Death After Operation In Auckland Hospital

Press, Volume XCVII, Issue 28619, 23 June 1958, Page 15

Death After Operation In Auckland Hospital

(New Zealand Press Association)

AUCKLAND, June 22. A patient died in the Auckland Hospital after being under an anaesthetic for two hours while efforts were made to remove a mutton bone lodged in his throat, according to evidence given before the Coroner (Mr A. Addison) on Friday. He returned a verdict in accordance with the pathologist’s report that Douglas Eric Steele, aged 36, married, died during the operation because of respiratory obstruction and anoxic cardiac arrest resulting from oedema of the larynx and instrumental perforation of the oesophagus. Referring to the post-mortem examination finding that Steele’s gullet was torn in two places, the Coroner said it was “patent that the procedure caused the tears and that they were an important factor in his death.” On the other hand, he said the pathologist’s report disclosed other contributing factors. Dr. J. C. Wilson, resident medical officer, said that she examined Steele at 9 p.m. on April 16—three hours and a half after he had swallowed the bone. Because of Steele’s heavy build she “anticipated that the anaesthetising would be difficult.” The general condition of Steele was satisfactory throughout the operation. To Mr F. M. Haigh, who appeared for Steele’s relatives, Dr. Wilson said that she could not see the bone during her examination. She called the ear, nose, and throat registrar. Dr. Maxwell, who re-examined Steele. She- could not see the bone either Senior Telephoned Dr. Maxwell, said Dr. Wilson, telephoned a senior ear, nose, and throat surgeon. Dr. Elder, returning to say that they were to carry out the operation at 10 p.m. Dr. Wilson said, in answer to Mr Haigh, that no further procedures were carried out to find the site of the bone. Dr. Maxwell, she said, spent about 20 minutes trying to pass an instrument into the patient’s gullet. A message was sent to Dr. Elder, who also had difficulty passing the instrument. The operation finished about 11.45 p.m. The instrument was removed and about five minutes later the tube in the throat was removed. Then the patient began to show signs of distress, and an unsuccessful attempt was made to reinsert the tube. Steel died shortly after midnight. Dr. Allison, the anaesthetic registrar, said that she supervised the anaesthetising of Steele by Dr. Wilson. She told Mr Haigh that she did not notice anything to indi-

cate that the gullet had been injured as a result of Dr. Maxwell’s efforts to put in the instrument. Dr. M. D. Maxwell described the operative procedure she followed up to the stage Dr. Elder took over. Previous Experience She told Mr Haigh that she had performed 11 such operations before and helped at 13 similar ones. She told him she did not think the tears in the gullet were caused by her efforts to insert the instrument. She said she did not get the instrument that far. There was no bleeding up to the time of Dr. Elder’s arrival. Dr. S. G. Elder said that he found a lot of bleeding and seeping in the upper end of the patient’s gullet. The tears were a recognised hazard Of the operation, he said, the lining in the gullet “having the consistency of wet blotting paper.” Dr. Elder agreed with Mr Haigh that removal of the tube from the throat precipitated the patient’s respiratory distress.