MRS MACDONALD'S DEATH.

Otago Daily Times, Issue 18464, 27 January 1922, Page 7

MRS MACDONALD'S DEATH.

ESCAPE FROM DUNEDIN HOSPITAL. INQUIRY BY THE OTAGO BOARD. FULL EVIDENCE HEARD. REPORT TO BE DRAWN UP. An inquiry was held by the Otago Hospital Board last evening, into the circumstances under which a patient, Mrs Catherine Susan Macdonald, escaped' from the Dunedin Hospital. Mrs Macdonald escaped from the institution on January 5 and was found in a dying condition on January 17. • The Chairman said that the board hod to inquire into the escape of Mrs Macdonald iron* the Dunedin Hospital on January 5. As tar as the board was concerned he would like it to bo dearly understood that they had to rely on their responsible officers for, practically speaking, anything that occurred in any of their institutions. It was the board’s earnest desire to make sure that, the inmates in every one of their institutions wore well treated and oared for. It was most unfortunate that Mns Macdonald should, have gone out of the hospital in the way she had without being observed. They had no desire to shirk their duty in any way. If any of their staff were at fault fie was sure that the board would like to bo informed of the matter, and if it wore brought home the board would do its duty. The secretary of the board (Mr J. Jacobs) read all the correspondence relating to the ease and leading to the inquiry. On January 20 he had forwarded the following letter to the Acting-Superintendent of the Hospital (Dr Vivian); —“1 am directed to ask if you will furnish a full report in regard to the leaving of the Dunedin Hospital of the late Mrs Macdonald on which there has been bo much' newspaper comment of late. I am further directed to ask if you will state who is to blame, if anyone, and who would be responsible for any negligence in this matter, if any.” The same day a telegram was received from the Public Health Department asking for information to enable the department to reply to the following questions asked by the Hon. Mark Cohen in the Legislative Council: (a) Whether Mrs Macdonald suffered from mental, derangement at the time of her admission to the hospital and (b) why the fullest publicity was not given? He then wrote further to Dr Vivian as follows:—“Referring to my letter to you of even date regarding death of Mrs Catherine Susan Macdonald I am in receipt of a telegram from the Department of Public Health as per copy enclosed. Please let me have - your report thereon immediately to enable me to reply thereto.” Mr Jacobs then read Dr Vivian’s report, which was as follows: DR VIVIAN’S REPORT. The _events leading up to this patient's admission naturally made us suspicious cf her mental condition. To determine her mental state Dr Fitchctt (the honorary physician, under whose care she was in hospital), Dr Falconer, and I carefully examined her. It was quite obvious that the patient was in.a poor state of health, but she was quite rational in her speech, made no absurd suggestions, was not suspicious, answering questions quite freely and clearly. Giving to the patient having a suspicious lung condition which was most probably tuberculous she was put into a room by herself alongside the ward and opposite the ward kitchen. _ The nurse on duty could see the patient in bed each time she entered and. left the ward kitchen, so that the patient was under almost os close observation as afiy patient in the ward. Further, the nurses were told to watch the patient carefully for two or three days and to report any signs of mental aberration. None of the purses noticed any defects, the patient always speaking quite sanely and rationally. In reply, then, to the Hon. Mr Cohen’s, first‘.question,. I should say that "careful examination did not ( reveal any signs of mental derangement either on the patient’s ■admission to hospital or during her stay here Further.. the patient seemed t 6 be improving in her general. health and to bo sleeping better. Two or three nights prior to her departure, she asked the nurse not to disturb her at night, for, as she was a fiffht sleeper, each time the nurso came in she woke up. .With regard to Mr Cohen’s second question, first the Times said “the Hospital authorities did not even take the trouble of notifying IhSt. husband that his wife had been admitted to the institution.” This ‘seasily explained. Mrs Macdonald said that she w;as separated from her husband, and did.not wish him to be informed. Further, site would not give his address. Secondly, “The- Hospital authorities notified the police, but for some reason known best to /themselves did not follow the usual custom of informing the press so that the attention of the public might be drawn to the j fact that someone was missing and the recovery of the person rendered more probable.” When it was found that Mrs Macdonald was missing the police and the people who had sent Mrs Macdonald in wore at onco notified. ‘ It is the custom for the press to ring the Hospital daily, and the porters give any news they think may be of interest. Having notified the police and the people ■who had sent Mrs Macdonald into the Hospital, I consider that we had fulfilled our duty to both the patient and the patient’s friends. The police informed Mir Macdonald of his wife’s disappearance. I believe it was the police or the patient’s husband to notify the press if full publicity was desired. I do not consider that there is any blame attachable to anyone for this sad occurrence. As the coroner said in his snmming-up: “It is easy to bo wise after the ©vent,” and we must now regret that a special nurse was not deputed to watch Mrs Macdonald constantly, but wo must realise that it : s impossible to watch carefully and constantly every patient in the Hospital, especially at night time. , DR FALCONER’S REPORT. Mr Jacobs proceeded to read correspondence relative to the summoning of Nurse Cameron to Dunedin, .and other witnesses, for the inquiry; He also read the following report on the matter from Dr Falconer, the medical superintendent, under date January 24 ; “ Further- to the report of the acting medical superintendent, dated January 20, I beg to forward additional particulars ns follows;—A week or so before the admission of Mrs Macdonald to the Dunedin Hospital on the 20th ult. the friends of the patient rang me up and asked the procedure m regard to the admission to the Warrington. Rest Horae, whore they thought it advisable- for the patient to go. I whs told that the patient was nervous and run down, and I asked particularly if there were any suspicion of mental trouble, and was assured there was not. I advised them to obtain a recommendation from her own doctor, and present the same to Mr Oumniings or to bring the patient up for examination at the out-patients’ department* of the Hospital. The patient attended the out-patients’ department on December 13, 1921, and was examined by Dr Murray, who desired her to attend Dr Lyth’a clinic tor an opinion by Dr Lyth in regard to the condition of the chest. This the patient failed to do. Tho dav before or tno day of the admission of the patient to llie Hospital I was again rung up by friends, who stated they desired her admission to the Dunedin Hospital preliminary to being sent to the Warrington Rest Home, and I advised that she should corns up next day for examination by the assistant medical officer at 11 a.m.,‘when she would be admitted'Mo the Hospital if found suitable. No mention was made to me of any circumstances that would lead the friends to suspect the patient of any mental weakness. Tho patient was admitted by tho assistant medical officer (Dr Vivian) on December 20, 1921, and was placed in a special room off Houghton ward by the assistant medical officer (Dr Vivian) for tho reason stated by him. “ During the patient's stay in the Hospital there wore no signs of mental aberration noticed by the medical attendants or nurses, and a report furnished to me, nor did I myself, on my visits to tho ward have reason to suspect that tho patient was other than of the ordinary type of neurotic patient who is run down in health from physical disability; the other patients in tho ward considered her quite normal mentally, ' It was a matter of great surprise to all concerned when tho patient left the Hospital under tho circumstances she did, I was on duty on that date, and, after investigating the occurrence, confirmed tho assistant medical officer’s action. I did not

suggest notifying the press, as I took it for granted that the police would attend to such matters if found necessary. 1 was surprised to read in the press report of the inquest that the patient, “ had taken to' the bush some four months before,” no information over having reached me in regard to such a i circumstance from the friends who applied for tho admission of the patient. 1 think there must bo some mistake on this Cohen’s second question that the Dmes said ‘ the Hospital authorities notified the police, but for some reason best known to themselves did not follow the usual custom of informing the press, 1 point out that the quotation from the iunes is not accurate, in so far that the words ‘ neither followed ’ were used by the dimes in place of tho words ‘did not follow as given above. In any case tho writer of tne Times article must be .unaware of the nature of tho usual press reports obtained. from Hospital, and the reference thereto m . Dr Vivian’s letter requires sorpo explanation. Several years ago the official press reports were issued daily by the house steward s office after confirmation by the .medical superintendent. These were discontinued at the request of one of tho local papers, which pointed lout to the Hospital Board that the former practice of allowing a reporter to interrogate the hall porter for items or public, interest was preferable from, their pbint of view. This the board allowed after mv pointing out that the Hospital authorities could not bo held in any way responsible for the nature of such, press, reports. X have- personally never initiated any such reports to tho press for several years past. THE FIRST WITNESS. Sidney Dunkley said that Mrs Macdonald had dome some sweeping and cleaning work tor an organisation of which ho' was treasurer and ho had first met her in April, and in December she said that she was run down m hoaltn, bne then ©aw Mr Bryan King, and he secured,a position tor her as housekeeper at Monungton, but she could not carry out the work. Witness said that bo might get her into the Warrington Rest Homo. He said that she could not take her little girl with her, but that he would get the girl into the Children’s Host Home. Watties© arranged with Mr Oujnnidngs to get her '• into .the. rest home. The child vyais quite, willing to go to the rest, homo, and. its mother was also willing to let it go. On Tuesday morning, December 18, he was rung up to say that Mrs Macdonald had leit the bouse where she wo© staying, b'ho was not discovered till the Monday night, when she bad walked into the Children's Rest Home. Witness went to the Children’s Rest Home and asked her why she had lett the house, Mrs Macdonald was .fully dressed. Bhe. said that she -could not sleep, and tiiat she had gwae into the bush and gone to sleep. .Mrs .Macdonald was put to bed and given something to eat. Next morning ho rang up the hospital, and they agreed to take hire Macdonald in. He saw Mrs Macdonald on the Sunday before she went away {roxn tho hospital. There was nothing wrong- mentally with Mrs Macdonald when witness saw her on the, Sunday. She ©aid that she. would go out quite happy to the rest home, so long os she knew her child was being well looked after. To Dr Falconer: There was no mental weakness in Mrs Maodonald so a© he could see in any way whatever. .She refused to tell witness anything about her husband. ’■ Dr Falconer remarked that Mrs Macdonald had taken up tho eatne attitude as regards her husband when she was in the hospital. ■ 1 f DR FITCHETTf’S EVIDENCE. Dr Fjtehott said ' that he had -seen Mrs Macdonald during her stay in the, hospital: She spoke in a perfectly rational and clear way. He knew that sue had gone away on a previous occasion. Sne made liglft of it, arid said the I. she had gone oik to see her child. She was a little Lit depressed, and emotional. Ho did not regard her as of unsound mind. It was thought that she was suffering from a lung trouble and that was why she 'was kept in the one room. He had questioned the nurses, and - they too were satisfied’ that she was mentally sound. He had ‘ indicated to the nurse that she should, be watched closely, a® ho was anxious to ' get information regarding her mental ■ state: Mrs Maodonald was perfectly clear ih her mind. Dr Fitehett continued that he had been called to see Mrs Macdonald when she had been found in a, dying condition. It was only an accident that he hod been balled to see Mrs Maodonald —not because he had been formerly connected with the case. 1 She had on a night dress, and a dressing gown, and outside - that a red ulster. TWELVE DAYS WITHOUT FOOD. In answer to a question by the chairman Dr Fitchctt said he thought it was possible that the deceased could have livedi for the period she did without food. She would probably eat roots, or leaves', or she might have got some food in some way. Ho had been informed that the ground on tho bank where she had been found had been tom up and trampled down as if she hadi been in the same spot all the-timo. He was a little surprised that so little notice had been taken of the fact dt her disappearance. Ho\ supposed that she inusfc have done away with herself. It had never occurred to him that the deceased had gone into the bush. \ FURTHER MEDICAL EVIDENCE Dr Eric Vivian, assistant medical officer, said he was in charge of the, patient in tho absence of Dr Fitehett. He said that Mr Dunkley came down to see him bn the morning ol December 20 and told him that Mrs Maodonald won in the Children’© Rest Home. Mr Dunkley was rather concerned about her and wanted some medical opinion as to whether she was a fit case. for medical treatment or whether she should, go to the "Warrington Rest Home for a holiday. Ho (Dr Vivian) arranged with Mr Dunkley that she should be sent to tho hospital, and she arrived about 11.30 that morning from tho Children’s Rest Home. Ho saw the patient; she did not impress him a© being mentally affected at all. With regard, to the patient’s escape Dr Vivian said that the night porter reported. the matter to him as soon as it was found that she was missing. Witness told the'night porter to notify the police and to ring up tho rest home where she came from, . He also gave instructions to search tho hospital grounds. There were no signs of her. At tho time be did not think it at all necessary for tho patient to have a special nurse. She talked quite rationally all the time. Mr Larnach: “Don’t you think, ■ doctor, it was your duty to advise tho chairman ot the board ?” Dr Vivian: “I reported it to Dr Falconer.” Mr Larnach asked if Dr Falconer reported the matter to the chairman. Dr Falconer said that he did not. In reply to a further question Dr Vivian said he did not notify tho husband as the patient, when admitted, did not wish him to know where she was, and ,did not give his address. Dr C. S. Murray said ho examined tho late Mrs Macdonald at tho outpatients’ department. lie thought she was in a very poor state physically. There was the question of a holiday, and witness considered that tho patient should have a complete rest. There were no mental symptoms at all, but ho considered the patient was run down, and neurotic. .He made a few notes of her condition at tho time. There was suspicion of trouble about the lungs, but no mental, symptoms. Mrs Macdonald asked if he thought the fact that the doctor considered her case tubercular had not depressed the deceased. Dr Murray said “No; she was not aware of what opinion they held.” THE NURSES’ EVIDENCE, Violet Breeze said that she was the sister in charge on the morning of June 5. She last saw tho deceased just before 7 o’clock on the evening of the 4th. She noticed that the deceased was occasionally depressed. She ©aid that she hod a nervous breakdown, and was rather worried about her child. She appeared to bo quite all right mentally. She had a good appetite, and was one of their nest patients. ’ They were asked if deceased had shown any mental symptom®, but they had seen none at all. Nurse Cameron had told her that Dr Fitehett had tallied over tho case with her (Nurse Oameron), and that ho had said “ Oh, well, we can just wateh her.” Deceased hod slippers and stockings, Jvut bad apparently gone out with bare foot. Witness did not know anything about tho ulster deceased was ©aid to have on. Ethel Miles said that she was night assistant in tho ward on the evening of January 4 and the morning of January 5. Witness saw the deceased, a little after midnight. As soon as the deceased was missed it was reported to her, and she reported it to the night porter. Deceased had told Nurse Cameron that she (deceased) was a light sleeper, and that she did not like to be disturbed. At no time had tho deceased given any indication that she required watching. It -was tho usual thing for a nurso to let a patient sleep as long as she could. The deceased had fold Nurso Oameron that she (witness) had disturbed her in her sleep on, on'* occasion. May Cameron, nurse, ©aid that 1 she was

in charge of Houghton Ward on the night of the fourth and the morning of the 6th of January'. Witness saw the patient last about midnight. She did not {See her again. She was not absent from the Houghton Word all that time—witnesb was in- and , about the ward constantly. The 'door of Mrs Macdonald's room was just opposite where witness was. If deceased wanted witness she had just to coil. The previous night the deceased hod said that she and another sister had awakened her and that she did not then sleep too well, Deceased was a good sleeper, and it was partly because the deceased had not desired to be disturbed that she had not visited her. It was left to the nurses’ own discretion as to when they visited a. patient. To, Mrs' Macdonald.—She thought it quite unnecessary to go into the room—she was ao close to the patient’s door, Ihe deceased might have slipped out while witness was in the ward. They were longer than usual in going to the deoeased’e bed* that morning as they desired to give her a better sleep. Deceased disappeared some time between midnight and 10 past - five. When they went into the room the bed was empty and the window was open. She could not say whether the deceased had gone out of the window. The window was closed at midnight, but it was open in the morning—that was the bottom part of the window. The windows were always kept dosed at the bottom. Clarice Simpson, relief sister in the Houghton Word in the early morning of January 6, did not see Mrs Macdonald at all. Witness was in Houghton, Word 1 at 20 past three. Nurse Cameron was there ail the time. Margaret Myles, matron of the hospital, said that she had seen Mrs Macdonald every day. No special instructions were given to (lie. nurses as regards Mrs / Macdonald. Mrs Macdonald did not 1 wikH 'to be disturbed at night and she had shown no signs ,of beihg mental. Nurses were given to understand that they had to keep a .general watch over the ward. They were not short handed. -Witness considered that Nurse Cameron was a dai-eful nurse. She did not think that it was out of the ordinary that visita had not been paid to the .patient, seeing, that she had shown no eigns of, being mental and had also desired not to, bo disturbed. , The • Chairman said that he • had been given to understand that the hospital had rung up the police and that the police had rung up Mr Macdonald. Mr Dove said that the board.could not ring up Mr Macdonald, because they did not know anything about Mr Macdonald.’ Mr.Larnach said that, the board did not know anything about it until they saw; it in the papers. “Those things, have got to Qpase,” ..said Mr Larnach, “or I dm’ going £9 make a little disturbance.’’ ‘ AN INTERLUDE. Mrs Macfie said that Mr Macdonald (the husband of the deceased patient), was present, and would like to be allowed to ask a few questions. , The Chairman said that was a matter for members to decide. He had his own opinion' on the fcoint.' '/ Mr Dove expressed; the view that, as thd board ' was seeking the fullest information Mr Macdonald’s questions should be wet. corned. "'.'V _ Mr • Larnach considered it would only, be right to allow the’ questions. Mr Macdonald was an interested party., and in justice to itso'f and to the public, in order to relieve the-miblio mind of' any doubts, the board should allow Mr Macdonald to ask questions. The Chairman intimated that the evidence of Dr Falconer would be taken first! EVIDENCE BY DR FALCONER. - I . , Dr Falconer said, that when , he was formed of the disappearance; of . the patient he ascertained that the assistant, medical officer, had notified the friends who had sent the case in, and also notified the police. He had to attend the conference -with the Hon. W. Downio Stewart that morning. It was his intention to inform the chairman, but he did not have any groat opportunity of doing so. He recognised that the chairman should have been advised. The next day he was called out of town through-ill-ness in. his own family, and the matter slipped his memory. He ' confirmed, the action taken by the assistant medical officer. He did not think there was anything to add, tq his report, everything, was in it. . Mrs Jackton asked if it was npt customary for ,tho police to notify the press pf such matters. The Chairman said he was not in a position to say. Mrs Macdonald, pointed; out that it was usual for tho press to ring up the hospital porter in regard to hospital, matters. The hour of the occurrence was such that inquiries would probably not have been made of the night porter, and *ho probably did not think of mentioning tit, to the day porter.. : ■ , - Mr Larnachlf : there is anything to report in connection -with the Hospital I reckon that it ought to come from the Hospital authorities.” _ • Dr Nowlands asked the medical superintendent his idea as to what publicity should be given, regarding occurrences in the Hospital. Ihe matter of deciding when information. should be given and. when withheld offered greater difficulty than perhaps, Mr Larnach considered. -i , Mr Larnach said that the true information .should be given in every case. Dr Falconer said he thought that no information should’ bo given to the press that any patient or any friends of tho patient objected to. He; considered that his patients had os much. right to be considered private patients a« any patients in a private hospital. It stood to reason that Mrs Macdonald’s disappearance should have been ,reported to the press. Ho had not considered it necessary, as ’ the police and the relatives. were notified. ,Ho had made a mistake. Had he known that the police had riot notified the press lie would have made a point of seeing the police. Unfor-tunately—-he did not want this to be taken as an excuse—he went but of town and did not road the paper, or, at any rate, not closely. He was 1 surprised to find that the police had not notified tho press. Had be been in town he would have made. a point of seeing the police. , 1 MR MACDONALD’S EVIDENCE. William MacDonald, husband of Catherine Susan Macdonald, was .given permission to make a personal explanation.' He made a number of statements regarding his domestic relations, and was interrupted by Mr Dove, who desired to know’vrtiat these statements had to do with tho case. Mr Macdonald would be permitted to ask any relevant questions. Mr Macdonald, however, went on to/ make a number of more or less irreJoyant,' statements. EVIDENCE CONCLUDED. The Chairman said that this concluded tho taking of evidence. The hour was late (10.15 p.m.), and ho thought it would be better to refer the matter to the Hospital Committee, which consisted of all the members of the board, for a report. Tho report would oome before tho next Ordinary meeting of the board. Mrs Jacksonsaid that she thought tho boar*) should express its sympathy with Mr Macdonald. Mr Larnach agreed that it must have been very distressing to Mr Macdbnald.