Girl died in hospital; lack of oxygen

Press, 20 December 1985, Page 13

Girl died in hospital; lack of oxygen

A girl, who underwent surgery at Ashburton Hospital, suffered from a lack of oxygen while under anaesthetic and later died, the Coroner’s Court heard yesterday. The Coroner, Mr Neil Mac Lean, found that Demelza Jane Rogers, aged seven, died as a result of an episode of hypoxia, or lack of oxygen, during the anaesthetic. The girl needed surgery after a motor accident on the Main South Road at Rakaia on April 25 last year. Complications developed during the operation and she was later transferred to Christchurch Hospital where she died in the intensivecare unit on May 1 last year. Counsel for the Rogers family was Mr P. Ludlow, while Mr C. J. Hodson appeared for Mr P. J. Godfrey and Dr J. X. Louw, of Ashburton Hospital. Constable M. W. E. Smith, of the Christchurch police, said that the girl was injured in an accident at the intersection of Ferguson Street and the Main South Road, Rakaia. A car driven by Bruce Ewing Moore faileu to stop at the give-way controlled intersection and collided

with a car driven by Graeme Lindsay Neil Rogers, in which the girl was travelling. Moore was subsequently charged with carelessly using a motor-vehicle and causing the death of the girl. He denied the charge, and counsel, Mr C. A. McVeigh, later told the police that Moore would defend the charge. Constable Smith said that he subsequently received a report from a pathologist, Dr P. R. Kelleher, who performed a post-mortem examination on the girl. He said that the main cause of death was the hypoxic episode which happened while she was under anaesthetic. Because the death was not directly and substantially related to the accident, the charge was amended to careless use of a motor-vehicle causing injury. Moore admitted the charge and was convicted and fined $lOOO and disqualified from driving for two years.

He appealed the sentence and at the High Court in Timaru Mr Justice Barker allowed the appeal, reducing the fine to $7OO and the disqualification to 15 months.

Part of the judgment of His Honour said, “... and it seemed clear that at least a contributing factor to her death was medical misadventure.” A surgeon at Ashburton Hospital, Phillip James Godfrey, said that Demelza was admitted to the hospital after the accident. He was told that she had been a back-seat passenger wearing a safety belt. After the accident, she had apparently walked round and had not shown any sign of injury. On admission, she had some mild abdominal tenderness and signs of seat-belt bruising on the stomach. Mr Godfrey said that she was kept under observation and about two hours after her admission it was felt that she should undergo surgery. Her condition had deteriorated and she had signs of peritonitis. It was found that the trouble was due to a ruptured small bowel. Everything was . going smoothly, he said, when suddenly she developed marked slowing of her heart and heart massage was commenced to maintain circulation. Resuscitation began immediately and the operation was finished. By then, she

appeared to be suffering from signs of cerebral anoxia, or lack of oxygen to the brain. Mr Godfrey said that a chest X-ray after surgery showed "extensive consolidation of both lung fields.” He discussed the problem with doctors working in the intensive-care unit at Christchurch Hospital and she was then transferred there. Mr Godfrey said that he raised the possibility that perhaps she might have in-

haled some vomit during the operation. But his anaesthetist, Dr John Louw, assured him that he did not think that this was the case because an endotracheal and nasogas tube had been in place. Other possibilities discussed included the bruising of the lungs at the time of the accident, or septic shock secondary to the bowel perforation. John Xavier Louw, the medical superintendent at Ashburton Hospital, outlined

the actions he had taken as the anaesthetist during the operation. The patient had shown a marked slowing of the pulse and a drop in blood pressure. She was given cardiac massage and as a result her pulse rate increased, but blood pressure remained fairly low. Mr Louw said that the patient was not seen to inhale vomit during the operation. Cross-examined, Dr Louw said that it would have taken up to 10 minutes to recognise the problem and

have the patient’s heart beating regularly. Mr Ludlow: Why is a seemingly healthy girl in for a routine operation now dead? Dr Louw: I really don’t know. The Coroner said that the case seemed, perhaps, one of those unfortunate matters that happened at times. The girl had gone to Ashburton Hospital in a lifethreatening situation and needed surgery. The outcome of that had been one which nq-one had wanted, he said.