Inquest into the death of Heather Winchester

Findings and Recommendations

Findings and Recommendations of Inquest

Case Number: 2019/304802

Date of Findings: 28 February 2025

Magistrate: Deputy State Coroner, David O'Neil

CORONIAL LAW - Elective surgery, informed consent, Jehovah’s witness, documents indicating wishes, documents prepared in USA, unsuitability of documents for NSW.

Responses

Recommendations 

To the Hunter New England Local Health District

1. That the Hunter New England Local Health District put in place a requirement, (as distinct from an expectation), that a member of the surgical team must review the preanaesthetic clinic notes prior to surgery. Whether this is part of an updated clinical procedure safety policy or contained in some other document is a matter for the Local Health District.
2.  The timeout procedure contained in the Clinical Procedure Safety Levels 1, 2, and 3 policy document be reviewed so that any anomalies, for example, a blood screen conducted for a patient that has refused a transfusion, are identified before surgery.
3.  A procedure be implemented that is followed by all relevant medical staff whenever a patient identifies as a Jehovah's Witness, which includes;
   • advising the patient of the availability of the Jehovah's Witness Hospital Liaison Committee and informing the patient that they can contact the committee if they so wish;
   • an appropriate form for partial refusal of blood products;
   • a checklist of blood products that the hospital has available for patients;
   • a list of all documentation which should be sought from the patient.
4.  That the Chief Executive at Hunter New England Local Health District takes steps to resume regular meetings between the church's hospital liaison committee and the directors of medical services at each hospital within the district, with the aim to develop strategies to enhance clinicians' understanding of what treatment would be considered reasonable and compatible with Jehovah's Witness patients generally and what resources are available to staff in such circumstances.
5.  Training and education provided to visiting medical officers and locums be reviewed to ensure they understand how to access all relevant electronic records and their responsibility to do so.

To the Christian Congregation of Jehovah's Witnesses Australasia

1. That all New South Wales congregants be advised that Worksheets 1 and 2 are no longer to be relied upon, and that they should not be used at all for any purpose. This advice should be relayed through all available resources, including literature, both electronic and print, information to elders, and at places of worship.
2. That the church advise congregants in New South Wales the precise status of the development or otherwise of products from human or animal haemoglobin which could be used to treat patients in New South Wales when those patients are suffering with acute anaemia or massive blood loss. This advice should be relayed through all available resources including literature, both electronic and print, information to elders and at places of worship.