SOMETHING LACKING

Dominion, Volume 20, Issue 244, 12 July 1927, Page 10

SOMETHING LACKING

PREMATURE DISCHARGE OF HOSPITAL PATIENT “THIS IS ONE OF THE MISTAKES” ' Dominion Special Service. Christchurch, July 11. “It seems to me that there has been 1 lack —1 don’t want to.say a lack oi care—but a lack of something which should not have been wanting. I shall leave it to the public and to the : Hospital Board., to say whether any remedy is possible.” - . These remarks,were made by Mr. E. D. Mosley. Coroner, at. the conclusion of the inquest concerning the death of Mrs. Elizabeth McKnight, who died at the Public Hospital on June 30 as the result of a fractured skull, which was not revealed till the post-mortem examination was made. Her death occurred after she had been discharged and then subsequently readmitted in an unconscious condition. Dr. A. C. Sandston, honorary surgeon at the Hospital, said he saw. Mrs. McKnight the second day after her admission. When he next saw her (on Friday,- June 17) she was completely conscious. He was told she had been admitted on the Wednesday night previous, having fallen off a tram while under the influence of alcohol. The X-ray report was negative of fracture. He had seen the photograph himself since. He did not see it at the time as it was customary for the report to be sent to the ward. He examined her, but,' feeling the skull, could find no fracture. There was some tenderness and slight swelling of the muscles of the neck .at the base of the skull. Mrs. McKnight was able to take her food. She was not unconscious when admitted. On the following day .Saturday) she appeared quite ordinary so far as witness could judge, and he was asked if she might be allowed-to go out. He said she appeared to. be all right, and if she still appeared so she might go out in the next day or two. ...

In reply to the Coroner, witness said he suspected head injury.

The Coroner: We do not know as much of these things as a medical man, but what seems extraordinary to me is that such a fracture should have escaped detection. You know the facts? Dr. Sandston : Yes.

The Coroner: She was admitted on the 15th, discharged on the 19th, readmitted on the 27th, and died on the 30th. The post-mortem by Dr. Pearson yon have read? Dr. Sandston: ■ Yes. So far as a fracture is concerned, a three-inch fracture at the base of the skull is not a long fracture,, and it would be very difficult to- decipher in an X-ray photograph ■- The Coroner: It seems strange to me that- she should be sent from liotpita l when the history of her case was known —the fact- that her head ha.l been injured -in a fall. - . Dr. Fox, superintendent of the hospital, stated that if -a fracture could not be felt through an open wound and tire X-ray and the patient’s symptoms- failed to. reveal it, then it - was practically impossible.-- to detect the fracture. Witness explained that apparently the injury was so situated near the bi?.in that it would take some time before the inflammation would be seen The Coroner: That is all the more reason why . she should have- been watched.

“Thai: is so,” said witness. ."I’m quite sure,” continued the Coroner, “that had the whole history of the case been made known to you yon would not have ‘fallen in.’ I am going to call the evidence of the son, who called, on her three times, and will say she never ..recognised’him.” James McKnight, a sou of deceased, stated that lie saw his mother three times in hospital, and she did not know him, but just mumbled away, talking all sorts of rubbish. .A nurse said to him on the third occasion (Saturday, June 18) : “Your mother will be going home to-morrow.” There were two nurses nearby, when his. mother was rambling in her - speech, but he did not draw their attention to her babbling. Witness did not think she was fit to be taken home.

The Coroner, after.referring to the evidence that the fracture was very difficult to detect, said: “But there is something more than that. The evidence of the son was sufficient to convince a Coroner that the woman should not have been discharged from hospital on June 19. I am quite satisfied that had Dr. Sandston been made aware of all the circumstances he would not have consented, even tacitly, to the woman’s discharge. I understand that superintendent has strict regulations regarding the admission and discharge of such cases, and if they had been carried out I don’t Think the woman would have been discharged. At the same time, it is quite probable that she would have died in any event. One does not like to think that a patient should be so. discharged,” concluded the Coroner. "The public mind would not be easy if that practice prevailed, but I do not think that it does, and the public is under the impression that the hospital is well conducted. I suppose mistakes must happen, and this is one of the mistakes.” The Coroner then returned a verdict that death was due to haemorrhage and laceration of the brain following a fracture of the skull.