CORONER’S QUERIES

Gisborne Herald, Volume LXVIII, Issue 20635, 15 August 1941, Page 4

CORONER’S QUERIES

HOSPITAL PROCEDURE GIVING ANAESTHETIC WOMAN PATIENT'S DEATH (Per Press Association.) AUCKLAND, this day. Questions concerning the manner in which an anaesthetic was administered to a deceased person were asked by the city coroner, Mr. F. K. Hunt, S.M., when an inquest was held into the death in the Auckland Hospital on July 19, of Lucy Mary Pryer, aged 77 years, a widow. The deceased was admitted to the hospital on July 13 with a fractured thighbone and died under an anaesthetic. Sub-Inspector Calwell represented the police and Mr. Spence the relatives of the deceased. Dr. Walter Gilmour, acting medical superintendent and pathologist at the hospital, said that after making a post-mortem examination his opinion was that death was due to respiratory failure during anaesthesia. Dr. Donald Bartlett Gash, house surgeon, said the deceased was taken to the operating theatre at 8.15 a.m. on July 19. Dr. Horsley, who was acting as anaesthetist, left while X-ray plates were being taken and shortly after 9 a.m., a sixth-year student named Garlick, who had replaced her, drew his attention to the patient’s condition. He ordered the necessary steps to be taken, but it was not possible to resuscitate the deceased. Adjustment of Machine Dr. Alice Horsley said she had been an honorary anaesthetist at the public hospital since 1915. After the surgeon, Dr. Selw.vn Morris had manipulated the patient’s limb, she adjusted a machine giving the patient oxygen equivalent to atmospheric air. which was normally perfectly safe for an indefinite period. The coroner: Do you not think that, having observed the way the patient took the anaesthetic, it was better for you to have remained until the operation was finished? Witness: I am sure I should have remained. My action was against the ordinary custom and the rules of the 1 hospital. The coroner: From what I have learned from Dr. Gilmour, it probably would not have made any difference, but I do not think it is right. The witness stated that she had hoped to be back for the major part of the operation, but when she had finished a case at the Mater Hospital a second serious case delayed her. Comparatively Small Dose Clive Garlick said he was a finalyear medical student completing his studies at the public hospital. Part of his studies included the administration of anaesthetics under the supervision of the honorary anaesthetist. The deceased’s condition was good when Dr. Horsley left and she was being given a comparatively small anaesthetic dose. Her condition was satisfactory until about 9.15 a.m. when suddenly her breathing changed. In spite of all efforts at resuscitation she was not revived and was pronounced dead at about 9.25 a.m. The witness said he was fully conversant with the type of machine used and had previously administered three or four gas and oxygen anaesthetics under supervision. “1 should like to make it clear that while I said the cause of death was an anaesthetic, it had nothing to do with the administration of it,” stated Dr. Gilmour. "I am perfectly satisfied of that and Garlick knew how to work the machine and had enough experience to enable him to carry on.” “I felt when’l heard the facts that the matter should be inquired into,” said the coroner, ”and this inquiry will have its effect in the future. The cause of death was respiratory failure during anaesthesia and there is no evidence to show that the anaesthetic was improperly administered, or that the woman was not under proper care.” The coroner added a rider that the attention of the Hospital Board should be drawn to the fact that the deceased when under anaesthesia, was not under the care of an anaesthetist for the whole of the period.