Inquiry into nurses’ fatal mistake ‘unnecessary’

Press, 23 September 1983, Page 3

Inquiry into nurses’ fatal mistake ‘unnecessary’

PA Wellington The Labour Party’s call for a one-person committee to consider the death of a woman in Whangarei Hospital was unnecessary, said the Minister of Health, Mr Malcolm, yesterday.

A Coroner had earlier described the death of Mrs Harriett Lewis, aged 87, of Whangarei, as the worst case of maladministration he had encountered.

At an inquest in the Whangarei Coroner’s Court, before Mr A. D. Copeland, it was found that Mrs Lewis had died from internal injuries received when a highpressure oxygen line was wrongly connected to a breathing tube in her windpipe. Mrs Lewis’ lungs had been inflated until they had burst.

Labour’s health spokesman, Dr Michael Bassett, said yesterday that a committee of inquiry should be held into the death. Mr Malcolm said that under Section 13 cf the Hospitals Act, any death under or as a result of the administration of an anaesthetic must be reported to the Anaesthetic Mortality Committee. “Immediately following the tragic death, all correct procedures were followed; administrative staff instituted their own steps fo ensure the situation would not re-occur and the Anaesthetic Mortality Committee was advised,” he said.

“The independent committee has already thoroughly investigated the incident and has made recommendations to the Northland Hospital Board which were put into effect some considerable time ago,” he said. Detective Senior-Sergeant Errol Jones, of the Whangarei C. 1.8., told the Court that investigations had established a strong prima facie case for a charge of manslaughter against the nurses in the recovery room, Mesdames M. J. Russell and C. S. Olver.

However, the nurses’ unfamiliarity with recoveryroom procedures, their inexperience, and the lack of

supervision and instructions given them by the anaesthetist or nursing administrators, were among reasons he gave for the police not prosecuting. “It appears that they were so ignorant that they were sure their actions were right,” he said. He said the Northland Hospital Board’s liability in Mrs Lewis’ death had been investigated, but it was considered there was insufficient evidence to proceed with criminal charges. Concluding his summing up, the Coroner said: “It is all very well for hospital boards to cut down on staff and to maintain full services, but the public are entitled to assume that they will receive proper standard treatment. “This unfortunate death is the worst case of maladministration I have ever struck.” “I would like to make it clear that I do not consider this death was due to the two nurses, but to the failure of administrative staff to provide adequately trained nursing staff,” he said. Both nurses had told the Coroner that they assumed the other knew the correct procedure for giving oxygen to such a patient.

The Court heard that the senior nurse in the recovery room, Mrs M. J. McKenzie, who would have known the correct procedure, had been assigned to show a new nurse around the hospital when the accident happened.

Dr Bassett said: “The public have a right to reassurance, in the knowledge that such a tragic series of events that took place in Whangarei will not be repeated.” The executive director of the Nursing Association, Miss Patricia Carroll, said the incident highlighted a grave need for hospitals to ensure the highest possible standard of nursing care was provided to patients at all times.

“We have repeatedly stressed to nursing administrations the need to ensure that nursing staff in complex situatations be fully qualified and fully experienced,” she said.