DEATH AT OPERATION.

New Zealand Herald, Volume LXVII, Issue 20668, 13 September 1930, Page 14

DEATH AT OPERATION.

REOPENING OF INQUIRY.

VERDICT NOT AFFECTED.

PROCEDURE OF SURGEON.

WRONG DRUG FROM NURSE

[by TELEGRAPH. —PRESS ASSOCIATION.] CHBJSTCHURCII. Friday. Tha Jpnnwit was reopened this morning into tho death of Miss Violet Monica Salmond, late headmistress of the Craighead Diocesan School, Timaru. At the previous proceedings the following verdict had been returned: "That death was caused by alkaloidal poisoning, due to cocaine, which was injected by mistake, instead of nco-cocaine, round the tonsils of Miss Salrnond before an operation for tho removal of the tonsils. No blame \« attachablo to the operating surgeons." This morning tho coroner, Mr. 11. A. lYourig, S.M., after explaining how tho first inquest caino to be held immediately after death and with no representatives of the press present, said that later ho became satisfied that the public mind was agitated over tho matter and that it was advisable that confidence in the submission to local anaesthetics should as far as possible bo maintained. "1 thereforo got in touch with tho witnesses and their solicitors," continued Mr. Young, "and all agreed that I would bo doing a public service in holding a further inquiry. " Tho solicitors present havo approved of certain witnesses being called, who will givo evidence as to tho practice in the administration of local anaesthetics.

Informal Public Inquiry.

"I am of the opinion that in New Zealand an inquest cannot at present be formally reopened. These proceedings are, however, with the consent of all concerned, more in the naturo of an informal public inquiry on matters arising out of the inquest, but which cannot affect the verdict already found by mo as coroner."

Mr. F. S. Wilding, counsel for Dr. T. A. Mac Gibbon, the operating surgeon, said the coroner's decision had been toeeived by all interested parties with unqualified approval. "The relatives of the deceased aro absent," said Mr. Wilding, "but I am pleased to see that they aro represented by counsel. I should like to gay that the general public strongly upholds }our decision to have a further inquiry in this matter. That is not because we think there was any undue hurry in the first place. No doubt of partiality has been raised. Tho facts were candidly admitted by the chief actors, but the matter has aroused such a wave of fei»ing and sympathy that it is advisable to see whether some further precautions may bo taken to lessen the pos eibility of a recurrence.

"Dr. Mac Gibbon has been the victim of anonymous attacks, both by letter and telephone. They were mostly from .women."

Mr. Young: I myself was much impressed with Dr. MacOibbon's fairness nnd sympathy to the then're nurse, in conditions which must liavo been very distressing to him.

Request for Anaesthetic. Greta Clarkson said that previous to the case in question she had assisted Dr. Mac Gibbon at an operation at St. George's Hospital. Tho doctor then asked witness for neo-cocaino in a syringe. In the case under inquiry the doctor had asked for the anaesthetic.

Tho matron at St. George's Hospital, Daisy Thwaites, said Nurso Clarkson was a clever and capable nurse. Prior to tho operation the nurse had been doing theatre work for ten days and the operation in question would have been her 31st. She had assisted Dr. Mac Gibbon on several occasions before, but only once when that particular drug was used.

Mr. Sim: Is the use of cocaine and adrenalin frequent ? Witness: Yes; but neo cocaine is uscrf only by Dr. Mac Gibbon. Other surgeons use only cocaine or an external application. It is quite common to have cocaine in tho surgery for local anaesthetic purposes.

To Mr. Wilding: At the previous operation tho nurse had received sorno instruction regarding the caso as treated by Dr. Mac Gibbon.

To Mr. K. M. Gresson: From the timo that the patient caine into the room alio was never left. Confidence in Nurses.

Dr. Mac Gibbon said he had never had any trouble in St. George's Hospital. Tho nurses generally in public hospitals wero worthy of having confidence 'placed in them.

Mr. Wilding: It has been suggested that you allowed tho nurse to take the wholo blamo of this on her shoulders to screen yourself ? Witness: In what way do you want me to answer that ? The Coroner: I do not think it is necessary to go into that. I was quite impressed with the doctor's sympathy. " Those who know me know that I ■would not shelter behind any woman," said tho witness. " I have heard all sorts of. insinuations and I have tried hard to protect the nurse against public opinion and to take as much blamo as possible on my own shoulders, f do not attribute any blame to the nurso." Mr. Wilding: Has it been your practice to name a drug in the presence of the patient ? Wituoss: One of tho first things wo are taught as students is not to narno the drug. Witness said ho had had, in his 19 years of experience, two similar cases, but no serious consequences had ensued. Mr. Wilding: Can you account for this lamentable lanse on tho part of tho nurse ?

Witness: I cannot.. It was not duo to lack of care

In reply to a further question witness said that he thought that Iho moro conscientious a poison was, the more likely he or she was to make a mistake Duty Lelt to Nurse.

Pr. Mac Gibbon said bo could havo himself filled the syringe, but both his hands were occupied with the operation jind it was an ordinary procedure for tho surgeon to leave that duty to the nurse, who was always competent to do it.

Witness described the operation, saying that soon after it started tho patient got rest jess, and while he was trying to soothe hor, lie noticed that her mouth was twitching. He asked the nurse what she put in the syiinge. and slio replied adrenalin and cocaine. He threw tho instruments aside and told Dr. Crawshaw ihat artifi< i»l respii ation iiium be adopted. The usual remedies for cocaine poisoning wore followed In such cases the patient usually recovered in two hours They were with Miss Salmoud foi three hours and a half. The error made by the nurso was certainly not due to lack of care on her part. She was a good nurse. He did not blame tho nurse at all. It was puro misadventure. Evidence was given by I.)rs. Crnwshaw. Sandston and Guthrie, all of whom agreed ■with Dr. MacGibhon's procedure iri allowing the nurse to filf the syringe. Refraining from naming the drug was the usual and correct practice.

Tho coroner thanked counsel for their nblo co-operation in a public service. The points raised were of a delicate nature and required detached thought. He would ,pc.i'haps (jxpiess an opinion at a later date.