HOSPITAL TRAGEDY

New Zealand Herald, Volume LXX, Issue 21473, 22 April 1933, Page 2 (Supplement)

HOSPITAL TRAGEDY

MISTAKE IN OPERATION CHLOROFORM FOR ETHER NURSE BLAMED BY JURY Evidence that chloroform was administered as an anaesthetic by a doctor who believed it was ether was given at an inquest at Rochester last month. The inquiry concerned Richard Boyeo Jackson, aged 45, an inspector of fitters at Chatham Dockyard, who died in hospital. Mary Blanche Jackson, the widow, said that while on passage home from Hongkong her husband became ill and was admitted to hospital orj March 6 for an operation to be performed the next morning. She added: " Dr. Roffey said to mo at the hospit.al ' You will hato me in a moment. I gave him tho anaesthetic. Thoy gave me tho wrong bottle.' The doctor was distressed, and I said to him: ' Then you could not help it. You are to be pitied as well as me. " Dr. A. W. G. Woodforde said he was about to perform the operation and that Dr. Roffey was the anaesthetist. On the anaesthetic table, he added, there were three small bottles containing three different kinds of anaesthetics. Dr. Bernard Wilson Roffey, senior assistant anaesthetist at the hospital, said ho started administering ethylchloride, and then took the bottlo marked " other," putting drips on to a mask. The patient's breathing be-

came difficult. He restored him, and then dropped what he thought was ether on to the mask again. Mr. Jackson's breathing again stopped, and he died. Jackson's death was abnormal, witness went on, and, while endeavouring to find the cause, he discovered that the bottle marked " ether " contained chloroform. He formed the conclusion at the time that the chloroform had contributed to the man's death, but, he added, " That is not now my opinion." Dr. C. W. Greene, police surgeon, said that the post-mortem revealed valvular disease of the heart and fatty degeneration of the heart muscles. In answer to counsel for Dr. Roffey ho said that whatever anaesthetic had been used the man would probably have died as a result of it. Ether would have caused a similar strain upon the heart. Nurse McAdam said that on the morning of the operation she filled two bottles on the anaesthetic table, but she did not touch the ether bottle, as it was already full. The Coroner: Can you suggest how chloroform got into the ether bottle? Witness: 1 have no idea. The jury found that death was due to syncope, accelerated by the administration of the wrong anaesthetic, and absolved Dr. Roffey and Dr. Woodforde from all blame. " We are of the

opinion," added tlio jury, " that the mistake in regard to the bottlo was due to an error on the part of Nurse McAdain." Tho announcement of the verdict was followod by a distressing scene. Before the foreman had completed liis reading of the jury's findings, Nurso Wilhelmina McAdam rose from her seat in court and cried: " It is not true: Oh, God, help mo. 1 did not do it. What shall I do? What shall I do? Will someone comfort mv poor mother?" Nurses led her out of the court crying and waving her arms frantically. The jury also expressed the opinion that in future stricter supervision in regard to anaesthetics should bo observed.