Fault In Anaesthetic Machine Caused Death Of Woman

Press, Volume C, Issue 29620, 16 September 1961, Page 10

Fault In Anaesthetic Machine Caused Death Of Woman

(New Zealand Press Association

AUCKLAND, Sept 15. A married woman with three children died in Auckland Hospital from the effects of an overdose of cyclopropane administered as an anaesthetic during an operation for the removal of an abscess, according to the finding of the Coroner. (Mr W. S. Spence. S.M.) at an inquest today. The woman was Dorothy Heather Anderson, aged 34. William John Watt, direc-

tor of anaesthesia for the Auckland Hospital Board, said that about midday on June 26 he was told a patient had collapsed and that cardiac massage was being given He detailed restorative treasures taken until the woman's heartbeat was restored. "I saw the patient again about 5 p.m. when she appeared to be recovering, but death occurred about 9 p.m,” said Watt.

He said he could find no error of technique or judgment anywhere and it appeared that the anaesthetic machine might be at fault. He instructed that it be tested.

“I suspected that the flow meters on the machine might be delivering more anaesthetic than was shown and this was found to be the case.” said Watt. He said that the normal weekly maintenance of anaesthetic machines did not include tests of the gas flow meters. If they were suspected of being faulty they were sent to the United Kingdom for testing. Tests on the cyclopropane flow meter |>n the machine

used on Mrs Anderson showed that a small fragment of glass had broken at the bottom of a tube through which the flow meter piston passed, said Watt. This had. presumably, been displaced in such a manner as to prevent the free rise of the piston which moved up the cylinder as the gas flow was increased. "I am certain the dead woman got more cyclopropane than the anaesthetist thought he was administering.” said Watt. He said he could give no reason for the breakage and as far as he was aware, there was no similar case in medical literature The mishap was,’ from his experience and inquiries, unique. The chances of the accident occurring again were infinitesimal.