NAPIER HOSPITAL

Manawatu Standard, Volume LVII, Issue 197, 21 July 1937, Page 11

NAPIER HOSPITAL

FINDINGS OF COMMISSION

TREATMENT. STAFFING AND ADMINISTRATION

The findings of the Napier Hospital Commission, which recently concluded its inquiry, were issued to-day. They cover all aspects of the subjects dealt with in the evidence, including treatment, staffing, training of nurses, administration, etc., and make pointed criticism as well as recommendations for future guidance.

TREATMENT OF CHILDREN. OUTBREAK OF DISEASE. MEDICAL STEPS REVIEWED. Per Press Association. WELLINGTON, July 21. The Napier Hospital Commission consisted of Mr E. IJ. Mosley, S.M. (chairman), Sir James Elliott, and Miss Cecilia MeKeniiy. During the hearing of the inquiry, which occupied thirteen days, 54 witnesses were heard, and the evidence - required 784 foolscap pages. In the first place, the. Commission was asked to inquire into and report Upon generally the circumstances in which, between May and October, 1936, certain children, being patients in the Shrinipton Ward of the Napier Hospital, contracted the disease known as vulvo-vagiliitie resulting from infection, and ail matters relevant to the discovery, control, and treatment of the disease in these patients. The Commission found that the first patient was, ill its opinion, infected before being received into the Napier Hospital, but the fact that the patient was So infected was not discovered,

the patient having been admitted for another complaint. Subsequent cases i were infected within the Napier Hospital from the first case and from one another by a breakdown in supervision and nursing technique. “Such iniected cases of vulvovaginitis may be inadvertently received into any iiospital when the infection is present in children who are admitted ! for an entirely different complaint, i - such as pneumonia, etc.,” states the j Commission. "The medical evidence wo; received was unanimously to the effect, that the making of a microscopical | examination of all children brought for | admission to a hospital to detect the | possibility of this disease and guard the iiospital against this infection is not ail absolute safeguard, and it has other objections. However, when a case of this kind in a children’s ward is detected or suspected, it is of the utmost importance that vigorous steps should be taken to prevent the spread of this dreaded infection to other chil- • dren. ‘‘lii the case under review, the ward sister segregated the patients by removing them to side-rooms, no more suitable accommodation being available in the liospital. The ward sister did not receive adequate directions necessary to meet the situation. When an infectious disease breaks out in a general liospital, it is the immediate duty of , ' the medical superintendent to take charge and act with promptness and vigour. In our opinion, Dr. J. J. Foley did not take such prompt and vigorous measures as the situation demanded. | “The duty of making sure that the nursing technique is sound and effective throughout the hospital, and particularly in the ward concerned,’ is a responsibility which belongs to tile matron. She failed to realise what might

reasonably have been expected of her in this situation, and put too much dependence on the ward sister. “The ward sister, oil her part, did not receive sufficient direction from higher authority. The manner in which thermometers were used, and other obvious defects ill nursing technique, such as insufficient constant supervision of junior nurses and insufficient facilities for disinfection, cannot be condoned, and weie priine factors in the spread of the disease of vulvo-vaginitis in the children’s ward.

“If tho matron, as requested by the ward sister, or on her own initiative, had provided special nurses to care for the first group of infectious patients, probably there would have been no second outbreak of the disease. “One of the vulvo-vaginitis patients was under the care of Dr. J. Allan Ilerry, while four others were uridei the care of other members of tl\e honorary staff. Dr. A. D. 8. Whyte was perfectly satisfied with some form ol local treatment of this complaint m the belief that the natural course might bo tedious, but that ultimately such treatment* would succeed. Dr. J. Allan Berry adopted an experimental method of heat treatment by means of very hot baths. TREATMENT CRITICISED. “We recoernise that medical treat-

meat by moans or heat (pyrotherapj, is a fully recognised method of treatment if giyeii With suitable appliances, lor suitable complaints, under the control of a highly technically trained staff, and having regard to the age aim resistance of the patient. “\Ve have no doubt that Dr. J. Allan Berry’s method of treatment of his patient was crude, not properly supervised, not supported, as any special investigation should be, by proper records. It was proved to be unwarranted and dangerous. “We are satisfied that the treatment of the first series of patients, other than the one under the care of Dr. J. Allan Berry, was not in accordance with the instructions of the medical practitioner in attendance on such patients. The ward sister gave evidence that without any authority whatever, she had adopted a very unusual course. She subjected Dr. A. D. S. Whyte’s patients to the same drastic hot bath treatment that Dr. J. Allan Berry’s case was receiving. This ward sister alleges that her course of action was unknown to Dr. J. Allan Berry himself, to the medical superintendent, or to the matron. “We think that the unwarranted and perhaps unprecedented conduct of the ward sister was instigated directly or indirectly by Dr. J. Allan Berry, who did not consider it his business to consult Dr. “Whyte. “It is, in our opinion, the duty of the riieclical superintendent, in consultation with the honorary medical officer attending to the particular case (if necessary) to notify the parents of the children, without any unnecessary delay, of the fact that they have contracted an intcrciirrent aiid 'infectious disease. The medical superintendent, probably in the belief that this contagious disease of vulvo-vaginitis might soon he cured, and with the knowledge of the state of public opinion in regard to venereal infection, unduly delayed

his notification to the parents. For whatever reason, he departed from the correct principle and committed a serious error of judgment.” ADVISING THE PARENTS.

Referring to the question of the steps that were taken to acquaint the parents with the nature of and any dangers attached to the treatment proposed to be given to patients, and to obtain the parents’ prior consent thereto, the Commission states that it was well aware that it was not necessary in every change of treatment that the doctor in charge should notify the parents or friends. “As regards the treatment adopted by Dr. J. Allan Berry, however, a new element is introduced,” it continues. “The treatment I that lie adopted had never been ap- | plied to young children before. It required a staff with special technical training, and was undoubtedly dangerous. Therefore, we strongly condemn the failure of Dr. J. Allan Berry to obtain the parents’ prior consent. He was also culpable in not notifying the medical superintendent or any other doctor of the staff of the treatment ho proposed.” PRESENT SAFEGUARDS. Touching on tile measures that have since been adopted to guard against j the untoward recurrence of the diseaso in the hospital, the Commission states: “Since this outbreak of vulvo-vaginitis, there has been a very great public outcry, a Hospital Board inquiry, and the institution of a Royal Commission. These facts have greatly assisted in the adoption of more vigilant safeguards iii the hospital against the spread of j recurrent and infectious diseases. At I the Napier liospital now, all female I children for whom admission is sought 'for any disease arc tested microscopijcally for the presence of the germ that causes vulvo-vaginitis. If the result of | this examination is positive, it is a complete safeguard. If, on the other hand, the result of the microscopic examination and culture is negative, it may give rise to a feeling of false security. It is well known that in positive cases the causative germ cannot always he demonstrated.

“In our judgment, on the evidence, while it is a matter of great importance to prevent the admission of a child infected with this disease into a general ward, it must be conceded that such a case may be inadvertently received into the most efficient hospital.' We wish to emphasise again that it is most important to take steps to limit the disease to the initial case and to prevent any of the other patients from being contaminated. We consider that nine cases of this disease in one ward is an excessively large number.”

DISAPPEARANCE OF X-RAY FILM. Circumstances surrounding the taking of certain X-ray films which could not be produced for reference when required were dealt with by the Commission, which states in this connection: “The evidence reveals the following facts: The film which, led to this inquiry was one of three relating to three patients all under Dr. J. Allan Berry’s care, and all of these films at one time or another were removed. They were all of considerable importance, particularly in connection wjth certain contemplated litigation Or claims for compensation. They were mysteriously returned to the X-ray room after the board decided to cail in the aid of the police. The evidence suggests that the films were abstracted by some medical practitioner or nurse. However, each person examined denied all knowledge of how the films were abstracted or returned. The methods of recording, handling, storing and caring for X-ray films are quite satisfactory. It is important that X-ray films should be readily accessible for medical purposes at all times.” HEALTH OF THE NURSES.

Corning to the question of the health of the nurses, the Commission finds that the general principles adopted for the detection of symptoms of ill health in nurses (including pupil nurses) are recognised in the Napier Hospital, but the question arises as to whether tligse are strictly and constantly adhered to in practice. “The large proportion of youthful and inexperienced pupil nurses, a condition of under-staffing, the difficulty in providing suitable accommodation for the nurses, arid perhaps the want of more adequate recreational facilities, are some of the special considerations which cause difficulties in this hospital,” comments the report. “Long hours of duty without adequate relief have also an important and detrimental effect on the health of the nurses. Under such circumstances, nurses are reluctant to impose an inevitably additional burden on their fellow-nurses by reporting sick; lienee we have evidence of nurses who have continued on duty when they ought to have been having medical attention.

“Excessive hours of duty have been worked by nurses in the Napier Hospital. The hours assigned for pupil nurses were 59} in one week and 48 hours the following week, though these hours were seldom adhered to, being often exceeded. As many as from 60 to 70 hours were at times worked with no weekly day off duty, and for considerable periods—in some cases as long as _ six to 10 weeks. The fact that legislation provides that no unregisHired nurse be kept on duty for more than 56 hours in any one week was unknown to the matron or to anyone else connected with the hospital. This legislation was charted in 1909 and l'o-ennctod with additions in 1932..

‘As long, exacting hours worked by the nurses had such an important hearing on their health, the matron should have been more emphatic in her representation of the situation to the board. The matron would thus have appeared to have acquiesced in tbe unfortunate situation. Tbe board allowed tbe increase in the number of hospital patients to outpace the accommodation provided for the nursing staff. Both the matron and the hoard thus failed to appreciate limit responsibility in the provision of what is necessary for the health and welfare of of the nurses in an established hospital training school. “Two good tennis courts are pro-

vided for the nurses: Apart from this, the hospital site is too small to permit of arrangements being made for other forms of outdoor recreation. There is much need for improvement ill encouraging indoor recreation and entertainment by organisation for this purpose. WORKING OF THE BOARD. “The evidence discloses that the working of the Hawke’s Bay Hospital Board lias not been harmonious, and the board has been divided into two rival sections, broadly representing Napier, and Hastings and surrounding districts,” coutin/.cs the report. “The board has also been sharply* divided on the question /if Dr. J. Allan Berry’s dismissal from the honorary staff. The situation is further complicated by the fact that Dr. Berry is both a member of the board and of the honorary staff ; he thus act's in the dual capacity of employer and employee. “The board has held special inquiries, reports of which have appeared in the newspapers; this has not tended to promote harmony. This unrest, with its resultant lack of effective co-operation, must necessarily have permeated the whole administration of the hospital throughout its various branches, and was detrimental to the discipline of the nursing staff. “Dr. J. Allan Berry’s resistance to a majority of the board in refereilco to his proposed dismissal as a member of the honorary staff was entirely subversive of discipline, and this, together with Other _ factors, helped to divide the nurses into two camps. The evidence given before us also proves that Dr. Berry’s conduct, both as a member of the honorary staff and as a member of the hoard, was such as to merit tlie severest condemnation. Dr. J. Allan Berry is the only member of the honorary staff whose conduct calls for adverse comment. D.r. .T. Allan Berry’s personal association witn some- members of the nursing staff has been of such a very serious nature that we have no option but to recoinpiend that the evidence in reference to this be placed before the Medical Council of New Zealand for consideration of what disciplinary action within its province it might consider necessary.

“In reference to the heat treatment given to his own and other patients suffering from vulvo-vaginitis in the Shrinipton Ward, wc have the following observations to make: His want of candour, to put it mildly, in his relationships with his professional brethren on the honorary staff, with the medical superintendent, the matron, the child’s parents, the Coroner, and with the board, was detrimental to the discipline and co-operation of tile nursing staff. “Apart from the hoard, there are m the Napier Hospital three administrative heads, namely, the medical .superintendent, the matron, and the man-aging-secretary, each with a certain degree of independence. Tbe disorganisation in tbit hospital ns a result of such triple control is opposed to the maintenance of Satisfactory discipline and co-operation. '. . . “The system of control is full of possibilities for the creation of difficulties. There should he only one head, clearly defined, namely, the medical superintendent, and he should ho the head of the institution not only in theory, but in fact. The matron should be responsible to the board through tbe medical superintendent. Silnilhrly, the managing-secretary, who should be designated by the word ‘secretary’ and not ‘managing-seoretary,’ should be responsible to the hoard, except as to his secretarial duties, through the medical superintendent.”

TRAINING OF NURSES. Dealing with the organisation, control, and supervision of the training of nurses at the hospital, the report says: “The duty of a hospital board establishing a training school is to provide the means of giving pupil nurses adequate training in nursing. Pupil nurses, under supervision, perform a substantial part of the nursing service. The matron, as the head of the training school, is responsible for the requirements laid down by tbe Nurses’ and Mjdwives’ Registration Board being fully met. It is the duty of the matron, thereforo, to advise the liospital hoard of requirements for the training school.

“In our opinion, dissatisfaction among the pupil nurses might have been averted if tbe temporary nature of tlie situation had been more fully explained to them. In the case of the outbreak of vulvovaginitis, the need for extra supervision was not sufficiently appreciated. “In this connection the of two registered nurses, one in substituting unauthorised treatment, the other in carrying out such treatment for patients, should, in our opinion, be referred to tbe Nurses’ and Midwives’ Registration Board, and wo recommend accordingly.” The Commission finds that the teaching of tlie theory of nursing, medical and surgical, by the medical stuff appears to have been fairly met. though on the nursing side the teaching is inadequate. One part-time tutor-sister cannot do all the work. “A full-time tutor-sister is an imperative need at this hospital,” it says. “The very essential whole-time training period of nurses (held for one month or less at Napier Hospital) should, according to present-day practice, extend over three months.’! Summing up on this question, the

Commission considers that the organisation, control, and supervision of the training of nurses in the Napier Hospital is unsatisfactory, and should, be reviewed bv the Nurses’ and Widwives’ Registration Board. THU ADMINISTRATIVE SIDE. “In regard to matters relating to the management and administiation of the Napier Hospital, your Commissioners are convinced that it is contrary to proper administration and discipline that any person should at the same time hold office as a member of the Hospital Board and as a member of the lionofaiy staff. “We are also of the opinion that, for obvious reasons, it is wrong for a member of the Hospital Board to act as Coroner with respect to any patients who have died in the hospital. “We consider that it is improper that a member of the honorary staff should retain his position as such when a majority of the board members desire to dispense with bis services. If legislative authority is necessary, it should be taken to gi\e power to prevent such occurrences.

“Where the Minister desires to exercise his authority with respect to action or contemplated action hv the board he should be possessed of full power to enforce sueJ.i authority. There appears to he lack of statutory authority enabling a Minister effectively to deal with the position where a hospital board makes unwarranted or arbitrary decisions, which may not be in the best interests of the institutions under its control, or consistent with the best hospital policy for the Dominion.

“Tho position of the medical superintendent, Dr. Foley, restricted ns it was by by-laws, custom, and other-dis-turbing influences, lias been very difficult. We think that a medical superintendent whose experience has been limited to the Napier Hospital might be given necessary study leave, on pay, to enable him to visit hospitals in Australia and in New Zealand to observe standard principles and practice in medical administration.

“We think that the honorary Staff generally should he transformed into a part-time part-paid visiting staff. Hospital practice and private practice are inter-related and complementary in any community.

NATIONALISED HOSPITAL SYSTEM. “There Is much to he said for the contention that the hospital system in New Zealand should bo, ill a large measure, nationalised,” says the report. “It might well bo under the control of commissioners responsible as regards broad policy to the Minister, and through him to Parliament. Sucli commissioners would not he influenced by political or local pressure to tho same extent as a hospital board, or by tho ill-effccts of rivalries and jealousies, as exemplified in Napier and Hastings. Certain it is that hospital hoards, if retained, should have their powers clearly defined and strictly limited. “It would not be unreasonable, also, that the Government (seeing that it generally provides as much money for hospitals as do ratepayers) should have direct representation on local hospital hoards or committees of management. The very extensive and efficient system of hospitals under the control of the London County Council is administered without hospital boards. Under effective and independent central control, hospitals could be properly graded and co-ordinated. The opportunity as at present for hospital hoards to increase the status of what should in a proper system ho minor hospitals, and perhaps heavily overhurden ratepayers, should not occur. In other | words, expenditure and expansion should he controlled. To lessen overcrowding of expensive hospitals, grading of hospitals is essential. “A centrally-organised system of district nursing is an important auxiliary of hospital service and materially lessens unnecessary pressure on costly hospital . accommodation. Combined with this, there should be an organ-

ised medical service for such people as are unable to afford private medical attention and nursing, many of whom can be treated cheaply and satisfactorily in their own homes.”