Surgery tried to blame mum Cherie Guest for her own death

A day clinic claimed a woman who died after eye surgery had pressured them to conduct the procedure – however a coroner has found that was “patently wrong”.

Cherie Guest died five days after undergoing laser surgery for cataracts.

A day surgery that performed a fatal operation on an at-risk mother despite multiple red flags later tried to blame the dead woman for “pressuring” them to conduct the procedure that killed her.

St Albans mum Cherie Guest, 61, died in August 2018, five days after undergoing laser surgery for cataracts, which a coroner found she should never have undergone.

The Coroner’s Court heard that the childcare worker, who required an oxygen tank to breathe, and her daughter Angela repeatedly raised concerns with Victoria Parade Surgery Centre about the procedure that required her to lie flat for extended periods.

But they were never told Mrs Guest was deemed an ‘ASA 4’ risk – a patient with severe systemic disease that was a threat to life – which made her automatically ineligible for the operation.

Ms Guest died aged 61.

Nor were they told that staff had argued about cancelling her treatment, or that anaesthesiologist Dr Fabian Purcell withdrew over his “grave fears” for her safety.

Instead, an inquest heard that on the morning of the operation on August 13, eye surgeon Dr Joseph San Laureano told Mrs Guest “there were no risks” and the procedure went ahead.

Immediately afterwards, the woman who suffered severe restrictive lung disease and had turned blue in theatre, was rushed to St Vincent’s hospital where she continued to deteriorate and died on August 18.

In a report to Safer Care Victoria about Mrs Guest’s death, surgery chief executive Tim Puyk claimed she and Angela were “pushing for surgery”, had “pressured” the surgeon to perform it, and that Angela was “well aware” of the hospital’s concerns and the risks of going ahead.

“These statements were patently wrong,” Coroner Katherine Lorenz said on Thursday in handing down her findings into Mrs Guest’s death.

She found that Mr Puyk’s comments “may have had the effect of misleading Safer Care Victoria”.

The Guest family had no idea of the report’s existence until the coronial probe.

Outside court, Angela called the comments “morally reprehensible”, “very far from the truth and deeply concerning”.

“We did the opposite … we asked questions, we were cautious, and here is a man (Mr Puyk) who basically blamed my mother for her own death,” Angela said.

Cherie Guests’s daughter Angela Guest says Tim Puyk’s comments were ‘morally reprehensible’. Picture: David Crosling

She said she believed the report was the surgery’s attempt to cover up what occurred.

“It was fairly black and white.”

On August 13, 2018, Mrs Guest arrived to the East Melbourne surgery “short of breath and anxious” for the two-part procedure, with staff becoming so concerned they pushed her back in operation queue.

During the first phase – where a femtosecond laser machine emulsified the lens in her left eye as she lay down on a hospital bed – staff failed to monitor Mrs Guest’s oxygen levels, which dropped to just 60 per cent.

Her lips turned blue, but surgeon Dr San Laureano – the only doctor in the room after Dr Purcell withdrew – claims he didn’t notice, even though he was operating on her face.

During a break before the second part of the procedure, where a new lens would be implanted, the court heard Mrs Guest was overheard loudly saying “she didn’t want to lie down again”.

She and her daughter said they feared having to lie flat for a longer duration – upwards of 20 minutes – was “going to be a disaster”.

But they were told the second phase had to go ahead or Mrs Guest would risk losing her eye.

In the end, she lost her life.

Dr San Laureano – who was the only person that felt Mrs Guest was fit for surgery – later told the court that “eye surgery does not impact on other body systems”.

“At no stage did I think she was going to have a respiratory arrest, that thought didn’t enter my mind,” he said.

While he told the court he had a “genuine belief” the surgery was safe, the coroner found “there was no basis” for this belief.

Coroner Lorenz found that Mr Puyk, Dr Purcell and Dr San Laureano all failed in their duty, and if either one of them had done their job and cancelled the surgery, Mrs Guest would not have died.

The court found that Mrs Guest did not give informed consent to the procedure because she wasn’t aware of the risks, that her death was preventable and her surgery should never have been performed.

However, no recommendations for change were made.

Maurice Blackburn principal Dimitra Dubrow said “this is as strong a coronial finding as I’ve seen”.

The Guest family is now exploring their legal options.