A FATAL LAPSE.

Auckland Star, Volume LXVIII, Issue 7, 9 January 1937, Page 9

A FATAL LAPSE.

PATIENTS DEATH.

MISTAKE BY ANAESTHETIST.

LONDON, November 22.

A "temporary lapse of memory" by a doctor while administering an anaesthetic led to the death of a girl aged six. who was undergoing an operation at Sutton and Cheam Hospital, Surrey, it was revealed at an inquest at Sutton recently. The anaesthetist, Dr. T. B. Pitts, of Cheau, explained that he took a-cylinder containing pure carbon dioxide and administered it, instead of a mixture of oxygen and carbon dioxide. On hk behalf it was stated that the position of the cylinders had been changed. Dr. E. M. Newman said that Mr. Dingley, the surgeon, had begun the operation when it was noticed that the child, Julia Mothersole, of Byron Gardens, Carslialton, was becoming cyanosed. Injection and Massage. The operation was stopped. Mr. Dingley told Dr. Pitts to give the child pure oxygen, and on going to the other side of the operating table he (Dr. Newman) noticed that the child waA receiving pure carbon dioxide. This was immediately corrected, artificial respiration was administered, as well as injections; the heart was also massaged without sncce-s. Dr. Xewman added that Dr. Pitts had resigned from hi- j>ost as anaesthetist. Entire Blame. Mr. H. C. Dick.us. for Dr. Pitts, said he was taking thp blame on himself, and was not suggesting that anything at the hospital was not as it should be. Other ev,<lence was given that the condition of the mastoid trouble was such that, unless a surgical operation was periornied, the child would undoubtedly have died. Dr. Pitts was asked by Mr. Dickens: How you came to make this mistake is as muen a mystery to you as to 1 d " «* ■»- •« MacManon (for the parents).: Does it amount to this: the unfortunate error was made bv rour mistaking the cylinder on the "troKev and that the position of the various cylindeis had been altered since voir . v,s,t to hospital *— I think it was just a temporary hj-e of memory. A \eidict of death bv mi-cdi ent u:e Vias recorded.