A brief summary of communications with the appropriate authorities. This does not include the time consuming additional applications needed to be made outside of the hospital notes for access to information such as the communications made between Dr Sampaio and the his peers, the EEG scans, Alinas GP notes, the medical testing equipment used by SCH etc.
The contact below represents only those that were willing to reply. Several Doctors were approached, Specialists, Lawyers, legal experts and even Judges.
Despite speaking with several solicitors, none would be willing to review the case as they are aware that in NSW Courts, only the Hospital notes are accepted as evidence. They reminded me of a time limit and the extraordinary costs, which would make this case a near impossible task of fair resolution, in particular since the complaint was against a Doctor and Hospital. Legally in NSW, Solicitors are not even allowed to listen to the recordings made of Doctors at SCH
It was suggested that these facts are known by Medical Professionals in advance, who in turn adapt the Hospital notes at the time accordingly. Also that any statement made in contradiction of the events as recorded by the Hospital Staff are often dismissed as an emotional error of judgement or recollection by the patient in a time of stress.
Communications with the Health Care Complaints Commission, January 2020
20 January 2020
Dear Mr Murtagh,
I am writing to confirm that I have received your request to review the Commission’s decision regarding your complaint about Dr Hugo Sampaio.
The purpose of any review is to ensure that there were no mistakes made throughout the assessment process and that all the available information was taken into consideration. If it is found that errors have been made or new information has been provided for the Commission to consider, then the assessment decision may be amended accordingly. You will be advised of the outcome in writing at the completion of the review.
An email from Mr Murtagh to HCCC – 27/04/2020
Thank you for letting me know the issues. I’ve added some recorded files, my editing is not very good so I’ve taken an approximation of the conversation aspects regarding Ketogenic diet, so it is not taken out of context. Otherwise these meetings are often over an hour
I have concerns that a lot of information seems to be either omitted of deleted in the hospital notes, I have contacted the hospital via patients friend and was assured that there were in completion. i.e. the benefits of the ketogenic diet, responsiveness to Alinas condition when omitting sugar from medicines and diet. I understand a Doctor has to be both truthful, and also write accurate notes. This has clearly not been the case, and so affecting the diagnosis investigation
The reply to this from the HCCC 28/04/2020
Dear Mr Murtagh,
I understand the Commission’s assisted resolution process has recently been closed. I am therefore hoping to finalise the review soon given I now have the independent clinical information. In reviewing everything, I am having trouble accessing the audio file you sent in. Are you able to please re-send this in a different format. If you are able to do this via a secure file transfer via dropbox that would be good or attach the actual file to an email direct to me should work also.
Kind regards,
Leanne Evans
Senior Review Officer
Health Care Complaints Commission
Wed 29/04/2020
Sorry about the delay in getting back to you Mr Murtagh. However, unfortunately, the Commission is unable to take those audio recordings into account in its review of your matter. I will continue to review the matter based on the information we have and hope to have an outcome for you in the next week or so.
Communications with Darren Anderson- Resolution Officer (HCCC) 17/04/2020
A response was received from the SCHN in late October. The SCHN response was provided to you and it was agreed that the Commission would seek the advice of a peer neurologist to indicate whether the care provided for Alina during the admission met the expected clinical standard. Before seeking the clinical advice, you provided a detailed, annotated reply to the SCHN response outlining your concerns with the treating team’s diagnosis and highlighting features of the illness that you were concerned had been disregarded by the treating team. All the complaint documentation and, in particular, the SCHN response from October 2019 and your 17 November reply to it, was provided to the independent peer to consider when framing their advice. Identification of a peer neurologist to provide the advice took longer than anticipated and I apologise for the associated delay.
While I am unable to provide you with a copy of the clinical advice, key points are summarised below:
The peer was of the opinion that the most likely cause of Alina’s condition was a progressive neurological disorder, of genetic origin.
The peer felt that a mitochondrial disorder was likely, but that expert geneticists in the field would be best placed to consider whether the CARS2 genetic mutation was the specific cause.
The peer was not of the opinion that Alina’s symptoms were caused by glucose intolerance or viral encephalitis.
The peer felt that the approach taken to managing Alina’s complex symptoms was appropriate and noted that the treating team consulted with specialists across a wide variety disciplines throughout the admission to inform the treatment response to her progressive deterioration.
The absence of peer criticism of the care provided for Alina means that the prospect of successful disciplinary action against any individual involved in Alina’s care is remote. As a consequence, the Commission is unable to progress the matter further. While I understand that this outcome is unsatisfactory from your perspective, it is clear that the available options for resolving your complaint have been explored and exhausted and, as a result, the file of your complaint about the SCHN is now closed.
This is the end of the communications with the Medical Board and HCCC who firmly close any further communications and explanation
To the father this response seems incredibly unlikely that Alina, who had been suffering from a documented persistent virus since birth, that suddenly became a Genetic illness (Bayes theorem) which had absolutely no supporting evidence other than the opinion of a Neurological team who habitually withheld information from the Hospital notes and also lied on enquiry.
Therefore it seemed that if the Hospital notes were so misleading that it would be better to write up a diary of events, with the videos and audio files inserted at the time to compare against the notes taken. This would also include the appropriate supporting medical papers. This was saved on pdf, and given the size was sent as a Gmail link to the following groups and persons (The Coroner, the Police, the Minister of Health etc.)
The replies were as follows:
NSW State Coroners Court, Lidcombe, NSW11 Jan 2021
11 January 2021
Request to Assume Jurisdiction- DECLINED Alina Poppy MURTAGH
Dear Mr Murtagh
Thank you for your email received 3 December 2020 requesting the coroner assume jurisdiction into the death of your daughter, Alina Poppy Murtagh. Firstly please accept my sincere sympathy for the passing of your little daughter. I am writing on behalf of the Duty Coroner who has reviewed your application, associated medical records and the report provided by the Duty Forensic Pathologist.
The Coroner will only take jurisdiction in a death when it occurs in the following circumstances:
(a) where the person died a violent or unnatural death;
(b) the person died a sudden death the cause of which is unknown;
(c) the person died under suspicious or unusual circumstances;
(d) the person’s death was not the reasonably expected outcome of a health related procedure;
(e) the person died while in or temporarily absent from a declared mental health facility within the meaning of the Mental Health Act 2007 (NSW).
The Duty Forensic Pathologist advises the letter from the HCCC clearly states the outcome of their investigation, including a report from an independent reviewer (paediatric neurologist), also offering an opportunity to the family to further discuss the case if it became necessary. The review also provided a most likely cause of death in this case. All of the HCCC findings were deemed reasonable to the Duty Forensic Pathologist with no care and treatment issues identified.
The Duty Forensic Pathologist further notes that no post-mortem (autopsy) examination was performed, which may have provided additional important information to establish the cause of death and may have assisted a possible coronial inquiry.
Based on the documentation received it was the view of the Duty Forensic Pathologist that no significant prospect of identifying any important additional or fundamentally different factors contributing to Alina’s death would be revealed. As a result of this recommendation the Duty Coroner has determined no further coronial involvement would be undertaken and jurisdiction was declined.
Please do not hesitate to contact the Court on 8584 7777 if you have further enquiries.
Yours faithfully,
Ann Lambino
Registrar
Per: Jill Forrester
Co Ordinator Coronial Case Management Unit
Contacting the Minister of Health for the 3rd time and receiving a repeat copy of previous replies – 11/10/21
“…There is overwhelming proof of foul play and, I’m saddened to say, homicide and concealment. It very likely the true reason why the HCCC and MB didn’t allow my contribution to be included was it would expose the Doctors as inept and dishonest, and the Hospital and medical community as ignorant of current medical research and knowledge, and the unchecked limitations of its testing equipment
…I’ve no doubt it will be apparent, chronic Enteroviruses are the cause of autoimmune diseases like Diabetes (in this case its EV71). Also, the cause for vaccine injuries…”
Minister of Health; Brad Hazzard – 16th Dec 2021
Firstly, it is worth noting that since the outcome of the HCCC and Medical Board resolution that the Hospital, despite their claim had refused to respond to any inquiries regarding Ali’s death. No effort at all has been made to respond to concerns.
The advice given by Minister Brad Hazzard demonstrated a lack of knowledge in the process of which he should have a complete understanding. The NSW Ombudsman was slightly confused since they had no jurisdiction over the Medical Board
A response from the NSW Ombudsman, 10 Nov 2021
10 November 2021
Dear Mr Murtagh
Unfortunately, a regulatory agency’s investigative process and the evidence it relies on are part of its regulatory discretion. In deciding the action it should take on a matter, the regulatory agency would be required to take into account a broad range of factors including the likelihood of success in taking any regulatory action and its available resources and priorities.
I would like to again acknowledge the seriousness of your concerns and I appreciate that it was suggested to you that you make a complaint to our office. However, for the reasons explained, I am sorry our office does not have the relevant role or power to direct the agencies to act in the ways you seek.
I should also note there is a statutory exclusion in clause 2(b) of Schedule 1 of the Ombudsman Act which specifically provides that the Ombudsman has no power to investigate:
2 Conduct of—
(a) a court or a person associated with a court, or
(b) a person or body (not being a court) before whom witnesses may be compelled to appear and give evidence, and persons associated with such a person or body, where the conduct relates to the carrying on and determination of an inquiry or any other proceeding.
Where a regulatory body, such as the Medical Council, inquires into a matter and it has the power to compel evidence (whether or not it exercises that power), our office has no jurisdiction to review the conduct of a such a body.
You are welcome to call to me on (02) 9054 XXXX if you would like to discuss this matter further or if you have any further questions.
Regards
Senior Investigation Officer | Complaints and Investigations Branch | NSW Ombudsman
Level 24, 580 George Street, Sydney NSW 2000
After contacting several members of the Child Death Review Team (CDRT) an organisation in NSW designed to review, prevent and reduce the death of Children in Australia.
Following several messages left for the Police representative of this organisation Detective Superintendent Danny Doherty (stationed at Parramatta) contact was received by a member of the Police force from this district
29th November 2021 – NSW Police Force
29 November 2021
Re: Death of Alina Poppy Murtagh, Born: 12 May 2016.
Dear Mr Patrick Murtagh,
Firstly, I would like to extend my deepest sympathies regarding the death of your daughter, Alina Poppy Murtagh.
The NSW Police Homicide Squad leads and drives the NSW Police response to homicide and coronial investigations at all levels and specialises in the investigation of murder, suspicious deaths, specific critical incidents and specific coronial investigations including the investigation of multi-fatalities where five or more deaths have occurred in New South Wales1.
I first spoke with you on the 13 October 2020 over the telephone where you explained the circumstances surrounding the untimely death of Alina. On this occasion I ask that you send me an email with the information you referred to during this conversation, which you did in the form of two separate emails. You also referred to a series of voice recordings you made between you and medical staff who provided care to Alina, and the other parties were unaware of the recordings. Stating your justification for contravening the Surveillance Device Act 2007 was to, protect the lawful interest of Alina as she was 18 months of age, in an induced coma and unable to protect her own interests. I believe you were referring to Section7{3)(b)(i) Surveillance Act 2007. Your conversations with me indicated these recordings contained the information which showed medical staff were involved in ‘Covering up’ their treatment of Alina. On the 13 October 20211 received two emails from you:
Email 1 of 2 contained the following.
• An email thread between you and Leanne Evans (Senior Review Officer HCCC) commenced on 27 April 2020 concluded on 29 April 2020.
• An email thread between you and Detective Sergeant Robert Cipolla (Investigations Manager, Burwood Police Area Command) which commenced on the 14 September 2021 and concluded 05 October 2021.
Email 2 of 2 contained the following.
• A Google Link. (I was unable to access this link due to NSW Police System restrictions.)
• A summary of the circumstances surrounding the death of Alina Murtagh as described by yourself.
• An email thread between you and Detective Sergeant Robert Cipolla (Investigations Manager, Burwood Police Area Command) which commenced on the 14 September 2021 and concluded 05 October 2021.
• An email thread between you and Leanne Evans (Senior Review Officer HCCC) commenced on 27 April 2020 concluded on 29 April 2020.
The reference you make to the cases of Alfie Evans and Charlie Gard in the United Kingdom are framed within a Civil/Human Rights Jurisdiction and not Criminal.
I have read through these email threads and am of the understanding that you have sort the services and assistance of the Health Care Complaints Commissions (HCCC). It is evident from the email thread that the HCCC did finalise their review and in doing so would not consider digital recordings you made between you and medical staff without their consent. The written response from the HCCC was not contained within the two email threads.
I have read through the email thread between you and Detective Sergeant Robert Cipolla. The email thread indicates you had telephone conversations with DS Cipolla where he provided you with advice. This is evident in the email from DS Cipolla dated 4 October 2021, “In respect to what you ask in the body of your email what I can say is that I’ve tried to help you the best way I can by providing you with various options to which you seem to be dis-satisfied with and/or have tried yourself.”
On the 2 November 2021, I spoke with DS Cipolla regarding your enquiries. I was informed DS Cipolla referred you to the NSW State Coroner and to consider engaging a solicitor regarding Civil litigation.
On 3 November 2021, I contacted the NSW Coronial Support unit and obtained a copy of a letter from the NSW Coroners Court (*annexure to this document). The Registrar, Ann Lambino declined to assume jurisdiction, stating,
“Based on the documentation received it was the view of the Duty Forensic Pathologist that no significant prospect of identifying any important additional or fundamentally different factors contributing to Alina’s death would be revealed. As a result of this recommendation the Duty Coroner has determined no further coronial involvement would be undertaken and jurisdiction was declined.”
On the 22 November 20211 received the USB thumb drive and envelope containing a single hair attached with a piece of clear tape. I have retained the USB and returned the hair to you via registered post on the 23 November 2021 (Tracking number RPP44 63700 51000 85039 78606.)
On the 23 November 20211 conducted a review of the following audio files contained on the USB:
There is no way of verifying the times, dates, locations, voices, and persons present during these recordings. Most recordings seem to be disjointed and/or stitched together and the context of the conversations can be difficult to evaluate. There is no forensic value attached to these recordings and I did not identify any information within these files which constitutes a criminal offence.
I have read the letter by Dr Mary McCaskill (Acting Director Governance and Medical Administration) Sydney Children’s Hospital Network, dated 25 October 2019 (*annexure to this document). The letter is a response to Damian Anderson (Resolution Officer, HCCC). The five paged letter addresses the care provided to Alina and the steps taken by hospital and medical staff.
I have read the letter by Damien Anderson (Resolution Officer) HCCC, dated 14 April 2020 (*annexure to this document). This letter provides a response from the HCCC relating to their assessment of the care and treatment of Alina while she was under the care of Sydney Children’s Hospital. The HCCC engaged an independent Peer Paediatric Neurologist who reviewed your case. The summary below is an extract of this letter and outlines their findings,
• The peer was of the opinion that the most likely cause of Alina’s condition was a progressive neurological disorder, of genetic origin.
• The peer felt that a mitochondrial disorder was likely, but that expert geneticists in the field would be best placed to consider whether the CARS2 genetic mutation was the specific cause.
• The peer was not of the opinion that Alina’s symptoms were caused by glucose intolerance or viral encephalitis.
• The peer felt that the approach taken to managing Alina’s complex symptoms was appropriate and noted that the treating team consulted with specialists across a wide variety disciplines throughout the admission to inform the treatment response to her progressive deterioration.
The absence of peer criticism of the care provided for Alina means that the prospect of successful disciplinary action against any individual involved in Alina’s care is remote. As a consequence, the Commission is unable to progress the matter further.
The NSW Health Care Complaints commission (HCCC) is an independent government agency which was established to maintain the integrity of the NSW Health System. They are responsible to investigating/ prosecuting and referring matters to the appropriate law enforcement agencies when required. The objective of the HCCC is to protect the health and safety of individuals. The response you received from the HCCC states an independent peer review was conducted in relation to the care and treatment of Alina by the Sydney Children’s Hospital. The Peer did not establish criticism of the care provided to Alina.
Based on the conversations and material I received; you are of the belief that Alina’s death was a result of Criminal negligence. Criminal negligence is when a person acts with disregard to obvious risks to human life and safety, beyond reasonable doubt as outlined,
‘In R v Pullman (1991) 25 NSWLR 89, adopting what was said in the speech of Lord Atkin in Andrews v OPP (1937) AC 576, it was held that to prove manslaughter by negligence at common Jaw, the Crown must establish such a high degree of disregard for the life and safety of others as to be regarded as a crime against the community generally, and as conduct deserving punishment. It follows, of course, that this applies also to causing grievous bodily harm by a negligent act under s 54 of the Crimes Act 1900.’
After careful review and consideration, I have not identified any action/s or behaviour which meets the standard of Criminal Liability. This is based on the material which I have referred to in this letter and the material I have read contained on the USB you provided me. You have engaged two impartial agencies who have both reviewed Alina’s case. If you are unsatisfied with the responses from the NSW Police, HCCC and NSW State Coroner, I support the advice of DS Robert Cipolla and recommend you engage a solicitor regarding Civil litigation.
I am terribly sorry for your loss and the trauma this has caused you and your family. If you have any further questions or concerns, please do not hesitate to contact me.
Kind regards
Adam Noy
Detective Acting Sergeant Unsolved Homicide Team State Crime Command PH: (02) 8835 8806
A same day email reply was sent to Det. Sergeant Adam Noy on receiving this above communication.
If there was reason to dismiss the recorded conversations due to their format, that they were simply reduced in length due to fatigue of listening to some meetings exceeding an hour [The initial contact made with the Officer included the original & complete files via Gmail but he could not open them]. If he wished I could re-send the full length originals with ease. And with this, it is a rather simple procedure to date, or confirm the location of the recordings by “right clicking the files and selecting properties” and that I simply did not have the technical ability to fake conversations nor was running a “studio” at the same time as attending to Alina in the ICU or on the ward
Second to this, and importantly “why were the videos that were included in the USB thumb drive, that gave context to the hospital notes not included in his report?” these videos that clearly showed improvement in Alinas condition following a trial of Anakinra, surely these could not be faked, and so proving that the autoimmune medicine was effective and so raising the concern of homicide
Detective Adam Noy did not reply.
This email was repeated again two weeks, this time to include a screen shot that not only could offer the time and date of the recordings, since Google Timeline was active on my phone, it could also pinpoint the actual location as well
Again, Det Adam Noy failed to reply.
There was a distinct impression that although the communication as addressed to myself, it was written for the benefit of someone else in the chain of command, although appearing very detailed and thorough, like the review made by the HCCC, it found reason to ignore the evidence and recordings which were an exact reflection of events as they occurred; More reliable than the Neurologists notes themselves who had deliberately withheld information and had showing they had clearly lied
To suggest the reviewing organisations are impartial, is only valid they select the information to be considered.
In order to request the Police actually review the information given to them, rather than their preferred selection, a complaint was raised with the LECC
Law Enforcement Conduct Commission 7th March 2022
LECC
LawEnforcement
ConductCommission
Phone: 02 9321 6700 Fax: 02 9321 6799
Level 3, 111 Elizabeth Street, Sydney NSW 2000 Postal address: GPO Box 3880, Sydney NSW 2001
7 March 2022
Patrick Murtagh
Reference: CASE2022336
Dear Mr Murtagh,
I refer to your online correspondence of 15 January 2022 concerning your complaint about the NSW Police Force.
“…Following an assessment of your complaint, the Commission has decided that it is not a matter justifying investigation by the Commission and accordingly, we will refer it to the police for their action or investigation. The police will contact you directly to discuss the complaint and inform you of the action they have decided to take. Please note this may take around 4 weeks. The action taken by police may be overseen by the Commission to ensure the handling of your complaint is appropriate…”
Yours faithfully,
Pp Ngaire Kirwan
Team Leader – Assessments
Further contact with NSW Ombudsman in 2024 resulted in a reply from SCH regarding the policy on the reporting the patients medical history
The policy of SCH regarding communications
”SCH states that it is not usual practice to obtain medical records from GPs, and often, the information required is available in the letters from the GP to the SCH. Oral history from the patient is obtained from the patient’s family upon initial assessment, and relevant information is documented in the medical records. The emails from family are considered and referred to the medical records where clinically relevant”.
In conclusion it would very much appear that there is an exploited loophole used by Doctors to avoid investigation of criminal investigations.
The systems in place, such as the HCCC, Medical Board, Ombudsman or even Solicitors only have the capacity to review under limited powers of “civil” investigations, which interpretation of legality allows exclusion of evidence submitted by patient or family member, and placing emphasis only on the report made by a Doctor under question
Criminal Investigations are made by a Coroner or Police. The Coroner will accept the Medical Boards outcome. The Police will reply with absurd reasons not to investigate, such as, “The recordings of events are only applicable if made by the person themselves” (an 18 month old toddler in an induced coma) or, “Cannot verify the time/date/location/persons present at time of location” (of a digital recording that is time/date/location stamped, and clearly a conversation between Doctor and parents regarding daughter)