WONDER v MACK

INDEX TO BRIEF A. OBSERVATIONS B. PLEADINGS

1. Statement of claim 2. Defence 3. Amended defence 4. Part 33 particulars

C. INTERROGATORIES & PARTICULARS 5. Plaintiff's answers to interrogatories 6. Defendant's answers to interrogatories 7. Request for particulars 8. Answer to particulars

D. PLAINTIFF'S WITNESS STATEMENTS 11. Statement of plaintiff 12. Report of Dr Alfred dated 26 August 1983

E. DEFENDANT'S WITNESS STATEMENTS 13. Statement of Dr Susan Mack 14. Statement of Dr Julian Swift

F. MEDICAL RECORDS 15. Consent forms 16. Casualty record and clinical notes 16. Hospital discharge report

G. REFERENCE MATERIALS 17. Excerpt from "My Body My Decision"

WONDER V MACK

BRIEF TO APPEAR

OBSERVATIONS

In this matter, the plaintiff, Eva Wonder, is suing the defendant, Dr Susan Mack, for damages for personal injuries arising out of an operation on 18 March 1983.

The plaintiff is a registered nurse. At the time of the operation, she was married with two children.

The plaintiff says that she saw Dr Mack because she was experiencing acute abdominal pain. She had previously experienced abdominal pain and in fact had had her right ovary removed in 1981.

When the plaintiff consulted the doctor, she says that she told her in clear terms that she was of the view that hysterectomies are often performed without due cause on young women and that she was anxious not to have her uterus removed unless it was absolutely necessary, eg because of cancer.

The plaintiff was admitted to hospital and the defendant ultimately performed a total hysterectomy, apparently in the belief that the uterus was cancerous, or could become cancerous, and removal was in the best interests of the patient.

The plaintiff asserts that the removal of her uterus was totally unnecessary and that she has suffered greatly as a result of the doctor’s negligence. She claims that her suffering is not only physical but also emotional and indeed has led to the collapse of her marriage and a complete personality change.

Counsel will see that liability is very much in dispute. Counsel will also note that the matter is to be heard with a jury.

IN THE SUPREME COURT OF NEW SOUTH WALES COMMON LAW DIVISION SYDNEY REGISTRY No 3982 of 1984 EVA WONDER Plaintiff SUSAN MACK Defendant STATEMENT OF CLAIM Hilton & Co Solicitors 180 Phillip Street, Sydney 2000 DX 397

1. The Defendant is a duly qualified

medical practitioner. 2. At all material times the Defendant

carried on practice as a specialist gynaecological surgeon.

3. In the month of March 1983 the Plaintiff retained and employed the Defendant as such specialist gynaecological surgeon for reward to be paid to her by her to carry out the operative procedure of laparotomy.

4. It was an implied term and condition of the said employment that the Defendant would exercise all due professional skill care and attention as a specialist gynaecological surgeon in the treatment and management of the Plaintiff.

5. It was a further term and condition of the said employment that the Defendant would not perform a total hysterectomy upon the Plaintiff unless there was definite evidence of cancer.

6. Alternatively, the Defendant was under a duty of care to the Plaintiff to exercise all due professional skill care and attention as a specialist gynaecological surgeon in the treatment and management of the Plaintiff

7. The Defendant submitted the Plaintiff to laparotomy at Dapto Base Hospital on 18th March 1983.

8. In the course of such operation, the Defendant removed the Plaintiff's uterus and performed a total hysterectomy upon the Plaintiff.

9. In breach of the said term and condition alleged in paragraph 4 hereof, the Defendant failed to exercise all due professional skill care and attention as aforesaid and was negligent. PARTICULARS OF NEGLIGENCE (a) Unnecessarily removed the Plaintiff's uterus and performed a total hysterectomy

upon the Plaintiff. (b) Failed to take a proper history in that - (i) she made no enquiry as to the duration and nature of the

Plaintiff's complaints; (ii) she made no enquiry as the Plaintiff's medical history; (iii) she failed to discover or if discovered failed to properly record and recall

the fact that the Plaintiff had had a right oophorectomy. (c) Failed to make proper enquiries as to the Plaintiff's prior medical history in that

she failed to have regard to the history taken by herself from the Plaintiff relating to the procedure of right oopherectomy referred to above.

(d) Negligently concluded that the right sided mass found at laparotomy was a right ovary.

(e) Failed to properly diagnose the right sided mass found at laparotomy as an ectopic pregnancy.

(f) Failed to defer the decision to remove the Plaintiff's uterus until proper and/or complete pathology was available.

(g) Wrongly instructed the pathologist as to the nature of tissue sent for examination. (h) Removed the Plaintiff's uterus upon the basis of the pathologist's verbal advice

on tissues wrongly described by the Defendant to the pathologists as a right ovary.

(i) Failed to recognise that the receding left ovarian mass was a corpus luteum haematoma of pregnancy.

(j) Failed to properly manage the Plaintiff's post-operative pain. (k) Failed to properly manage the Plaintiff's post-operative mental reaction. (l) Failed to properly manage the Plaintiff's healing processes.

10. In breach of the term and condition alleged in paragraph 5 hereof, the Defendant performed a total hysterectomy upon the Plaintiff when there was no evidence of cancer.

11. Alternatively, in breach of the duty of care aforesaid, the Defendant failed to exercise all due professional skill care and attention and was negligent in the treatment and management of the Plaintiff.

PARTICULARS The Plaintiff repeats the particulars set out in paragraph 9 hereof. 12. As a result of the Defendant's negligence and/or breach of contract, the Plaintiff was

injured and suffered and will continue to suffer loss and damage. PARTICULARS OF LOSS AND DAMAGE

Surgical removal of the uterus and performance of total hysterectomy upon the Plaintiff. Pain Nervous shock consequent upon the Defendant's erroneous advice to the Plaintiff after the operation as to the cancerous nature of the organs removed. Post-operative infection. Prolapse of the internal organs. Inability to do heavy work. Psychiatric disturbance. Frequency of micturition. Pain on micturition. Deprivation of the capacity to undergo surgical rejoining of the fallopian tubes and thereby to have the opportunity to bear further children. Surgical adhesions.

A 5cm area of abscess within the abdomen consequent upon the Defendant's failure to properly manage post-operative infection.

13. As a result of the negligence and/or breach of contract as alleged, the Plaintiff was put to added costs for hospital and medical attention.

PARTICULARS These particulars will be provided on an up-to-date basis prior to the trial. 14. The Plaintiff claims damages, interest and costs. TO THE DEFENDANT:

SUSAN MACK 158 MORNY STREET, DAPTO

If there is no attendance before the Court by you or your Counsel or solicitor at the time and place specified below, the proceedings may be heard and you will be liable to suffer an order against you in your absence. Before any attendance at that time you must enter an appearance in the Registry. TIME: PLACE: Law Courts Building Queens Square Sydney 2000 PLAINTIFF: Eva Wonder PLAINTIFF'S ADDRESS FOR SERVICE: c/- Hilton & Co ADDRESS OF REGISTRY: 5th Floor, Queens Square SYDNEY NSW 2000 FILED:

.......................................... Solicitor for the Plaintiff

IN THE SUPREME COURT OF NEW SOUTH WALES COMMON LAW DIVISION SYDNEY REGISTRY No 3982 of 1991 EVA WONDER Plaintiff SUSAN MACK Defendant DEFENCE Berensen & Associates Solicitors 180 Phillip Street Sydney 2000 Tel: 233 7416

1. The Defendant admits the facts alleged in paragraphs 1 and 2 of the Statement of Claim. 2. The Defendant does not admit paragraphs 3,4,5,6,7 and 8 of the Statement of Claim. 3. The facts alleged in paragraphs 9,10,11 and 12 of the Statement of Claim, and each of them are denied. 4. The Defendant denies that he was negligent as alleged in the Statement of Claim or at all. 5. No admissions are made as to the Plaintiff's alleged loss, injury and damage and it is denied that the injuries and disabilities claimed were caused by anything done or omitted to be done by the Defendant. ...................................................... Solicitor for the Defendant FILED:

IN THE SUPREME COURT OF NEW SOUTH WALES COMMON LAW DIVISION SYDNEY REGISTRY No 3982 of 1991 EVA WONDER Plaintiff SUSAN MACK Defendant AMENDED DEFENCE Berensen & Associates Solicitors 180 Phillip Street Sydney 2000 Tel: 233 7416

1. The defendant denies the allegations in paragraphs 3,5,9,10,11,12 and 13 and each of them of the Statement of Claim filed in these proceedings. 2. In answer to paragraph 8 of the Statement of Claim, the defendant admits that in the course of the operation, the plaintiff's uterus was removed but otherwise denies the allegations in that paragraph. 3. In answer to the whole of the Statement of Claim, the defendant denies that the Plaintiff is entitled to damages. 4. Further or alternatively, the defendant says that the plaintiff was negligent and that her negligence caused or contributed to the alleged damage suffered by her. PARTICULARS (a) The plaintiff failed to instruct the defendant not to proceed to total hysterectomy. (b) The plaintiff signed a Consent Form dated 15 March 1983; (b) The plaintiff failed to undergo psychiatric or other counselling post-operatively. ...................................................... Solicitor for the Defendant FILED:

IN THE SUPREME COURT OF NEW SOUTH WALES COMMON LAW DIVISION SYDNEY REGISTRY No 3982 of 1984 EVA WONDER Plaintiff SUSAN MACK Defendant STATEMENT OF PARTICULARS Hilton & Co Solicitors 180 Phillip Street, Sydney 2000 DX 397

1. PARTICULARS OF INJURIES: (a) Surgical removal of the uterus and

performance of total hysterectomy without medical justification or consent of plaintiff.

(b) Pain. (c) Nervous shock consequent Plaintiff

upon defendants erroneous advice to the plaintiff after the operation as to the cancerous nature of the organs removed.

(d) Post operative infection. (e) Prolapse of the internal organs. (f) Psychiatric disturbance. (g) Frequency of micturition. (h) Pain on micturition. (i) Inability to do heavy work (j) Deprivation of the capacity to

undergo surgical rejoining of the fallopian tubes and thereby to have the opportunity to bear further children.

(k) Surgical adhesions.

(l) A 5cm area of abscess within the abdomen consequent upon the defendant's failure to properly manage post operative infection.

2. PARTICULARS OF CONTINUING DISABILITIES (a) Continuing psychiatric disturbance (b) Inability to do heavy work. (c) Depression (d) Abdominal pain. (e) Frequency of micturition. (f) Continuing incapacity to bear further children. 3. DETAILS OF OUT-OF-POCKET EXPENSES (a) Dr Mack's operation fee: $425.00 (b) Dr Ian Smith (i) consultation 10.10.83: $18.80 (ii) opinion on adhesions 18.02.85: $43.00 (paid on medicare) (c) Dr Moon consultation fee 11.09.84: $85.00 (d) Fares to Sydney to see doctors 4. PARTICULARS OF CLAIM FOR ECONOMIC LOSS (a) Prior to the operation performed by the defendant on the plaintiff on 18 March 1983, the

plaintiff was employed as a casual registered nurse. Details of her employment from 1 July 1979 to 30 June 1983 are as follows:

(i) Commonwealth Department of Health Gross and net earnings 01.07.79 - 30.06.80 Gross: $4,923.00 Net: $4,480.00 01.07.80 - 30.06.81 Gross: $5,495.00 Net: $4,943.50 01.07.81 - 10.02.82 Gross: $3,360.00 Net: $3,301.80 (ii) Drs J.J. Solly and Partners: Gross and net earnings: 15.11.82 - 26.11.82 Gross: $1,060.00 Net: $1,060.00 (b) Particulars of her employment since the operation on 18 March 1983 are as follows: (i) Kiama and North East Hospital 07.05.84 - 30.06.84 Gross: $ 544.00 Net: $ 424.00 (iii) Wollongong District Hospital 01.07.85 - 30.06.86 Gross: $4,697.00 Net: $3,551.00 (iv). Wollongong District Hospital, as a casual relief registered nurse: 02.01.86 - 04.07.89: Totalling 1,394 hours at $12.01 per hour= $16,741.94 and 276 hours at $12.50 per hour = $ 3,450.00 Total Gross Pay = $20,191.94 (Net earnings for the 1989 tax year were $6,059.38). (c) Particulars of Future Economic Loss $475.30 gross salary per week, as adjusted from year to year under the Public Hospital Nurses (State) Award from the date of this Statement and continuing indefinitely, together with periodic increases in the earnings of comparable employees from time to time. The plaintiff claims total incapacity for work as a consequence of her injuries and ongoing disabilities as from the date of this Statement. ............................................. Plaintiff's Solicitor.

IN THE SUPREME COURT OF NEW SOUTH WALES SYDNEY REGISTRY COMMON LAW DIVISION No. 3982 of 1991 EVA WONDER Plaintiff -v- SUSAN MACK Defendant PLAINTIFF’S VERIFIED STATEMENT IN ANSWER TO INTERROGATORIES

The plaintiff answers the defendant’s interrogatories as follows: 1A Prior to or during 1983 did the

plaintiff receive any advice, description or explanation from a medical practitioner or other person concerning the nature and/or effect of a surgical operation in the nature of a tubal ligation or tubal anastomosis?

1A Yes. 2Q If so:

a) from whom? b) when? c) where? d) what was the substance of

the advice, description or explanation?

2A a) Dr Thomas

b) 1977 c) Dapto d) That Dr Thomas would

perform a bilateral partial salpingectomy.

Hilton & Co Solicitors 180 Phillip Street SYDNEY 2000 DX 397 Sydney Tel: 235.2874

3Q Before or during 1983 did the plaintiff receive any advice, description or explanation from

a medical practitioner or other person concerning or in relation to he possibility of a successful reversal of a tubal ligation or tubal anastomosis operation?

3A The plaintiff had read numerous articles in various medical journals and spoken to women who had had previous successful surgery to rejoin their fallopian tubes after tubal surgery. The plaintiff had also spoken to members of the medical profession and allied fields about the subject, after 1970 and prior to 1983.

4Q Has the plaintiff received any advice, opinion or treatment from a medical practitioner

concerning any mental disturbance, nervous complaint or psychiatric condition? 4A Prior to March 1983, no. .................................................................................

Solicitor for the Plaintiff

AFFIDAVIT On the day of 1991, I EVA WONDER, of ................., in the State of New South Wales, nursing sister, say on oath: 1. I am the plaintiff. 2. The answers to these interrogatories are true to the best of my knowledge, information

and belief. Sworn by the deponent ) at ) ) ................................................ Before me ) ............................................................................. Solicitor/Justice of the Peace

IN THE SUPREME COURT OF NEW SOUTH WALES SYDNEY REGISTRY COMMON LAW DIVISION No.3982 of 1991 EVA WONDER Plaintiff -v- SUSAN MACK Defendant DEFENDANT’S VERIFIED STATEMENT IN ANSWER TO INTERROGATORIES

The defendant answers the plaintiff’s interrogatories as follows: 1Q On 18 March 1983 at Dapto Base

Hospital in New South Wales did the defendant carry out a surgical operation (hereinafter called “the operation”) upon the plaintiff?

A. If yes, i) was the defendant

then acting in her capacity of specialist gynaecological surgeon? If no, in what capacity was the defendant acting?

ii) Was the defendant the surgeon in charge of the operation? If no, identify who was in charge.

1A Yes. A. i) yes

ii) Yes.

Berenson & Associates Solicitors 180 Phillip Street SYDNEY 2000 DX 397 Sydney Tel: 233.7416

2Q If the answer to interrogatory 1 herein is “yes”, then in the course of the operation did the

defendant see or identify any tissue and/or organ within the plaintiff‘s body which she then believed to be her right ovary? A. If yes, in the course of the operation did the defendant remove that tissue and/or

organ which she believed to be her right ovary? B. If yes, at the time of that removal, what had the defendant herself observed as to

the location, size, shape and condition of the said tissue and/or organ which led her to believe that: i) what she saw was the plaintiff’s right ovary; and/or ii) it was necessary to remove it?

2A The defendant saw a 6cm haemorrhagic adherent right adnexal mass which she believed was ovarian in origin. A. The defendant removed the mass and sent it to pathology for a frozen section

report. B. The defendant declines to answer this interrogatory on the ground that it is a

matter for evidence.

3Q In the course of the operation did the defendant perform a total hysterectomy upon the plaintiff? If yes,

i) When was the decision made by the defendant to perform a total hysterectomy: a) prior to the operation? If yes, specify at what time, or b) in the course of the operation? If yes, specify at what time (in relation to the stage of the operation).

ii) Did the receive any advice or assistance in coming to that decision? If yes: a) from whom did the defendant receive such advice or assistance? b) was that advice or assistance written or oral? c) if oral, set out in detail the words spoken to the defendant and by whom they were spoken. If written, identify the relevant document.

iii) At what stage of the operation was the total hysterectomy performed? iv) what observable indication (and if none, state none) had been seen by the defendant which led her to form the opinion that it was necessary that a total hysterectomy be performed on the plaintiff? v) what other facts, matters or things apart from observable indication led the defendant to form the opinion that it was necessary that a total hysterectomy be performed on the plaintiff? vi) what pathological tests were ordered by the defendant and/or had been carried out:

a) before the operation; b) after the operation; c) during the course of the operation?

vii) In respect of each pathological test ordered by the defendant or carried out specify:

a) the nature, extent and purpose of the test; b) by whom each test was carried out; c) the words used to communicate the result thereof the the defendant; d) when the result was communicated to the defendant and if during the course of the operation specify the stage in the operation when she did so learn each result; e) from whom did the defendant learn the result of each such test; If the test results were written identify the relevant document. If oral, specify who delivered those results to the defendant, the words spoken to the defendant by that person.

3A Yes i) After the defendant received a pathology report concerning the mass. ii) yes.

a) The pathologist provided the pathology report by telephone to the anaesthetist who transmitted the essence of it to the defendant as the defendant was scrubbed and waiting. b) oral report c) with respect, this is a matter for evidence. However, the substance of the pathologist’s report was that the mass was probably an active cystadenoma with necrotic cells.

iii) As in answer to 4A(i) above. iv-v) With respect these are matters for evidnece. vi) a) Haemoglobin

b) Blood urea c) Electrolytes d) Groups and Rh and Blood cross match e) chest x-ray

vii) The defendant objects to answering these questions. 4Q Was any evidence of cancer with in the plaintiff’s body found by or identified to or relayed

to the defendant: i) in the course of the operation? If so, state the time (in relation to the stage of the

operation); ii) before the operation; or iii) subsequent to the operation? If yes state: a) what that evidence was; b) whether it was found by the defendant, identified to the defendant or relayed to

the defendant; c) if it was identified to or relayed to the defendant detail by whom it was so

identified or relayed and the words spoken to the defendant by that person and the words spoken by the to that person. If in writing identify the relevant document

d) the nature and extent of the cancer found in the plaintiff’s body; e) the organs, tissue or organic matter affected by the cancer so found in the

plaintiff’s body. 4A i) Yes, upon observation of the mass and upon receipt of the pathologist’s report

and also visual observations of the defendant during the course of the operation. ii) Yes, upon the examination. iii) The defendant objects to answering this question on the grounds of relevance.

The defendant objects to further answering these interrogatories on the ground that they concern matters of evidence and also on the ground of relevance.

.................................................................................

Solicitor for the Defendant

AFFIDAVIT On the day of 1991, I Susan Mack, of 158 Morny St, Dapto, in the State of New South Wales, medical practitioner, say on oath: 1. I am the defendant. 2. The answers to these interrogatories are true to the best of my knowledge, information

and belief. Sworn by the deponent ) at ) ) ................................................ Before me )

............................................................................. Solicitor/Justice of the Peace

.6 September 1984 Messrs Hilton & Co Solicitors DX 397 SYDNEY

Dear Sirs,

RE: MACK ats WONDER - SUPREME COURT PROCEEDINGS S3982 of 1984

As you are aware we act for the Defendant in the abovementioned matter.

Please provide the following further and better particulars of the Plaintiff's claim:-

A. As to paragraph 3.

(i) With respect to the Agreement alleged was the same:- (a) express, (b) implied, (c) partly express and partly implied.

(ii) If the answer to (i)(b) is in the affirmative, what are all the particular facts and circumstances from which it is alleged that such Agreement was implied and what are the implied terms?

(iii) If the answer to (i)(a) is in the affirmative is it alleged that such Agreement was:- (a) oral, (b) in writing, (c) partly oral and partly in writing.

(iv) If the answer to (iii)(a) is in the affirmative:- (a) Upon what date (b) At what place (c) By whom on behalf of each party, was it made and (d) What are the alleged terms.

(v) If the answer to (iii)(b) is in the affirmative, please identify the alleged writing and inform us when and where the same may be inspected. Please supply a photostat copy of the same.

(vi) If the answer to (iii)(c) is in the affirmative, please furnish particulars as requested in (iv) above in respect of the alleged oral part and as in (v) above in respect of the alleged part in writing.

(vii) If the answer to (i)(c) is in the affirmative, please furnish particulars as requested in (ii) above in respect of the alleged implied part and as in (iii),(iv),(v) and (vi) above in respect of the alleged express part.

B. As to paragraph 4.

(i) In so far as the answers are not provided in response to the requests made relating to paragraph 3 please specify:- (a) all the particular facts, matters and circumstances from which it is alleged that such a term was implied. (b) what precisely is the implied term.

C. As to paragraph 5.

In so far as the answers are not contained in respect to the requests made in respect of

paragraph 3 please provide with respect to the alleged term the particulars requested in relation to paragraph 3 of the Statement of Claim substituting for the word "Agreement" the words "term and condition".

D. As to the Particulars of Negligence set out in paragraph 9.

(i) In what respect is it alleged that the removal of the Plaintiff's uterus was unnecessary.

(ii) Is it alleged that the Defendant failed to make any enquiry at all as to the Plaintiff's medical history.

(iii) When did the Plaintiff have a right oophorectomy.

(iv) Specify and identify and the medical records referred to in paragraph (c)(i). Please provide a copy of the same.

(v) Identify the medical history referred to in paragraph (c) (ii). Please provide a copy of any relevant document.

(vi) Identify the results of ultra sound tests. Please provide a copy of the results.

(vii) Identify the ultra sound results referred to in paragraph (c)(iv). Please provide a copy of the same.

(viii) Identify the histories referred to in sub-paragraphs (c)(v),(vi) and (vii). Please provide copies of the relevant documents.

(ix) Was the instruction referred to in paragraph (c)(g) given orally or in writing. (i) If in writing please supply a copy of the writing. (ii) If oral:-

(a) What were the precise words used. (b) When were they spoken. (c) To whom, and (d) In whose presence.

(iii)What was the verbal advice referred to in paragraph (c)(h) and in particular (a) what were the precise words used. (b) when were they spoken (c) to whom and (d) in whose presence.

(iv) In what respect is it alleged that the Defendant failed to properly manage the Plaintiff's post operative pain.

(v) In what respect is it alleged that the Defendant failed to properly manage the Plaintiff's post operative mental reaction.

(vi) In what respect is it alleged that the Defendant failed to properly manage the Plaintiff's healing processes.

E. As to the alleged loss and damage:-

(i) In respect of any injury referred to in the Statement of Claim which it is alleged has lead to disability, particularise precisely the nature and expect of the disability alleged, and in

particular:- (a) the period during which the Plaintiff has in the past suffered disability; (b) whether the Plaintiff still suffers from disability; (c) whether or not the disability is alleged to be permanent; (d) if it not alleged to be permanent, the period into the future that it is alleged it will affect the Plaintiff.

(ii) Specify any treatment for which it is alleged the Plaintiff has incurred expense consequent upon the alleged grievances.

(iii) Specify any treatment for which it is alleged the Plaintiff will incur expense in the future consequent upon the alleged grievances.

(iv) Was the Plaintiff treated at any hospital for any condition allegedly resulting from the alleged grievances. If so kindly furnish the following:- (a) the name and address of the hospital; (b) the nature of the treatment; (c) the period in hospital Please supply authorities addressed to the hospital sufficient to enable the Defendant to obtain an extract of clinical notes relating to any such treatment.

(v) Kindly provide a schedule of all out of pocket expenses claimed.

(vi) Specify any matter relating to damages which has not been particularised in the Statement of Claim or an answer to this letter.

Yours faithfully,

Berenson & Associates

Messrs Berenson & Associates Solicitors DX 397 SYDNEY 8 May 1985 Dear Sirs WONDER V MACK: SUPREME COURT, COMMON LAW PROCEEDINGS NO. S13625 OF 1984 We now act for Mrs Dubois, the plaintiff in these proceedings. We shall file and serve upon you within the next few days a notice of change of solicitor, a notice to set down for trial and a requisition for trial with a jury. We set out below the plaintiff's answers to your request for particulars of 6 September 1984: A. As to paraqraph 3. (i) Partly express and partly implied. (ii)-(vi)Not applicable. (vii) 1. As to the express part:- (l) In answer to question A (iii), the plaintiff says that the agreement was oral. (2) In answer to question A (iv), the plaintiff says:

(a) on or about 15 March 1983; (b) at Dapto Base Hospital; (c) the plaintiff and the defendant; (d) that the defendant would perform a laparotomy upon the plaintiff.

2. As to the implied part: (a) The plaintiff would pay the defendant a fee; (b) The implied term is as alleged in paragraph 4 of the Statement of Claim. B. As to paraqraph 4. (i) (a) 1. The defendant was a medical practitioner. 2. The defendant was a specialist gynaecological surgeon. 3. For the purposes of the surgery undertaken, the plaintiff was the defendant's patient. (b) The implied term is as alleged in paragraph 4 of the statement of claim. C. As to paraqraph 5. The plaintiff did not consent to hysterectomy unless there was cancer. ~ As to the particulars of neqliqence set out in paraqraph 9. (i) There was no cancer. (ii) No.

(iii) 1981. (iv) The records kept by Tamworth Base Hospital. The plaintiff does not have copies. (v) The records kept by Dr Payne. The plaintiff does not have copies. (vi) Reports by Drs Cairns, O'Brien and Brown dated 20.1.83 and 22.2.83. Copies are attached. (vii) See (vi). (viii) Copies are attached. D.(sic) (i)-(iii) Without the benefit of discovery of the the defendant's documents and of answers to interrogatories, the plaintiff is unable to provide answers to this request. (iv) He did nothing. (v) He did nothing. (vi) The plaintiff developed an infection. E. As to loss and damaqe. (i) 1. In addition to the particulars of loss and damage set out under paragraph 12 of the statement of claim, the plaintiff alleges that she has suffered a total dis~upti~n of. her marital relationship~.~J"-~ 2. The plaintiff's disabilities arose on the date of injury and are continuing. (ii) Nil to date. (iii) This is not known at the present time. There may be a need to treat an abdominal abscess from which the plaintiff suffers. If it is to be alleged that this is the result of the defendant's negligence, then the plaintiff will provide particulars in due course. (iv) Not to date. (v) There are none to date. (vi) Increased risk of myocardial infarction. The plaintiff wishes to have discovery of the defendant's documents and to administer to the defendant interrogatories to which verified answers will be required. Would you please obtain instructions whether your client will consent to following this course. On the assumption that your client's response will be favourable to our client's proposal, we enclose a draft consent order for your approval. If you approve the form of the order, would you please endorse your consent and return it to us as soon as possible for filing. Yours faithfully

STATEMENT OF EVA WONDER

I was born on 23 April 1950.

I married my husband Richard on 10 July 1970.

We have two children, Rachel, who was born on 14 May 1972 and Thomas who was born on 23 June 1974. We were happily married until I had my uterus removed on 18 March 1983.

In the year 1977 I had my tubes tied.

In the middle of 1981 I had my right ovary removed by Dr Thomas. What led up to that operation was that, whilst working at the pathology laboratory, I had suffered an attack of pain in my right side, which at first I thought was an ovulation pain, but which became worse and worse and was diagnosed as an ovarian cyst.

In January 1983 I had a sudden severe attack of pain on my left side and all over my abdomen. The pain was the same sort of pain as I had had initially prior to the removal of my right ovary. Again, it occurred at ovulation time.

The pain subsided but became worse again a few weeks later so I went and saw Dr Mack. I told her about the pain. Dr Mack examined me internally and examined my abdomen. I mentioned the fact that in my nursing experience I had seen young women have their uteruses and ovaries removed unnecessarily and I didn’t want this to happen to me. Dr Mack said “I’ll put you into hospital tomorrow and I’ll try and get a theatre organised. You realise that you’ll have to have your uterus and ovary removed if you have cancer?” I said “Yes”.

I was admitted to hospital the following evening and was required to fast. The next morning Dr Mack came to see me and told me that she was not able to organise a theatre until Friday. She suggested I stay in hospital. However, I found the nursing staff rude and unpleasant and so I signed myself out. I signed myself back in on the Thursday evening. Late that night I was presented with a form by a sister and was asked to sign it. I read the document and it said something like “I hereby consent to anaesthesia and blood transfusion if necessary. I consent to the operation of laparotomy and any other surgical procedure that the doctor deems necessary.”

On the basis that Dr Mack had promised not to remove my uterus unless it was absolutely necessary, I signed the form.

The next thing I remember is waking up in recovery and asking “What did they take out?” and I was told “Your right ovary and your uterus”. I was shocked and upset.

The next day Dr Mack came to see me and said “I removed your right ovary and did a wedge resection on your left ovary. I sent the right ovary to pathology for a frozen section and there were some odd tissues and the pathologist wanted to get a second opinion. I thought it was best to remove your uterus then in case you had cancer. These frozen sections aren’t always reliable.” I said “You must be sure that I have got cancer to take my uterus out.” She did not answer. A few days later I was told that the second opinion confirmed that I did not have cancer but that I had had an ectopic pregnancy. I was furious that she had proceeded to remove my uterus and I said to her “It was quite unnecessary for you to remove my uterus.” She replied “It will save you having any period problems in the future.” This upset me further as I had never had period problems before.

My husband came to take me home the following day and as I was getting into the car my wound gaped open on one side. Dr Mack had not given me any orders as to what I could or could not do nor had she ordered any analgesics for my pain or any antibiotics. As a result my wound became infected and I had to return to hospital again for treatment.

Before this operation, I had a close, loving relationship with my husband and children.

After the operation, I spent at least two years crying for most of the day. I could not do any work properly and I wished I was dead. I felt like a desexed animal. I threw things around the house and clawed at things until my hands bled and I screamed. I know that this is consistent with grief, not being “mad”. Each time I have to think what it was like or have to write about it, or see some doctor for an opinion for court, it comes vividly back to my how bad it was and what some doctors are capable of doing to patients for whatever motivates them and their insecurities. It upsets me for days and I cannot eat or sleep or do the things that I am trying to do again, to try and lead some sort of normal life.

I cannot stand having my husband anywhere near me and we continually argue. Sex repulsed me. Eventually, after about three years, my husband left me and our children live with him. I have attempted to do some work but I continually experience pain and extreme discomfort. Also, I am no longer able to concentrate on the work that I have to do. I continually feel that I have been cheated and that nothing can repair the damage that this doctor has done to me. But I want this doctor to pay, and pay dearly for treating me in this way and I don’t want it to happen ever to anyone else.

I am now in almost constant pain. I have been to two other doctors, Dr Smith in October 1983 and Dr Moon in 1984 and they could not help me. Now I"ve given up on doctors. I hate them. I will not see a psychiatrist. I am not mad. They have done this to me.

I cannot lift heavy things without feeling an agonising pain in my abdomen. I am also constantly tired and lethargic. Almost every hour I have to go the toilet. I have tried working since the operation but it is too hard. In 1984 I worked for a month at the Kiama and North East hospital and earnt $424.00 after tax. In 1985 I tried again, this time at the Wollongong hospital doing casual nursing. I did that on and off until 1989. Over that whole period I earnt the grand total of $24,000. Before the operation, I was earning about $450 net per week.

I am most upset that I cannot have any more children. When I had my tubes tied it was because I was told that it was the only safe form of contraception because my husband would not have an operation. I cried all the way to the hospital and all the way home. The only comfort was the fact that it could be reversed. Now I have lost my womanhood forever.

STATEMENT OF EVA WONDER

I was born on 23 April 1950.

I married my husband Richard on 10 July 1970.

We have two children, Rachel, who was born on 14 May 1972 and Thomas who was born on 23 June 1974. We were happily married until I had my uterus removed on 18 March 1983.

In the year 1977 I had my tubes tied.

In the middle of 1981 I had my right ovary removed by Dr Thomas. What led up to that operation was that, whilst working at the pathology laboratory, I had suffered an attack of pain in my right side, which at first I thought was an ovulation pain, but which became worse and worse and was diagnosed as an ovarian cyst.

In January 1983 I had a sudden severe attack of pain on my left side and all over my abdomen. The pain was the same sort of pain as I had had initially prior to the removal of my right ovary. Again, it occurred at ovulation time.

The pain subsided but became worse again a few weeks later so I went and saw Dr Mack. I told her about the pain. Dr Mack examined me internally and examined my abdomen. I mentioned the fact that in my nursing experience I had seen young women have their uteruses and ovaries removed unnecessarily and I didn’t want this to happen to me. Dr Mack said “I’ll put you into hospital tomorrow and I’ll try and get a theatre organised. You realise that you’ll have to have your uterus and ovary removed if you have cancer?” I said “Yes”.

I was admitted to hospital the following evening and was required to fast. The next morning Dr Mack came to see me and told me that she was not able to organise a theatre until Friday. She suggested I stay in hospital. However, I found the nursing staff rude and unpleasant and so I signed myself out. I signed myself back in on the Thursday evening. Late that night I was presented with a form by a sister and was asked to sign it. I read the document and it said something like “I hereby consent to anaesthesia and blood transfusion if necessary. I consent to the operation of laparotomy and any other surgical procedure that the doctor deems necessary.”

On the basis that Dr Mack had promised not to remove my uterus unless it was absolutely necessary, I signed the form.

The next thing I remember is waking up in recovery and asking “What did they take out?” and I was told “Your right ovary and your uterus”. I was shocked and upset.

The next day Dr Mack came to see me and said “I removed your right ovary and did a wedge resection on your left ovary. I sent the right ovary to pathology for a frozen section and there were some odd tissues and the pathologist wanted to get a second opinion. I thought it was best to remove your uterus then in case you had cancer. These frozen sections aren’t always reliable.” I said “You must be sure that I have got cancer to take my uterus out.” She did not answer. A few days later I was told that the second opinion confirmed that I did not have cancer but that I had had an ectopic pregnancy. I was furious that she had proceeded to remove my uterus and I said to her “It was quite unnecessary for you to remove my uterus.” She replied “It will save you having any period problems in the future.” This upset me further as I had never had period problems before.

My husband came to take me home the following day and as I was getting into the car my wound gaped open on one side. Dr Mack had not given me any orders as to what I could or could not do nor had she ordered any analgesics for my pain or any antibiotics. As a result my wound became infected and I had to return to hospital again for treatment.

Before this operation, I had a close, loving relationship with my husband and children.

After the operation, I spent at least two years crying for most of the day. I could not do any work properly and I wished I was dead. I felt like a desexed animal. I threw things around the house and clawed at things until my hands bled and I screamed. I know that this is consistent with grief, not being “mad”. Each time I have to think what it was like or have to write about it, or see some doctor for an opinion for court, it comes vividly back to my how bad it was and what some doctors are capable of doing to patients for whatever motivates them and their insecurities. It upsets me for days and I cannot eat or sleep or do the things that I am trying to do again, to try and lead some sort of normal life.

I cannot stand having my husband anywhere near me and we continually argue. Sex repulsed me. Eventually, after about three years, my husband left me and our children live with him. I have attempted to do some work but I continually experience pain and extreme discomfort. Also, I am no longer able to concentrate on the work that I have to do. I continually feel that I have been cheated and that nothing can repair the damage that this doctor has done to me. But I want this doctor to pay, and pay dearly for treating me in this way and I don’t want it to happen ever to anyone else.

I am now in almost constant pain. I have been to two other doctors, Dr Smith in October 1983 and Dr Moon in 1984 and they could not help me. Now I"ve given up on doctors. I hate them. I will not see a psychiatrist. I am not mad. They have done this to me.

I cannot lift heavy things without feeling an agonising pain in my abdomen. I am also constantly tired and lethargic. Almost every hour I have to go the toilet. I have tried working since the operation but it is too hard. In 1984 I worked for a month at the Kiama and North East hospital and earnt $424.00 after tax. In 1985 I tried again, this time at the Wollongong hospital doing casual nursing. I did that on and off until 1989. Over that whole period I earnt the grand total of $24,000. Before the operation, I was earning about $450 net per week.

I am most upset that I cannot have any more children. When I had my tubes tied it was because I was told that it was the only safe form of contraception because my husband would not have an operation. I cried all the way to the hospital and all the way home. The only comfort was the fact that it could be reversed. Now I have lost my womanhood forever.

Messrs Hilton & Co 180 Phillip Street Sydney NSW 2000

26 August 1983 re: Ms Eva Wonder Dear Sirs, I have known Ms Wonder for the past 8 years, as well as her family. Indeed, she was a close friend of my daughter. I have seen Ms Wonder on two recent occasions, on 7 February 1983 and 15 August 1983. I also had a telephone conversation with her on 7 July. She is obviously very concerned about the treatment which she has received in Dapto and indicates a major part of this problem was a failure of satisfactory communication between the medical staff and herself. When she came to see me in February she did indeed complain of a recurrence of abdominal pain which had already begun to settle. A 7cm multilocular cyst had been detected in the left ovary on ultrasound but on clinical examination I felt that this had already begun to regress. Certainly, tenderness was quite minimal and the cystic structure could not be clearly delineated. I did suggest that she should stay in contact with her general practitioner and have a repeat ultrasound in one to two weeks. I also suggested that she should return to see her doctor if the problem recurred. My knowledge of subsequent matters is mainly based on hearsay from Ms Wonder and from your own letter. I have not received any communication from Dr Susan Mack or Dr James although Mrs Wonder did ask them to send me a report. I have received details from Dr Brendon Murphy, Pathologist, in Dapto in response to my request. I will return to these later. Her history indicates that she had a recurrence of her pain and returned to see her general practitioner. The repeat ultrasound suggested that there was a cystic mass on the right side in the region where the right ovary had previously been removed. I am not clear about the exact sequence of subsequent events but Ms Wonder has told me about the detailed discussion which she had with Dr Mack about her remaining left ovary and her very strong desire not to have a hysterectomy. Unfortunately her symptoms continued and she required surgery. I understand that this was carried out by Dr Susan Mack. I understand that Ms Wonder repeated her concerns about retaining her left ovary and uterus to Dr Mack unless there was absolutely no alternative. Dr Mack clearly carried out a wedge resection of the left ovary to remove a thin wall of cyst which on histological examination turned out to be a regressing corpus luteum hematoma. This is a not uncommon finding in the ovary under fairly normal circumstances. Dr Mack also removed a rightsided pelvic structure described as "a rubbery, nodular mass". In the histology request this has been described as a right ovary and clearly suggests that Dr Mack was unaware that the right ovary had previously been removed. This tissue was sent for frozen section for examination and the pathologist was clearly uncertain whether there might be malignant tissue in the mass or not. I understand that the distinction between malignant tissue and an ectopic pregnancy is sometimes difficult on frozen section. A definitive diagnosis of ectopic pregnancy was subsequently made by Dr Peter Russell at the Department of Anatomical Pathology King George V Hospital, Sydney. It was apparently at the point of uncertainty following the frozen section that a decision was made to carry out a hysterectomy also. This was presumably based on the suspicion that the unusual tissue might just be malignant.

It may sometimes be quite difficult for an experienced gynaecological surgeon to recognise an ectopic pregnancy at the time of operation. This is likely to happen at sometime during their careers to almost all gynaecologists. However, the doctor should certainly have been aware of this as a possible diagnosis since the right ovary had previously been removed.

Clearly, a different set of differential diagnoses must be considered if the surgeon knows that the ovary on that side of the body has already been removed.

There clearly would not have been any necessity for a hysterectomy if the diagnosis of ectopic pregnancy had been made during operation.

Clearly, there would have been no need for removal of the uterus if the diagnosis of ectopic pregnancy had been made by either the pathologist or the surgeon.

Although I am always hesitant to criticise a professional colleague, I find it extremely difficult to understand why a hysterectomy was carried out on the mere suspicion that some slightly odd tissue was present in the rightsided mass. I would have thought that it was more appropriate to await a firm pathological diagnosis and then plan further definitive treatment for serious disease such as cancer once all the information was available. This particularly applies when the patient clearly states that she told the surgeon that he should not carry out a hysterectomy unless cancer was confirmed.

After talking to Ms Wonder it seems clear that the major problem here has been a lack of communication with her by Dr Mack. She obviously feels that the situation was not adequately explained to her and she also was extremely upset that when she developed post operative pain that she showed very little interest in her problems. A patient who has had an unplanned hysterectomy usually requires much more counselling and concern than a patient who has had a well-planned elective procedure. Ms Wonder clearly has the impression that she did not receive the appropriate attention and counselling.

Prior to this surgery, Eva had always been a bright, happy, intelligent young woman with lots of drive - quite an accomplisher in fact. As well, she has been very thorough and with good application in any task she has undertaken. She is a good, loving and conscientious mother. Since the surgery, Eva has had a great loss of psychological wellbeing, variously described as “attacks of depression” and of “being depressed” with considerable disturbance to her feminine self image. In the early post operative phase she was also very ill and shocked and fearful that the hysterectomy which had been performed - against her express wishes - had in fact been because she had cancer. The change in Eva’s overall personality and approach to life has been quite marked. Yours faithfully,

STATEMENT OF DR SUSAN MACK

My full name is Susan Diane Mack and I live at 158 Morny Street, Dapto.

I am a registered medical practitioner having graduated from the University of Sydney in 1981. Following my graduation, I was employed for a year at St Vincent's Private Hospital in Sydney. Then I moved to Dapto and commenced in general practice.

Ms Wonder first presented to my surgery in about January 1983. I am uncertain of the precise date because I no longer have my notes from that time. However I do recall Ms Wonder because I had heard about her from some of the other doctors in Dapto. I remember that Ms Wonder presented complaining of acute severe left-sided abdominal pain. Onset of this pain occurred in mid-cycle. I was only able to obtain a brief history from Ms Wonder because of her discomfort.

I saw her again on 14 March 1983 and obtained further information, although Ms Wonder was again in considerable distress. Nevertheless Ms Wonder assured me that she had told me all relevant information, and she stressed that she was a nurse.

Her past history included tubal ligation in 1977. There was no indication given whatsoever that she intended falling pregnant at any future stage.

I undertook an internal examination and formed the view that further investigation was required. I think I also detected some swelling of the pelvic lymph glands on palpitation because I remember mentioning to her that a hysterectomy would be necessary if there was any evidence of cancer. The only comment I remember from Ms Wonder was "I can't stand operations. I'd do anything to avoid one." That statement was consistent with what I had heard about Ms Wonder from the other doctors.

I fully informed Ms Wonder that the laparotomy procedure may if necessary result in further procedure(s) being performed, such as cystectomies of the pouch of Douglas, total hysterectomy and salphingoophorectomy.

The following day Ms Wonder was admitted to Dapto Base Hospital. It was not possible to arrange a theatre immediately and I was told that Ms Wonder had discharged herself after abusing the hospital staff. That behaviour was also consistent with what I had been told by other doctors.

I recall the operation on Ms Wonder on 18 March 1983. During the operation I observed that the left ovary was cystic and haemorrhagic. A left ovarian wedge resection was performed. A right-sided mass was observed which was approximately 6cm in diameter. I was concerned by these observations about the possibility of cancer and accordingly I examined the patient's pelvic lymph glands (which I had previously noted were apparent on palpitation). They appeared to me to be enlarged. A sample was taken and referred for microscopic examination. The frozen section report indicated active cystadenoma with very few cells as the tissue was mostly necrotic. A definitive diagnosis of cystadenoma of the right ovary was made. In view of this, and the comment that the patient did not want to undergo further operations, a total hysterectomy was performed.

The right sided mass was subsequently diagnosed to be an ectopic pregnancy.

I should point out that it is really not possible to recognise a corpus luteum of pregnancy with any certainty. Corpus luteum haematomas are sometimes seen to occur in a normal menstrual cycle. The signs and symptoms as presented would not have drawn any surgeon’s attention as to the possibility of a pregnancy.

Following the operation I went and saw Ms Wonder and explained to her precisely what had occurred. I told her of my suspicions of cancer but tried to reassure her by stating that we were

obtaining a second opinion. Unfortunately she would not listen and went into a rage. I tried to explain more fully but she would not listen. She started screaming and shouting.

As soon as I received the results I went to Ms Wonder thinking that she would be pleased and relieved that she was free of cancer. Instead she commenced abusing me as soon as I entered the ward. I told her of the results of the further report but she paid no attention. She refused to let me examine her. I told her I would prescribe medication for her if she was in pain but she replied that she would not have anything further to do with me. I found out later that the patient subsequently discharged herself from hospital. I also found out that she had previously acted in this manner with other doctors who had attempted to help her.

I believe that at all times I acted in the best interests of the patient and in accordance with proper practice.

DR SUSAN MACK

Messrs Berenson & Associates DX 397 SYDNEY

12 January 1987

Dear Sirs,

REPORT RE EVA WONDER

At your request, I examined Ms Wonder today.

It was obvious from the outset that she was hostile to the concept of medical consultation and examination.

As she entered the consulting room, she was flushed and red-eyed and obviously antagonistic before a word was spoken. I went out of my way to put her at her ease, and indeed spent one and a half hours with her to this end. I questioned her about the details of her 1983 illness. Her attitude was one of total antagonism to doctors in general and this doctor in particular. She asserted that she had adamantly instructed Dr Mack that under no circumstances was she to perform a hysterectomy on her. However, I note that this is at variance with the documented facts, not the least of which includes her having signed a standard form of consent for such an operation, dated March 15, 1983, in which one of the surgical possibilities was noted as ? total hysterectomy.

I note that several complications did occur post-operatively. In my view, these are the usual relatively frequent complications of any abdominal operation. However, Ms Wonder, from her statements to me, was convinced that such complications arose as a result of professional incompetence by her surgeon. While not making any comment to her, I could not agree with this proposition. She told me of the various woes which had befallen her since this operation, including her financial and marital difficulties and continued physical ill-health. However, I gathered from her conversation that she is still living with her husband. The general thread of her complaints appeared to me to be obsessively directed vindictively towards Dr Mack. One of her main ongoing complaints at present was of recurrent bouts of lower abdominal pain and swelling, together with a sensation of a lump in the right lower quadrant of the abdomen which was only intermittently present. She told me that when this swelling occurred there was a gurgling and splashing in the abdomen. When the pain was present she passed frequent small, soft motions. When she was pain- free, her bowel actions were normal. There was no blood or mucous passed with the stools. She denied any urinary tract symptoms.

Having spent a very lengthy time with her in an attempt to gain her confidence, I did not examine her physically as I felt that there was little prospect of any gainful finding to be made and further, I was of the view that physical examination may indeed prove to be counter-productive. I did ask her to let me have a written and detailed account of all that she had told me during out consultation so that I may give every consideration to her various complaints when framing my report. She promised to do so and to ensure that I received this statement from her within a week. To date, I have not received any such statement from her.

In summary, therefore, it was my overall opinion that this lady is obsessively and vindictively disposed towards Dr Mack, holding her responsible for her continued ill-health since and various physical, financial and domestic problems which she claims to have encountered since 1983. In my view, she was suffering from an extreme non-organic reaction to her illness, manifesting itself with symptoms strongly suggestive of an irritable colon in terms of the symptoms which I have listed above. This condition is frequently encountered in patients with a higher level of nervous stress and is a classical psychosomatic manifestation. Her failure to abide by her promise to provide me with a written statement of the various complaints which she made to me during the consultation, I believe is further confirmation that her general assertions and allegations are not necessarily to be taken at face value.

If ovarian malignancy is present the correct management is to remove the uterus and both tubes and ovaries, preferably en bloc. If malignancy is suspected it is preferable to proceed in the same way, as if the ovary alone is removed a subsequent operation will be required to complete the pelvic clearance.

In this case Dr Mack had a frozen section performed which was slightly equivocal but suggested malignancy, which agreed with her clinical impression. All the immediate evidence suggested that this ovarian mass was malignant, and so the correct management was hysterectomy.

It will of course be obvious that this woman's reaction to hysterectomy has been extreme. The great majority of women having this operation respond to it in a normal appropriate fashion, but a small percentage respond in a pathological way, and clearly Mrs Wonder fits into that category.

I accept her presentation as a genuine one, rather than being contrived. Why she should have developed the attitude she has is not clear to me, but that she has had it lifelong is clear. When she was training as a nurse, she found the thought of hysterectomy repulsive and used to be upset by seeing young women in hospital for hysterectomy. She reacted adversely to the tubal ligation that she had in 1977. She did not want this done, but felt at that time that there was no chance that they would be able to afford further children and she had earlier been advised that she should not on any long-term basis take oral contraceptives. She felt something less than a woman after this operation, but coped with it, at least on the surface. She equally reacted to some degree adversely to an operation on the right ovary, which was done by Dr Thomas in 1981, as a result of severe right-sided pain. However, again, on the surface, she coped.

It is clear, however, that throughout her life she has been extremely adverse to the idea of hysterectomy in women in general and in herself in particular, and thus falls into this category of women who are going to react in an unusual way to hysterectomy, irrespective of the cause.

It is apparent, talking to Mrs Wonder, that it would not have mattered had the diagnosis been cancer and the uterus removed, the result would have been practically identical.

Yours faithfully,

TO BE INSERTED MEDICAL RECORDS Consent forms Casualty record and clinical notes Hospital discharge report