MATERNITY DEATHS.

Auckland Star, Volume 55, Issue 49, 27 February 1924, Page 7

MATERNITY DEATHS.

TO-DAY'S EVIDENCE.

HEALTH OFFICER QUESTIONED,

A CRITICAL EXAMINATION.

(Continued from Page S.)

The Court of Inquiry into several deaths from septicaemia was continued this morning, when Dr. Hughes. Medical Officer of Health, w. further examined.

The examination uf Dr. Hughes was continued. " The health ollicer said that when l>r. McCormick telephoned the office on tlie day before he returned from laotoma (a Friday), he rang and said he aaished to speak to Br. Hughes in relation to Kelvin. He was asked if there was anything tliey could do for him at the office, and he replied no.

Mr. I.eary (who appears with Mr. Duthie for *Dr. W. M. McCormick, Dr. W. N. Abbott, and Dr. E. Williams): Dr. McCormick did not knov there was a second medical officer there, and be determined to wait until Dr. Hughes returned on the next day and see him personally.

Dr. Hughes: The assistant-health officer was not there anyway—Dr. Boyd was away on leave. The Chairman (Mr. F. 4arl, K.C.): Miss Bagby was there, and she is an inspecting officer

Dr. Hughes said that private hospitalwere asked to keep charts of patients for six months, though the regulation which made this compulsory was not yet in force. When witness asked for the charts for 102:! there \aere a few prior to July missing, but this ivas explained by the matron saying that the wrong bundle had been sent away, lie had no reason to believe that the missing charts had been eona:caled from him. He made personal inquiries regarding the missing charts and found that in every case there had been nothing suspicious, the cases being normal.

On the chairman asking how many registered nurses there were at Kelvin, Dr. Hughes said he understood there were always two.

The Chairman: I notice in a circular issued to private hospitals by the Health Department that for each six patients there must be one registered muse, with adequate assistance. For the last tbrcc months of the period under review there were up to 14 patients in the hospital at a time. How many registered niidwives were at Kelvin during that period '. Dr. Hughes: I understand there were three or four at tbat particular time. Mr. Findlay (for Xurse Gibbon): I can assure the commission that there were always above the number. The Chairman: I want to clear up any suspicion that the hospital was understaffed. Dr. Hughes: When I visited the hospital in October it was not understaffed. The chairman then proceeded to question Dr. Hughes regarding the not.fication of Mrs. Delamore's case. Dr. Hughes said tbat Dr. McCoraiiek called on him at the odice just before closing at noon on Saturday, November 10, and reported the case of Mrs. Delamore. He asked him if he had any other cases, and he replied that he had a Mrs. Cartel*, with pneumonia.

Did the doctor simply call and say, ''I have a case of sepsis?"—l cannot exactly remember.

Is it usual for a doctor to call on the medical officer of health when he can make notice in writing. It seems to mc he must have had something serious to say to you and that he said it. He would hardly take the trouble to call and say, "I have a case of septicaemia,"' and then go away, would he? —I think we discussed symptoms, and I think he mentioned something about out to Kelvin. A Lesson on Duty. Well, it was your duty to go out at once, was it not? Did not Dr. McCormick inform you the case was vcrv serious?—l understood she was in a serious condition.

Dr. McCormick told you on the Satur. day morning that your presence at Kelvin was necessary?—l cannot remember very much what passed at the time, but J remember the doctor saying it was a serious ease.

That was shortly before noon on Saturday. What were your plans for the afternoon? —1 had none.

What did you do?— Just as I was about to leave the office a ring came from the City Council telling mc there was some mysterious illnesX at Parneli.

Did you consider thai more serious than the notification you had got from Dr. McCormick?—l certainly regarded it as a serious thing, and wanted to see that it was put right. I thought it might be very serious trouble. What time did you get to Parneli ? — About 12.30 or 1 o'clock. Did you take long to investigate this mysterious illness?—No; about half-au-hour. Did you then go home?— Yes, sir. I suggest it was your duty (all things being well and you in a normal state of health) to have gone out to Kelvin Hospital straight away?— Yes, sir. You did not do so; you were investigating a serious illness when it .seems to mc you should have gone to Kelvin, unless you can suggest something to the contrary. Then there was Sunday?—l was in bed on Sunday.

Were you seriously ill?—I had been unwell for some time.

Why Wasn't Someone Sent?

I suppose you and your officers some times work on Sundays?— Yes.

Well, what was the difficulty in sending Dr. Boyd or Miss Bagiey out. Here was a hospital, with a large number of patients, in which there is septicaemia. This is the third notification about this hospital. It is a bad case. You are invited before \l2 o'clock oil Saturday to go out. and instead of doing so, you investigate some complaint from the City Council made by goodness knows who. On the Sunday you are too ill to go yourself, but you have assistants. I would like to know why one of the assistants was not sent out, at any rate on the Sunday, if you were not well enough to go?— Well, Dr. r.._r«i was away. That is an excellent reason for not sendin"- Dr. Boyd, but what about Miss Ba"lcv? She could have been sent? — Yes. sir.

What time on (Monday did you arrive at Kelvin? —I do not think I went there before noon.

Scenr* this was the. third notification received about Kelvin, were you not somewhat perturbed when you .jot this information from Dr. McCormick?—Yes,

Well, then, it is all the more extraordinary, to my mind, that you did not go immediately to Kelvin, irrespective of this mysterious illness; or that, if you could not go, why you did not get someone else to go. There were 13 or 1- patients in that house at the time. As a matter of fact, you were ill at the time, and were absolutely unable to go on the Sunday, and possibly had lost a certain amount of that energy for which you "have been distinguished during your term of office.

"It does not appear that any real harm resulted from the delay in this case," added the chairman, '"because this was the last case. If the delay had been at an earlier period, it would have been extremely serious. That is my view." Isolation and Disinfection. Tn reply to Sir Donald Gavin. Dr. Hughes said the structural arrangements at Kelvin were not ideal for complete isolation. Tlie only isolation was to place tbe patient in a separate room, but there might be normal patients in other rooms across a narrow pas-age. Infected linen would also have to be carried through the passages.

Sir Donald Gavin: Do you regard that as satisfactory isolation?

Dr. Hughes: It is all that is obtain able.

What pails of the hospital were d!s Infected?— The rooms in which the cases occurred. Is that all?— Yes. Dr. Hughes said that Miss Baglev inspected Kelvin af.'.er the notification of the death of Mrs. Jones.

Dr. .1. X. Klliot: Is it not laid down that it is the duty of the medical officer himself to personally inspect and report and not leave it to any oflieer of the Department? After the ease of Mrs. -Tones had been notified you could have inspected the charts at Kelvin and seen for yourself whether the ease was isolated or if there were signs of epidemic, couldn't you':

Dr. Hughes: There was only one case notified.

Was it not for the medical officer to go and lind out from the charts whether there were any other cases? —Only one case had been re|iorted then.

Your view apparently is that if there is only one notification there is only one case? —Yes.

What the Charts- Would Show.

A reference to all the charts would possibly have shown you that Airs. Barker died in July, Airs. Morrison in August, and. further, that there was some doubt regarding Airs. Dacre's case, as suggested by the letter of Dr. Williams. Do you think a medical man would be more competent to assess the value of these charts and draw a conclusion from them than a nurse, no matter how well qualified the nurse might be, seeing that the question of diagnosis was concerned ?—Yes.

1 suggest that after the notification of Mrs. Jones' case a perusal j>f the charts at Kelvin would have shown another vieaa- than that this was an isolated case?— Yes, it may have.

Do you think the method of isolation at Kelvin was sufficient! —It is all that can be done. If we were to ask for everything desirable we would make things very uncomfortable for the hospitals.

Does that concern you ? —No, it does not concern mc.

Do you consider that in a private hospital a bathroom, water-closet and sink for washing bed-pans should be in the same room? —It is objectionable.

The chairman: After all these deaths was there no examination of the sanitary arrangements made by you or your officers ?—aXo.

In reply to the chairman Dr. Hughes said he was going to suspend two nurses who had attended Mrs. Jones, but he had received a letter from the Director of Hygiene at AVellington saying that such a course was not. necessary as long as the necessary disinfecting had been done. A Matter of Time. Mr. Johnston: You said you got to Kelvin on November 12 after noon?— Yes; it was after noon. What time actually was it?— About 2 o'clock. 1 think. May I suggest it was about 4 o'clock ? 1 would not say it was not. I was under the impression that it was about 2 o'clock.

You have far too much to do, have you not?— Sometimes I have.

Have you had more time to make sufficient inquiries of any of the cases now under review? —I would have had more time to go into Mrs. Jones' case if I had thought it necessary.

Mrs. Dacre's case?—l had as much as I could manage then.

Do you not think greater precautions against septicaemia should have been taken at Kelvin than in a place where complete isolation was possible?— Yes.

Do you know that Dr. Abbott attended Mrs. Jones after she was removed to the public hospital from Kelvin?—T have since learned so.

Don't you know that Dr. Abbott knew that Mrs. Jones had septicaemia?

The chairman: You cannot say, that; he may not have known she had septicaemia until after the post-mortem.

Mr. Johnston: Well, I was going to say he knew after. Didn't he make notification to your Department?

The statement was then made that in the circumstances the superintendent of the Auckland hospital, where Mrs. Jones died, would make the notification.

Mr. Johnston: I am going to prove by a medical certificate that Mrs. Jones was suffering from septicaemia for 12 da vs.

Mr. Leary questioned the truth of this. It was a matter of evidence.

Dr. Hughes said he did not think the infection could have spread throughout the hospital.

(Proceeding)