WRONG SOLUTION GIVEN

Ashburton Guardian, Volume 68, Issue 138, 23 March 1948, Page 5

WRONG SOLUTION GIVEN

Woman's Death in Hospital

EVIDENCE AT INQUIRY (P.A.) DUNEDIN, Mar. 22. A verdict that Amy Victoria Webster, a young married woman, died in the Dunedin Public Hospital on February 2 from asphyxia caused by sodium nitrile accidentally administered instead of sodium iodide was returned by the Coroner, Mr W. IT. Bundle, when the inquest into her death was concluded to-day. Mr Bundle expressed sympathy with the relatives, but said that on the evidence it was not open to him to make, any recommendation regarding the control or use of sodium nitrite.

Dr. A. C. Wilkinson, house surgeon at the hospital, said that Mrs Webster was admitted for an x-ray examination. He wrote a prescription for a sodium iodide solution to the patient’s treatment chart. The solution was needed to provide a shadow contrast during the examihation. He was present when the solution arrived from the dispensary, and when it was administered by Dr. Fitzgerald. He assisted in the treatment when the patient showed sign-3 of distress, but she died about 10.30 a.m. on February 2.

Dr. E. F. d’Ath, pathologist, and H. O. Keyes, Government Analyst, gave evidence concerning the amount of sodium nitrite subsequently discovered in the body, and Dr. d’Ath said. that asphyxia resulted from the administering of this substance. Henry Lawrence Brett, head dispenser at the hospital, said that, he received a verbal instruction concerning the required solution from Dr. Wilkinson. He had not the time to attend to it himself, but had written it down and given the note to one of his assistants. When he discovered after a visit to the dispensary by Dr Fitzgerald that it was possible a mistake might have been made, he wasted no time in taking antidotes to the patient, but in his opinion no antidote could have proved effective because' of the large amount of sodium nitrite administered. To Mr Bundle, witness said that sodium nitrite was not a poison under the Poisons Act, and no special precautions were taken ip the way of labelling. The substance was normally kept on a shelf where it had been on the day of the fatality and not in the poisons cupboard. Drugs were always arranged in alphabetical order, and -sodium nitrite stood next to sodium iodide. These two bottles were the only ones of their type on the shelves. He did not think that an average dispenser would realise just how poisonous sodium nitrite could be. Ronald FOrbes Menzies said that he was an unqualified assistant chemist with 17 years’ experience. He had been in his present position for four years. He had had to shift several bottles to reach the one which he wanted, that containing sodium iodide, and it was possible he had taken the wrong bottle. If be had made a mistake it was the first of hie career.