A PATIENT’S DEATH.

Hawera Star, Volume XLVI, 29 September 1926, Page 10

A PATIENT’S DEATH.

MISTAKE IN MEDICINE,

HOSPITAL JJOAaiiDIS. PROBLEM Strong criticism of the method of dispensing drugs at the. Timaru Hospital was made by the District Coroner, Mr. E. D. Mosley, at the inquest held at Timaru recently on a (patient who had died on Tuesday morning, as a result of being given a dose of barium carbonate instead of barium sulphate. It was disclosed in evidence that barium meals were administered tn the (hospital quite frequently, but no doctor saw them, though it was n written regulation that all drugs to be administered were to be checked, -and verbal instructions were that the bottle should be .handed either to the doctor or to the sister giving the medicine. The doctor or sister wou-lci read the label, measure out the 'dose., and re-read the label before giving the dose to the -patient. In this ease the sister who gave, the dose was not familiar with the dispensing regulations or the difference between carbonates and sulphates.

The coroner, in giving his verdict, said that the drug had been given in a haphazard and extremely casual manner, and that a with more experience than the one concerned (Dr. I. C. Fraser) would undoubtedly have prepared the dose himself, and given it to the sister. It was a position that must be remedied, and how it was to he done was a. problem for the Hospital Board to decide. Nothing, however innocuous, should bo given to a patient, that had not been made up by the medical officer in charge, or the dispensary sister. A BARIUM MEAL. Evidence was given by Dir. T. L. Parr, medical superintendent at the hospital, that the patient, Patrick McCann, -aged 44, was admitted to the bospital as a suspected cancer case, and was to have an X-ray examination. 1-Je gave instructions for the patient to be given a barium meal. This was done, and when he examined the patient at S p.m. he found -that deceased had abdominal pains, which witness attributed to the supposed cancer, and -it did not occur to him that the wrong barium had (been given. Next morning he- was informed by Dr. G. Rich -that the patient was showing -signs! of collapse, apparently from poisoning. Witness oMered the usual antidotes and restoratives, and hurried to the hospital, (but when he arrived the patient was dead. The ward sister -said that she asked Dr. Fraser what quantities were to be given to the patient, and was told 2oz. of barium and 2 oz. of bread crumbs. The nurse who was then in the dispensary looked, for the barium with witness. Dr. Fraser came in just as the bottle w-as found, but did not examine it, and witness weighed out the ingredients. Silie did not know whether the doctor .said, barium sulphate. Witness -did not show the doctor the barium- when she got it from- the dispensary. She. had had four and a-half years’ experience.

- Witness said that in the Dunedin Hospital all medicines were made up in the dispensary, and from there sent to the wards to "be administered accarding to instructions. She was not given any special instructions as to the rules upon joining the Timaru Hospital-. She had never previously made up a barium meal. In Dunedin it was always made up in the dispensary and sent to the ward. She did not know there were two kinds of barium. Dr. I. C. Fraser said that'when he was asked by the ward sister about the composition of a barium meal he looked it up, and told her 2oz. of barium, and bread crumbs and milk. The Coroner: It seems a, strange thing to me that a sister who‘does not know the difference between a carbonate and a- sulphate should be entrusted with such a responsibility. Witness said that when he saw the bottle in the- nurse’s hands lie took it for granted that it was sulphate. He had never seen the bottle before, and there was nothing to lead him to believe that the .bottle did not contain the sulphate. . <

The Coroner: You were the only doctor in the hospital at the time? — Yes. r

Didn’t you conceive it to be your duty to see that the correct ingredients were given?—No.' Continuing, Dr. leaser said that lie had a responsibility, but barium meals were administered on an average about twice a week, and no doctor saw them. He had no experience outside the Timaru Hospital, and had been at the institution for about eight months, and so far his record had been a good one. NO OTHER CAUSE OF DEATH. Dr. F. F. A. Ulrich, who performed the post mortem, said that he could not find any signs of cancer or other symptoms that would cause death, which was due to collapse and heart failure as a result of the poison. Mr. D. E. Finch stated that whatever happened in this case, it was a rule that no drugs should be given without being supervised by a doctor or the dispensary sister. —The Coroner said he could not but sympathise with the whole hospital administration in the unfortunate affair. The only person with any real knowledge of drugs at the time was Dr. Fraser, and he was tlie only-'person to whom the nurse could appeal as to what quantity and mixture was to be given. The doctor looked up liis books, told her the ingredients, and left her to prepare it. It was here that the leakiness of the hospital .system came in. A. doctor with more experience would undoubtedly have prepai-ed the i.uen.l himself, and then given it to the sister. He could only come to. the. conclusion, therefore, that Dr. Fraser was responsible. The formal verdict would be that deceased, Patrick McCann, died in the Timaru Public Hospital on September 21, death being due. to collapse as a result of a poison accidentally administered while deceased was a patient in the institution. the bottles of bariurii sulphate and barium carbonate were ordered to he detained by the police pending the case ffoin" before' tbe Health Department.