SIX WOMEN POISONED
DISPENSER'S ERROR WITH A DRUG
Through a dispenser's mistake, in handling a bottle containing a drug six, inmates of the Bethlein Royal Hospital, Southwark, were fatally poisoned. The victims were :—Mary Alice Baker, 57, formerly a lady's companion, ?of Brushwood road, Kew; Mary Berger Stephenson, 34. of no occupation, of Cricklewood; Mary Emilv Hoather, 34, wife of a railway" clerk,' of Victoria road, Romford, Essex; Violet Ella Lampriere, 21, single, daughter of a clerk, of Southend-on-Sea; Florence Beaton, 39, wife of a General Post Office overseer, of Chesterfield road, East Dulwieh; Maria Charlotte Louise Servante, 63, formerly residing in London road, St. Leonards-o'n-Sea. The victims each succumbed from the, effects of an overdose of amylene hydrate, a sedative drug. The drug comes from Germany, and since the war there has been somo difficulty in obtaining it. At the inquest on the first five victims named above Mr Ernest Pollock, K.C., on behalf of the Corporation of" London, the governors of the institution, expressed regret and sympathy with the. relatives of deceased, who had lost their dear ones at this time of gloom and sorrow. It was stated at the inquest that the drug had been used in the hospital for more than 12 years with : out anv injurious effect. Dr John G. Porter Phillips, medical superintendent of the hospital, explained that owing to the war they now had no house, physicians, as they had been called up, and it had been impossible to replace them owing to the shortage of doctors. Their staff consisted of three doctors instead of six, and as a result of the understaffing the work of dispensing had been carried out by one of the medical office"rs. Witness produced two bottles, one filled with concentrated amylene hydrate, and the other with the diluted drug, and pointed out that there was no apparent difference between the two. Dr Henry Tnavers Jones, who acted as dispenser, "said he was 33, and became qualified nine years ago. He had to make lip draughts practically every day. Witness described the dispensary, and produced a large brown bottle which, he said, usually contained diluted amvlene hydrate. On the day of the tragedy it w'as empty. It was on the right hand side- of the window as he looked out, and when he found it was empty witness turned to a similar bottle on the left hand side of the window. By its side was the blue bottle (produced). The latter was labelled "amylene hydrate,", and the brown one was similarly labelled. The empty bottle was labelled " diluted." Assuming that the blue bottle contained concentrated amylene hydrate, and that the brown bottle next to it was a reserve stock of the diluted drug he supplied the draughts from the larger bottle, which [he replaced on the shelf. The draughts
were in dne -course given to the patients. At about 11 o'clock "he was called to one of the patients, not dead, and a little later to Miss Baker, who was unconscious and breathing Btertoriously. He applied remedies. As it seemed peculiar that two patients should have been seized in this way, he looked about for a common cause, and discovered that he had dispensed concentrated amvleno hydrate instead of diluted. In .all 11 patients took the draughts. Of these four had recovered and two others were still in danger. Since then the sixth victim, Miss Servante, succumbed. .
Dr Barnard Henry Spillsbury, pathologist at St. Mary's Hospital, said the deaths were due to heart failure following the administration of amylene hydrate. Mr Pollock said he thought he could materially assist the jury by placing a few facts before them. The governors deeply regretted this misfortune, and Dr Jones regretted it exceedingly, and wished to take any responsibility if there was any that ought to be fixed upon him. He would accept that a chemist was a better dispenser than a doctor. As to the bottles, it might be that a system could be devised to avoid confusion in future, but in the best of regulated systems accidents did occur. The coroner said the case was a very exceptional one. They could not call these natural deaths, and it would be for the jury to say whether it was a case of misadventure or whether anybody was to blame.
The jury returned a verdict of " Death from misadventure" in each case, and they recommended that in future such drugs should bo kept in bottles" easily distinguishable by touch or label. Giving evidence at the inquest on Miss Servant©, Miss Emily Louise Ashton, a niece of deceased, paid a high tribute to the wonderful progress her aunt had made at the. hospital, and to the doctors and staff generally. Dr Spilsbury said death was due to heart failure and bronchopneumonia following the administration of amylone hydrate. It might have been a natural death, but he could not exclude the drug. Replying to Mr Pollock, witness admitted that if he had not heard of the drug ha would have found sufficient to account for death. It was impossible to say what a fatal dose was as there were no reported cases. It* was possible that Miss Servante would have died from pneumonia without the drug. The jury returned a verdict of "Death by misadventure," and added that no blame attached to anyone. They expressed an opinion that there should be a qualified male or female dispenser at the institution.
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SIX WOMEN POISONED, Evening Star, Issue 15696, 9 January 1915