
01:17:18,764 --> 01:17:20,897
It's okay.

1077
01:17:24,117 --> 01:17:25,771
It's all right.

1078
01:18:09,772 --> 01:18:11,338
What?

1079
01:18:14,341 --> 01:18:15,734
It's just unfair.

1080
01:18:18,998 --> 01:18:21,871
You are good, Liz.

1081
01:18:22,959 --> 01:18:24,090
I know that.

1082
01:18:27,572 --> 01:18:29,704
I missed his calls.

1083
01:18:29,705 --> 01:18:31,270
I could have taken them.

1084
01:18:31,271 --> 01:18:32,316
Yeah.

1085
01:18:35,319 --> 01:18:36,842
And you'll have
to live with that.

1086
01:18:38,104 --> 01:18:39,802
And I am so sorry.

1087
01:18:44,502 --> 01:18:45,851
Me, too.

1088
01:18:47,287 --> 01:18:48,767
So fucking sorry.

1089
01:18:49,942 --> 01:18:51,074
What a mess.

1090
01:19:09,527 --> 01:19:10,919
Jan, I was wondering...

1091
01:19:10,920 --> 01:19:12,311
Dr. Matthews?

1092
01:19:12,312 --> 01:19:13,399
Yes.

1093
01:19:13,400 --> 01:19:14,792
Excuse us a minute.

1094
01:19:14,793 --> 01:19:16,141
How can I help?

1095
01:19:16,142 --> 01:19:20,058
I wanted to speak with you
about a patient of ours.

1096
01:19:20,059 --> 01:19:21,146
Lisa Williams.

1097
01:19:21,147 --> 01:19:22,192
Yes.

1098
01:19:23,671 --> 01:19:26,848
Um, if it's okay, I'd like to
bring Jan in on this.

1099
01:19:26,849 --> 01:19:28,806
She was running the ward.

1100
01:19:28,807 --> 01:19:30,329
Jan.

1101
01:19:30,330 --> 01:19:31,375
Of course.

1102
01:19:32,289 --> 01:19:33,550
Okay.

1103
01:19:33,551 --> 01:19:35,900
Jan, this is about
Lisa Williams,

1104
01:19:35,901 --> 01:19:37,119
the sepsis patient
from a while ago.

1105
01:19:37,120 --> 01:19:38,207
Oh.

1106
01:19:38,208 --> 01:19:39,382
Mrs. Taylor was her surgeon

1107
01:19:39,383 --> 01:19:40,992
and wants to know
about her admission.

1108
01:19:40,993 --> 01:19:42,254
- Okay.
- Please.

1109
01:19:42,255 --> 01:19:46,737
Okay. Well, we had
her on the usual lines,

1110
01:19:46,738 --> 01:19:50,175
inspected the surgery sites,
and they were clean.

1111
01:19:50,176 --> 01:19:52,264
There was minimal
output in the drains.

1112
01:19:52,265 --> 01:19:53,571
Her abdomen was soft.

1113
01:19:54,572 --> 01:19:56,616
Well, you tell her, Jan.

1114
01:19:56,617 --> 01:19:59,228
I sat with Lisa from
about midnight.

1115
01:19:59,229 --> 01:20:01,273
She was pretty high
maintenance at this point,

1116
01:20:01,274 --> 01:20:03,885
and she began
to go into decline.

1117
01:20:03,886 --> 01:20:06,758
She was deteriorating.
The sepsis was advanced.

1118
01:20:07,541 --> 01:20:10,500
She called out.
She was anxious and agitated.

1119
01:20:10,501 --> 01:20:12,458
She was dropping her stats,

1120
01:20:12,459 --> 01:20:14,199
and cyanosis of the lips,

1121
01:20:14,200 --> 01:20:15,766
about one breath every second.

1122
01:20:15,767 --> 01:20:18,769
She was complaining
of being cold and tired,

1123
01:20:18,770 --> 01:20:20,205
and the catheter
was bothering her,

1124
01:20:20,206 --> 01:20:22,034
and her breathing
was very rapid.

1125
01:20:23,122 --> 01:20:26,690
We brought in the on-call
anaesthetist to intubate.

1126
01:20:26,691 --> 01:20:29,171
Was Lisa able to
speak with her parents?

1127
01:20:29,172 --> 01:20:31,130
Yeah, briefly.

1128
01:20:32,218 --> 01:20:33,828
But then they had
to leave the room.

1129
01:20:33,829 --> 01:20:35,699
She arrested during induction,

1130
01:20:35,700 --> 01:20:37,223
and we began resuscitation.

1131
01:20:38,094 --> 01:20:41,705
We worked for...
half an hour, I remember.

1132
01:20:41,706 --> 01:20:42,880
She was 29.

1133
01:20:42,881 --> 01:20:45,274
A young, strong woman.

1134
01:20:45,275 --> 01:20:46,623
Right.

1135
01:20:46,624 --> 01:20:47,668
Yeah.

1136
01:20:49,061 --> 01:20:52,890
Pronounced dead
about four... five...

1137
01:20:52,891 --> 01:20:55,633
- 4:48.
- 4:48. Yes.

1138
01:20:56,286 --> 01:20:57,461
Wee small hours.

1139
01:20:59,811 --> 01:21:00,812
Yeah.

1140
01:21:05,817 --> 01:21:07,687
Thank you for
caring for my patient.

1141
01:21:07,688 --> 01:21:08,993
Is that what you...

1142
01:21:08,994 --> 01:21:10,125
Is that what you needed?

1143
01:21:10,126 --> 01:21:11,561
It is, yes. Some of it.

1144
01:21:11,562 --> 01:21:13,389
I can get some more notes.

1145
01:21:13,390 --> 01:21:14,999
- I can...
- No.

1146
01:21:15,000 --> 01:21:17,916
No, it's all right.

1147
01:21:19,962 --> 01:21:21,964
Was she lonely
at all at the end?

1148
01:21:23,269 --> 01:21:24,575
We were all here.

1149
01:21:25,663 --> 01:21:28,230
Her family, right up
until the intubation.

1150
01:21:28,231 --> 01:21:30,059
I was with her during the night.

1151
01:21:33,453 --> 01:21:34,497
Thank you both.

1152
01:21:34,498 --> 01:21:37,675
This very... was very helpful.

1153
01:22:13,711 --> 01:22:16,844
Tena koutou, tena koutou,
tena katou katoa.

1154
01:22:17,454 --> 01:22:19,891
Good afternoon,
ladies and gentlemen.

1155
01:22:21,066 --> 01:22:22,545
My name is Andrew McGrath.

1156
01:22:22,546 --> 01:22:26,288
As you know,
I am head of surgery.

1157
01:22:26,289 --> 01:22:27,898
Sad day.

1158
01:22:27,899 --> 01:22:31,206
And we are here, unfortunately,

1159
01:22:31,207 --> 01:22:32,816
to remember Richard Whitehead,

1160
01:22:32,817 --> 01:22:35,036
one of our brightest
young talents

1161
01:22:35,037 --> 01:22:38,127
whose future has been
so cruelly cut short.

1162
01:22:39,215 --> 01:22:40,345
And in a few moments,

1163
01:22:40,346 --> 01:22:43,740
I would like us to
hold a silence while

1164
01:22:43,741 --> 01:22:46,482
we remember Richard
and the brilliant work he did,

1165
01:22:46,483 --> 01:22:48,092
the part he played in the team

1166
01:22:48,093 --> 01:22:51,052
of one of our most gifted,
accomplished surgeons,

1167
01:22:51,053 --> 01:22:54,099
Mrs. Elizabeth Taylor.

1168
01:22:55,492 --> 01:22:58,146
But before we do,
I would like to say this.

1169
01:22:58,147 --> 01:23:01,714
What we now know is
that Richard's passing

1170
01:23:01,715 --> 01:23:07,156
is the result of the terrible
toll of burnout.

1171
01:23:08,853 --> 01:23:10,201
This is a tragedy,

1172
01:23:10,202 --> 01:23:12,551
but one from which
we will all learn,

1173
01:23:12,552 --> 01:23:14,250
<i>must</i> learn.

1174
01:23:15,120 --> 01:23:18,731
Richard's passing is
a timely reminder to us

1175
01:23:18,732 --> 01:23:22,387
that all our staff
are vulnerable

1176
01:23:22,388 --> 01:23:24,999
to these extreme pressures.

1177
01:23:25,000 --> 01:23:27,088
And unfortunately,

1178
01:23:27,089 --> 01:23:31,006
Richard was, um,
one of its victims.

1179
01:23:32,050 --> 01:23:33,268
It's not easy having to work

1180
01:23:33,269 --> 01:23:35,400
with the responsibility
of life and death.

1181
01:23:35,401 --> 01:23:38,795
We, the hospital,
the administration, the board,

1182
01:23:38,796 --> 01:23:42,668
we absolutely recognize this,

1183
01:23:42,669 --> 01:23:45,803
and, um, we are
responding immediately.

1184
01:23:46,891 --> 01:23:49,675
We are, from this moment,

1185
01:23:49,676 --> 01:23:53,027
putting in place measures
to enhance staff well being

1186
01:23:53,028 --> 01:23:56,726
and our collective
mental health,

1187
01:23:56,727 --> 01:23:58,728
soon as is practicable.

1188
01:23:58,729 --> 01:24:02,559
Because we are all in this
together,

1189
01:24:03,473 --> 01:24:04,821
a team

1190
01:24:04,822 --> 01:24:06,649
and a community.

1191
01:24:07,955 --> 01:24:11,437
It is indeed
a sad day for us all.

1192
01:24:13,396 --> 01:24:15,963
A minute's silence, please.

1193
01:24:35,461 --> 01:24:38,246
I'd like to say something.
I think I should. Don't you?

1194
01:24:38,247 --> 01:24:39,334
- Yeah.
- I think I should.

1195
01:24:39,335 --> 01:24:40,335
Yes.
Just a short.

1196
01:24:40,336 --> 01:24:41,553
Yeah, as his registrar,

1197
01:24:41,554 --> 01:24:43,120
don't you think
I should say something?

1198
01:24:43,121 --> 01:24:44,470
Sorry.

1199
01:24:46,429 --> 01:24:49,344
I'd like to say something,
if it's all right.

1200
01:24:49,345 --> 01:24:50,867
Thank you.

1201
01:24:50,868 --> 01:24:52,043
Hello.

1202
01:24:55,220 --> 01:24:59,050
The reason we're all here
today is, as Andrew says,

1203
01:25:00,051 --> 01:25:01,313
a tragedy.

1204
01:25:03,010 --> 01:25:06,057
Richard Whitehead
was my registrar.

1205
01:25:07,014 --> 01:25:09,712
Many of you knew Richard,
and those of you who didn't,

1206
01:25:09,713 --> 01:25:11,844
I'm sure you can
identify with him.

1207
01:25:11,845 --> 01:25:14,718
He was a young man, 26.

1208
01:25:15,632 --> 01:25:18,764
And as a registrar,
he was still learning,

1209
01:25:18,765 --> 01:25:20,071
still training.

1210
01:25:21,594 --> 01:25:22,638
He didn't die.

1211
01:25:22,639 --> 01:25:24,380
He committed suicide.

1212
01:25:27,296 --> 01:25:31,430
And, um, he's dead now
because he overdosed.

1213
01:25:32,388 --> 01:25:33,736
That's the truth of it.

1214
01:25:33,737 --> 01:25:37,610
He took his own life in
a filthy garage, alone.

1215
01:25:38,785 --> 01:25:40,960
Elizabeth, that's enough.

1216
01:25:40,961 --> 01:25:42,614
We talk about teamwork.

1217
01:25:42,615 --> 01:25:44,226
- Liz...
- We talk about resilience.

1218
01:25:45,444 --> 01:25:47,402
Did Richard lack resilience?

1219
01:25:47,403 --> 01:25:49,491
This young man for whom
I am responsible?

1220
01:25:49,492 --> 01:25:51,841
Because if you're telling me
he lacks something,

1221
01:25:51,842 --> 01:25:52,886
I don't accept it.

1222
01:25:55,889 --> 01:26:01,286
I operated on a patient
that died after the surgery.

1223
01:26:02,331 --> 01:26:04,506
Richard was under
my supervision,

1224
01:26:04,507 --> 01:26:05,812
and he did as I asked.

1225
01:26:06,987 --> 01:26:09,293
I told him to push harder,

1226
01:26:09,294 --> 01:26:11,208
and I chose the timing,

1227
01:26:11,209 --> 01:26:12,731
and I chose the words I said,

1228
01:26:12,732 --> 01:26:15,212
and I chose the way I said them.

1229
01:26:15,213 --> 01:26:16,519
And he just...

1230
01:26:19,130 --> 01:26:20,436
It's my responsibility.

1231
01:26:22,002 --> 01:26:24,265
I am responsible
for the risks I take

1232
01:26:24,266 --> 01:26:25,876
every time I perform surgery.

1233
01:26:26,703 --> 01:26:31,228
And Richard is dead
because he blamed himself

1234
01:26:31,229 --> 01:26:33,188
for a mistake I made.

1235
01:26:36,669 --> 01:26:40,238
I didn't make my responsibility
clear enough to him.

1236
01:26:41,674 --> 01:26:43,633
He was a student doctor.

1237
01:26:47,463 --> 01:26:49,204
And...

1238
01:26:51,728 --> 01:26:53,468
And we're hanging

1239
01:26:53,469 --> 01:26:55,252
a target around his neck

1240
01:26:55,253 --> 01:26:56,385
with this vigil.

1241
01:27:01,303 --> 01:27:04,174
And I'm not going
to let this boy

1242
01:27:04,175 --> 01:27:06,133
be scapegoated publicly

1243
01:27:07,526 --> 01:27:10,964
by middle managers
and doctors-turned-bureaucrats.

1244
01:27:13,358 --> 01:27:15,490
We are in service.

1245
01:27:15,491 --> 01:27:17,796
We have a covenant
with our patients.

1246
01:27:17,797 --> 01:27:19,538
"I will save you
with my skills."

1247
01:27:21,497 --> 01:27:23,499
But we have a covenant
to each other.

1248
01:27:24,630 --> 01:27:26,588
We're in service
to each other, too.

1249
01:27:26,589 --> 01:27:29,940
Both those covenants are
being broken here today,

1250
01:27:31,246 --> 01:27:32,682
and I will not stand by

1251
01:27:33,987 --> 01:27:37,295
and help pretend
that's not the case.

1252
01:27:40,124 --> 01:27:41,212
That's enough.

1253
01:27:54,965 --> 01:27:57,271
Rest in peace, Richard.

1254
01:27:57,272 --> 01:27:58,621
Rest in peace.

1255
01:29:48,557 --> 01:29:49,949
This is what happened.

1256
01:29:54,606 --> 01:29:56,216
Lisa was very sick.

1257
01:29:57,479 --> 01:29:59,045
She had septicemia.

1258
01:30:01,134 --> 01:30:05,574
Although the original operation
was marred by an error I made,

1259
01:30:07,924 --> 01:30:09,186
without that error,

1260
01:30:11,101 --> 01:30:14,626
it's highly likely
she would have still died.

1261
01:30:16,454 --> 01:30:18,717
The sepsis was advanced.

1262
01:30:27,552 --> 01:30:29,074
Ev...

1263
01:30:29,075 --> 01:30:32,731
Even though
your operation went wrong...

1264
01:30:34,864 --> 01:30:36,605
she still could have died?

1265
01:30:42,785 --> 01:30:43,786
Yes.

1266
01:30:45,744 --> 01:30:46,745
Yes.

1267
01:30:51,315 --> 01:30:52,403
Yes.

1268
01:31:00,324 --> 01:31:01,890
Is there anything

1269
01:31:01,891 --> 01:31:03,719
you would have done differently?

1270
01:31:10,813 --> 01:31:12,292
That's the hard bit.

1271
01:31:13,337 --> 01:31:14,381
No.

1272
01:31:15,513 --> 01:31:16,645
I would not.

1273
01:31:18,429 --> 01:31:21,650
All the decisions I made
were to try to save Lisa.

1274
01:31:22,955 --> 01:31:24,782
If the operation
were to happen again,

1275
01:31:24,783 --> 01:31:27,307
I could make all
the same decisions.

1276
01:31:31,224 --> 01:31:33,487
But I would endeavour

1277
01:31:33,488 --> 01:31:36,142
to be better at explaining it,

1278
01:31:37,274 --> 01:31:41,104
be better at taking
responsibility.

1279
01:31:43,889 --> 01:31:45,630
I allowed doubt to creep in.

1280
01:31:58,295 --> 01:31:59,557
Lisa fought.

1281
01:32:00,732 --> 01:32:02,124
She fought really, really hard.

1282
01:32:02,125 --> 01:32:03,343
You need to know that.

1283
01:32:07,522 --> 01:32:09,088
In the end, her body gave up,

1284
01:32:11,047 --> 01:32:12,222
des...

1285
01:32:13,658 --> 01:32:16,531
despite all our
experience and care.

1286
01:32:17,923 --> 01:32:19,272
And please know

1287
01:32:20,491 --> 01:32:22,493
that your daughter
was cared for.

1288
01:32:44,559 --> 01:32:46,648
I wanted a good
outcome for Lisa.

1289
01:32:48,824 --> 01:32:50,303
And I'm so sorry.

1290
01:33:31,606 --> 01:33:32,781
Thank you.