HOSPITAL INQUIRY.

New Zealand Herald, Volume XXVIII, Issue 8474, 27 January 1891, Page 6

HOSPITAL INQUIRY.

The Commission, consisting of Dr. Giles, R.M., and Dr. G. Hassell, Medical Superintendent of the Avondale Asylum, appointed by the Government to inquire into the charges brought against Dr. Collins, of the Auckland Hospital, by Probationer Arnaboldi, commenced its sitting in the Resident Magistrate's Court yesterday, at eleven a.m. The respective parties engaged in the inquiry were as follow Dr. Collins and his counsel, Mr. Theo. Cooper; Mr. W. Berry and his counsel, Mr. O'Meagher; Miss Arnaboldi and her counsel, Mr. T. Cotter.

Mr. Cotter said that he appeared for Miss Arnaboldi at present, in so,far as he had au application to make, and that unless his application was granted he would withdraw from the case altogether. Mr. Cotter then asked the Commissioners for the names of those who had been subpoenaed to attend the inquiry. Dr. Giles stated that he had sent subpoenas to Miss Arnaboldi, Drs. Collins, Philsou, Hooper, and Daldy. Nurses Dixon, Jones, Beetham, Miss Goulstone, and Mr. Berry. Dr. Giles further stated that lie had asked Dr. Roberton to attend the inquiry. Dr. Roberton stated that he thought that there must be some mistake as he had nothing whatever to do with the matter.. Dr. Giles said he thought that Dr. Lindsay had seen the patient before he entered the Hospital, but that Dr. Lindsay told him that perhaps the man had been a patient of Dr. Roberton.

Dr. Robertou stated that Berry had not been a patient of las, and was excused from further attendance.

Mr. O'Meagher then asked the Bench to subpoena Robert Patterson, who had been present when the operation was performed. The Bench stated that they had the depositions of witnesses taken at the inquest in their possession, and that the evidence of Robert Patterson was amongst these, but that they would subpoena him if desired, as he could then be cross-examined.

Mr. Cotter said that he had to make an application for on adjournment. The Commissioners wore probably aware that Miss Arnaboldi's counsel. Mr. Rees, who had previously appeared for her, was now in Wellington. Mr. Rees had advised Miss Arnaboldi not to attend the commission, and Miss Arnaboldi had felt it her duty to abide by the advice of Mr. Rees. Mr. Lusk, who was managing Mr. Rees' business for him during his absence, had received the following letter from Mr. Rees in regard to the matter :—"Gisborne, New Zealand, January 19th, 1891. Re Miss Arnaboldi. I have written to the committee suiting that the inquiry ought not to be allowed to proceed before the present Commission. The issues are far too important, as they involve the constitution and efficiency of the whole system of local government throughout the colony. I am bo convinced of the improper constitution of the Commission that if the committee and Miss Arnaboldi determine to appear before it, I must withdraw from the case. Miss Arnaboldi is, however, not bound by any decision the committee may arrive at; and, in her own interest, and in the interests of suffering patients in the Auckland and other hospitals, she should refuse to have anything to do with an inquiry, unless it be help before a tribunal which the public will regard as above local prejudice, class feeling, and Government interference. But Miss Arnaboldi must use her own judgment. I shall be pleased to do my utmost for the vindication of her character, and for the welfare of those helpless people in whose cause she has drawn this storm upon herself; but I must see that the conditions under which the battle is fought are fair to both sides.(Signed) W. L. Rkes "

Whilst Mr. Cotter was reading this letter, the Commissioners remarked that they thought the letter was a highly improper one to read before them, but as Mr. Cotter had gone so far they would let him finish if he desired. Mr. Cotter then went on reading, and finished the letter.

The Commissioners said that with regard to Mr. Cotter's application for an adjournment, that Miss Arnaboldi had refused to have anything to do with the commission, and that Miss Arnaboldi must be presumed to have used her own judgment in the matter. They would not consent to an adjournment for a week merely on the ground that Mr. Kees might then be back from Wellington. Mr. Cotter then said that Mr. Rees had considered something was wrong in the manner in which the Commission had been appointed, and had got Mr. Whitaker to appear for him. The matter was then adjourned and this was the outcome of it. Miss Arnaboldi on Saturday at half-past twelve showed him the letter which she had received from Mr. Rees. He had told her that he could not agree with the advice given by Mr. Rees. He considered that it was not her duty to object to the personnel of the Commission. On Saturday she consulted Mr. husk, and asked Mr. Cotter to appear-for her. He then considered that he could not do justice to Miss Arnaboldi's case by taking up the matter at this late hour. He then asked their Worships for an adjournment for a week, as he had seen by that morning's paper that Parliament was likely to prorogue, and perhaps Mr. Rees might be able to be in attendance, or he would himself have time to prepare the case. Mr. Kees had been communicated with, and had been told the position in which Miss Arnaboldi would be placed. He had received notice from Mr. Dusk that a telegram had been received from Mr. Roes stating "Arnaboldi Commission adjourned." He did not know what this meant. Telegram No. 1. The Commissioners here stated that the following telegram had been put in their hands since they had commenced sitting :— " Will any inconvenience result if the enquiry is adjourned for a week ? —(Signed) I*. A. BUCKLEY, Colonial Secretary."

Mr. Cotter stated that no inconvenience would result, as the witnesses were mostly resident in or around Auckland, and if the adjournment were not granted Miss Arnaboldi would be placed in a position that would not be fair to her.

Dr. Giles said that on receiving the tele gram appointing him to this Commission he lost no time in making this fact known to the parties. Mr. Cotter said that the advice of Mr. Rees might have been given under a misconception. Under these circumstances he simply pressed before the Commission that some reasonable adjournment be granted in order that Miss Arnaboldi may be represented by counsel. He would like a week in order that Mr. Rees might be present. He would not presume to take any part in this case without preparation. Dr. Giles said that he did not consider any adjournment in this case was a reasonable one.

Mr. Cooper said that although he considered the application made by Mr. Cotter unreasonable, yet lie would not in the interest*; of Dr. Collins raise auy objection to it. It would be placing his client in an unfortunate position if it was afterwards said that a thorough investigation had been shirked. Although he did not think that such a charge could be justly made against his client, yet the public might not be satisfied. lie thought that Miss Arnabohii, through her advisers, had very grievously insulted the Commission on the ground that they could not be impartial judges. This was an insult to the.Commissioners personally, and to the constituted authorities by whom they had been appointed. Miss Arnabohii had been wrongly advised not to attend because of the pt:vxonnrj, of the Commission. He, therefore, would not oppose the adjournment, although the position taken by Miss Arnaboldi was an unreasonable out;. Their Worships had given It days' notice. This was ample time for counsel to be advised. Miss Arnabohii had been advised to disregard their mandate because of the 'personnel of the Commission, lie submitted that when the moving party took a stand like that she was entitled to no consideration from the Court. He felt that it was to Dr. Collins' interest to have the charges thoroughly investigated, so that the public should not say at _ some future date that Miss Arnaboldi was not prepared. He would only consent to an adjournment for a short time. Me left the matter entirely in the hands of the Commission, as Dr. Coliins had nothing to fear from the fullest and most complete enquiry. Mr. O'Meagher said that he was present, not to prosecute anyone, but merely to elicit the truth, and that this could not be done unless Miss Arnaboldi was properly represented by counsel. Mr. Cotter said he was sorry that Mr. Cooper had referred in such terms to Miss Arnabohii. Miss Arnaboldi was one who had been more drawn into this matter than the moving spirit in it. He siu.'!,ested that the Commission might fix a time when the examination of witnesses should take place. The Commissioners said they would not adjourn the case for a week, on the ground that Mr. Reos might he able to attend.Mr. Cotter pointed oar, that if any adjournment were made at all, it should be for a week. Thursday was a holiday. Friday, Dr. Giles would be engaged in the Resident Magistrate's Court. Saturday did not allow enough time lor the Commissioners to proceed any depth into the inquiry. The Commissioners hereupon retired to consult upon the question of an adjournment. On their return Dr. Giles said they considered the application was wholly unreasonable and could not be granted, as Miss Arnabohii had had fourteen days' notice in which to engage counsel. Though not insensible to the arguments in favour of an adjournment adduced by Messrs. O'Meagher and Cooper they thought that a certain amount of

consideration was due to themselves and their colleagues. They had had to make certain arrangements for their other business in order that-they might be enabled to sit. This was the outcome or some person or persons, aided by a portion of the press of Auckland, to discredit the Commission appointed by His Excellency the Governor. Mr. Cotter asked the Commissioners if they would grant any adjournment whatever? Dr. Giles said they would grant an adjournment till two o'clock. Mr. Cotter then withdrew, Dr. Giles at the same time expressing his regret that Miss Arnaboldi would not not have the benefit of his advice. MISS ARNABOLDI'S EVIDENCE. Margaret Dorothea Arnaboldi deposed that she was up till recently a probationer in the Auckland Hospital. She received her appointment from the matron, January Ist, 1890. She was acting in this capacity on December 23rd, when Joseph Berry was first admitted to the Hospital. Nurse Dixon, Brighton the porter, Dr. Daldy, and Dr. Collins saw him when he was admitted. Berry was first laid on the operating table and his hand bound up. Berry was then brought into the ward in which she was attending, and put to bed. Berry was cold and collapsed at the time, but was conscious. He was also vomiting. Nurse Dixon had charge of the ward in which he was placed. She noticed that Berry's bandage was saturated with blood about half-an-hour after _ho had been put to bed. There was lint, absorbent wool, and a bandage placed on the wound. She noticed that blood had soaked the dressing on the wound. About five minutes to twelve she was coming kick through the ward, and saw Berry sitting up in bed. He put the wounded hand in the centre of the quilt, and the quilt was stained with blood where the hand rested. Witness thcu summoned Nurse Dixon, who told her to fetch a lump of tow, on which Berry's hand was placed. Witness went away at twelve o'clock to attend to the dinner. She next saw Berry at about halfpast twelve, and observed that the tow placed under Berry's hand was wet with blood. About this time Berry asked witness whv the doctor did not stop the bleeding. He said that it would be the death of him. Witness then went off duty from one o'clock till a quarter to six. When witness returned Berry was lying very still, and the wound was still bleeding, but she could not state to what extent. The draw sheets which were wet with blood had been removed and fresh one put in their places. These sheets were removed before eight o'clock, and were also wet with blood. She last saw lierry at eight in the evening. The patient was lying quietly during the time he was under her observation except on one occasion when he sat up in bed. A glass of brandy and water was given to Berry during the day. Two hot water bottles were placed in the bed, one at the patient's feet, and one at his right side. Witness did not see any doctor enter the ward during the day. Nurse Jones came on duty at eight o'clock when witness retired. Nurse Dixon was on duty all day. Wituess knew of no attempt having been made to stop the bleeding before she left at eight o'olook. Berry was quite conscious in the morning, but deceased did not speak at all during the evening. She saw no signs of unconsciousness, but noticed a certain nervous twitching about Berry's lips. He vomited about three times shortly after he came in. She had been four months in the accident ward, and the only other bad case of bleeding that she had noticed was from the effect of an abdominal operation. Dr. Giles said he would like to know whether Mr. Cooper intended to cross-examine witness on this first charge, or if he would prefer to hear the evidence on the whole charges and then t<> cross examine the witness. Mr. Cooper said he preferred to adopt the latter course.

Witness was cross-examined by Mr. O'Meaghor as to whether Kerry had a bandage on the elbow. Witness replied that to her knowledge there was no bandage on his arm.

The witness then gave evidence in the case of Duncan McKenzie. McKenzie was brought down from Whangarei and admitted to the Hospital. McKenzie was then laid on the operating table and his leg was examined by Dr. Collins. The leg was tied on to a pdlow and had no splint. He was removed to No. 1 ward in this condition, and put to bed without having the bandages removed. Three pillows were placed under the leg and a cage placed over it. Dr. Collins superintended this operation, and then ordered the patient to receive a dose of morphia. The doctor told witness to give him milk and egg and a little brandy at intervals during the evening. McKenzie suffered a great deal of ' pain in his leg during the night. He thought that the bandage was tight (hiring the evening, and she went to Dr. Collins , about eleven o'clock, and he told witness to call Dr. Daldy. Dr. Daldy came and looked? at the bandage, and said it did not require anything doing to it. Dr. Daldy departed without giving any further directions, and the patient still complained of pain. About a quarter to twelve witness called Dr. Collins, who ordered her to give him another dose of morphia. Dr. Collins told witness to give the patient more morphia during the night if he needed it, and to use her own discretion. At a quarter to four in the morning she gave McKenzie another dose of 45 minims of morphia. This had no effect on him, and did not send him to sleep. Dr. Collins also ordered a close of calomel for McKenzie. Witness went off duty at halfpast seven in the morning and came on duty at eight o'clock in the evening. At ten minutes to ten in the day she saw McKenzie, but paid no attention to his state as Nurse Dixon was then attending to him. When witness came on duty at eight o'clock the leg had been set, and she was ordered to keep it moist with carbolic lotion. The patient appeared to suffer pain all that night. Dr. Daldv came to visit the patient during the night, out did not rind anything wrong In the position of the leg. From this time McKenzie remained in the Hospital for some days. She saw his leg dressed by Nurses Dixon and Jones, there being a piece of bone about two inches long projecting. There was a very offensive smell coming from the wound, which was covered with an unhealthy iooking pus. This wound was in the lower part of the leg, in front, and she could not say anything of the state of the leg higher up, being only present a few minutes. She believed that a record of the patient's temperature was kept, but could say nothing of the particulars, nor could she give evidence as to his diet. When McKenzie was received into the Hospital, he expressed an earnest hope that the doctor would save his leg. Witness was present when the leg was amputated. Dra. Daldy, Philson. Hooper, ami Collins were also present. The latter told the patient that he would have to lose his leg if his life was to be saved. Dr. Hooper said to Dr. Collins, " You'll never make a leg of that, doctor." The ventilators were then opened on account of the smell. Dr. Philson examined the leg, and pressed it, saying, "The pus has burrowed this far." The operation then went on. Dr. Collins put his fiuger along the bone, removing the lower part into a dish. The bone was severed about two inches below the knee. Dr. Collins drew Dr. Philson's attention to a nasty spot on the inner surface of the flap, and asked whether it should bo removed. Whereupon Dr. Philson said that lie should trim it off, and use a strong antiseptic. This was done, and Nurse Dixon handed Dr Collins some chloride of zinc. On fixing the last ligature Dr. Collins remarked that he had seen many jobs that looked more promising than the one in question. Witness had had said previously that the upper flap was gangrenous, but this was not from her own observation, but inferred from what she hail heard. A coroner's inquest was held in the case of Berry, but she did not give evidence, as it was not customary for nurses to do so in cases where death had taken place at the Hospital. She was, however, dissatisfied with the case.

By Mr. Cooper : She had no experience in nursing when she went to the Hospital, ami all her practical knowledge was gained at that institution. She had not seen Berry until he was placed on the operating table. He was suffering from a shattered hand, the wrappers round it being covered with blood. Berry explained to her how the accident occurred, his gun having exploded while he was shooting a neighbour's cat. He did not tell her when or where the accident occurred. Berry must have suffered from shock from the nature of the accident, but she believed he walked up the Hospital steps. Witness did not report the state of the man's bleeding to the doctor, nor could she say whether Nurse Dixon did so. She could not say whether Berry vomited after she gave him nourishment, and could not remember seeing the doctor in the ward the morning the patient was received. She did not carefully examine the hand and the bandages, but noticed particularly the flow of blood. She and Nurse Dixon removed the draw sheets, and found much more than a little blood. This was about one o'clock. The patient bled till two sheets folded twice were soaked through. Her previous statement to Dr. Macgregor on this subject was incorrect, she having stated on that occasion that there were four sheets folded. Witness 'intended by her complaint to point out that the amputation had taken place between ten and eleven o'clock at night, and she had heard the nurses say when Berry was brought out that he could not live. She did not think the patient had been treated as carefully as he ought to have been. Witness wac-asked if she considered that Dr. Collins had allowed the patient to bleed to death, but did not answer this. She considered that the arm should have been amputated earlier, and the neglect of the doctor to do this was the substance of her complaint. She thought the patient was in a position to sustain the shock of the operation in the morning. Witness neither complained to,

nor sought instructions from, Dr. Collins previous to seeing Dr. Macgregor on the subject. She did not particularly mention Berry's case to Mr. Monro, but went to him specially about McKenzie's case. She knew that her statements implied a serious charge of negligence against Dr. Collins, but she had not previously complained, as it was against the rules to speak about cases under treatment. McKenzie was a younger man than Berry, and more strongly built. She could not say whether Dr. Collins visited him before he went to bed on the night of his reception, at about twelve o'clock, but she would not swear that he did not. She gave the black .draught to the patient because it was in her discretion to do so, and she thought it was needed. Half-past three o'clock on the Ist November was not the first time Dr. Collins had visited McKenzie, but it was the first time he examined the leg. Witness had seen gangrene in one instance, but had dealt with no cases in the ward. She said, in her statement to Dr. Macgregor. "By this time the leg was gangrenous nearly up to the knee." She judged of the presence of gangrene by the smell, the decay, and the fact that pus was exuding. This had happened in all cases of injury which she had seen, with the exception of the smell. In answer to the question as to what she meant to convey by her complaint in this case, Miss Arnaboldi stated that she thought it strange that the leg had not been examined before, and that the other surgeons had not been called in sooner ; but, with regard to the gangrenous flap, the basis of her statement, <! That the upper flap was still in that state of gangrene after the operation," was the remark of the doctor at the time. She understood that McKenzie died of acute traumatic spreading gangrene. A relative of McKenzie, named Campbell, came in during the operation, but she knew nothing about nim. She heard nurses Jones and Beetham remark that the patient was dying at the time of the operation. Witness thought that if the operation had been performed sooner, the bleeding would have been stopped, and that he would have been better able to sustain the shock, as he was stronger in the morning than in the evening. Telegram No. 2.

At this stage Dr. Giles said that he had just received a telegram from the Minister of Justice, stating that His Excellency the Governor had directed that the inquiry should be adjourned for a fortnight. He had nothing more to say, but simply to adjourn as directed, and he hoped to have nothing more to do with the case. He had nothing to show him what the reasons for this action were ; but as it came from His Excellency, from whom he and his colleague had received their commissions, they must obey. The case would stand adjourned for a fortnight.