NAPIER HOSPITAL

Otago Daily Times, Issue 23224, 23 June 1937, Page 6

NAPIER HOSPITAL

COMMISSION OF INQUIRY OUTBREAK OF DISEASE HEAT TREATMENT RISKS MISSING X-RAY FILMS (Per United Press Association) NAPIER. June 22. The Royal Commission inquiring into the affairs of the Napier Hospital sat again this morning to investigate the administration to S. J. Montgomery of a drug known as neohydroil prior to the taking of an X-ray photograph. Recalled, Montgomery said that on several occasions he had complained to the matron about grit in the sago nudding. " On a later occasion I had for room mates some cockroaches," he added. I caught some, as I thought that if I complained I would be told I was delirious. When I went on another occasion to get a drink of water I saw some bread literally covered with cockroaches, and looking like a beehive. Dr* Foley said that the system now adopted in the hospital was to allow only necessary drugs to remain in the ward, proprietary lines having been removed to the dispensaryMr Grant: So if a doctor wanted one of those drugs he would have to sign for it?—Yes.

Have you been able to improve on that scheme? —No. It is considered fool proof. Nurses are familiar with their use.

Dr Foley added that there were many new lines coming out, but the dispenser on these occasions gave full instructions to .the house staff on their use.

Sir James Elliott: Is there not a separate language almost for certain similar proprietary lines?—Yes. Dr Cairney, questioned by Mr Foden, said that he thought it would be a further advantage if a dispenser when issuing a bottle like neohydroil would issue a special label giving the patient's name and the dispensary number, which would correspond on the dispensary book and the patient's treatment sheet. "It seems to me that it might one day happen that a ward nurse may come down with two treatments for patients, and get mixed." he added. Mr Foden: What suggestions can you offer as to who should be in the Xray room? —In a case like this two competent men, one to operate the plant and the other to give the injection necessary. This concluded the section of the inquiry dealing with the injection of a wrong drug prior to an X-ray photograph. REASONS FOR INQUIRY

The events leading up to the holding of the present inquiry were outlined by Mr E. T. Rees, managing secretary of the Hawke's Bay Hospital Board. "The first intimation the board had of the trouble was a letter from a Napier solicitor representing the parents," Mr Rees stated. "On August 31 a complaint was received from the lodge of which the parent was a member. These were passed to the medical superintendent on September 2 for a report, which was placed before the board on September 14. A special committee was set up, and held its first meeting on September 18. Several other meetings followed. The findings of the committee were finally placed before the board at a meeting. Eight people were called as witnesses, and one, Dr J. Allan Berry, did not appear. He gave no excuse for not appearing. The findings of the committee were adopted by the board and sent to the Department of Health." Mr Grant: Did Dr Berry send any HIGSSH£J6? Mr Foden: We do not need to drag Dr Berry in unnecessarily. Mr Mosley: Yes, I think you can leave it at that. Dr Berry may have had good reasons. Mr Lawry: Was any other doctor asked to appear and did not? —No. ARTIFICIAL HEAT TREATMENT Asked to give his general, views on artificial heat, Dr J. R. Boyd said it had been in vogue for a number of years. There were many ways of producing a certain temperature to the body to last over a certain period. The final thing aimed at in all cases was the same. It was to-day an established treatment for certain diseases looked upon as incurable. Mr Foden: In infancy and old age, are they desirable forms of treatment? —No, certainly not. It is recognised that the mechanism regulating the temperature of a child is unstable. Is pyrexia a more risky treatment for a child than for an adult?—Yes. What have you to say about a child being put to bed with a temperature of 108?—It would have to be watched carefully, as should it rise measures must be taken to lower it. As a general rule we can say there are no after effects of this disease on children. Do you consider these trials involved a risk?—All the literature on the subject is teeming with the risks. Has the comfort of the child a bearing on the success of the treatment?— Yes. You cannot safely keep a child in a hot bath of that sort for more than an hour. From your hearing of the evidence, would you say that the proper treatment was not used? Would it be putting it too strongly to say there was a number of defects?—There was a number.

If trials are to be conducted in cases of this kind, what are the requirements for carrying them out?—They should be undertaken in a specially selected institution with expert control .nd supervision. If justification of the interests of medical science is to be sustained records should be kept?—Yes, You no doubt consider that because of the fact that there are five children the experiment had been carried out on the group?—Yes, it was only a small group. What do you consider to be the cause of death?—Hyperpyrexia. Dr Harold Berry said the risk was about 1 in 2000. What do you say about that?—lf there is any risk the treatment should not be undertaken. Dr Allan Berry said that all treatments were risks?—Just an extravagant generalisation to my mind. Mr Foden: America is really the home of the treatment?—lt is the home of the experiment. Mr Bate: You will say that Dr Whyte's and Dr Ruttcr's treatments were correct? —Yes. Any heat treatment applied to children is a severe strain on them, more so if the heat applied is moist?—Yes. it is the restlessness and discomfort which affect them.

Do you think there was a constant rising of temperature in the case of this child?—Yes. What would you say if an experimenter asked for records to ho kept and then never referred 1o them?—T would not look upon hin as a scientist.

"In this cape the nurse- room 1: to havrsat in ignorance by the bedside ami watched the tcmncraturo coins tin." sriid witness in reply to Sir James Elliott. Tin's closed the evidence in this section.

X-RAY FILMS The absence of certain X-ray films from the Public Hospital X-ray department was investigated by the commission. The events leading up to the discovery that films were missinp were outlined by Dr H. F. Bernau. Mr Lawry: You are unable to say how they came to be missing?—No. You are not imputing their theft?— No. Mr Foden: You will agree that the films were missing at a very critical point?

Mr Grant: Am 1 correct in saying that Mr Rells's case was diagnosed almost immediately as sudecs atrophe?— Yes.

You know that Dr Harvey's reports ]on the first films negatived sudecs : atrophegm?—Yes. They were discovered in hospital ! just before the case came on? —I heard so.

Which doctor diagnosed sudecs atrophe?—Dr Allan Berry. Who made the complaint about their loss?—I do not know. What is your opinion about their loss?—I do not know. What is your opinion of the system of caring for films?—Very satisfactory. Have you had experience of any other films being missing?—No. Regalado Rells said that on September 13 lie met with an accident on a ship. Dr Harold Berry was summoned Witness was taken to hospital later. Dr Allan Berry arrived some time after the operation to his hand had "been performed. It caused him pain. He was sent to the hospital for an X-ray, five films being taken. A court case was pending, and it was found that the films were missing, Dr Berry being so informed. The photographs produced in court were the ones taken subsequently by Dr Harvey. Dr Harvey took the X-rays in his room to send home to England?—Yes. Do you think the board is to blame? —Yes Dr Harvey was in charge. Suppose the doctor went in and took the films without anyone knowing. Would you blame the sister and the doctor then? —The door is locked. Mr Lawry: You told Dr Allan Berry after seeing Dr Fitzgerald about it. Was Dr Berry surprised to learn that they were missing?—Yes. Mr Bate: You told Dr Harvey that you were annoyed about having to be X-rayed all the time?—Yes. You were annoyed about having the photographs sent Home to England?— Yes. We have some of the cleverest doctors in the world in New Zealand Mr Mosley: Could you name one? Witness: When I went to Wellington 1 was told by a doctor there that we had one of the cleverest doctors in New Zealand in Napier. lam not a friend of his. but his name is Dr Allan Berry.

MISSING FILMS RETURNED Sister Genet, who was in charge of the X-ray room, said that she had found the films behind the door on the morning when she went to the room. It looked as though they had been pushed under the door. There was a hole in the door through which it was probable someone had put a hand and opened the door with the films. Later another envelope was found under the door containing films of a third patient. All three were the patients of Dr Allan Berry. Who do you think would want access to the rooms? —It would have to be someone interested in the films. Who were the people interested?— Dr Berry and later Dr Fitzgerald, and also the three patients. Could you say who would be the most likely?—No. Was the hole in the door there when you changed the lock?—Yes. Mr Harker: Were there more sets of keys than the one to the new lock?— Two. 1 had them both. Were the films returned after you had changed the lock?—Yes, about six weeks later. Nothing has been missing since you ch/.nged the lock? —No. Dr Foley was not in Napier at the times the films were returned?—No. Mr Mosley: Could the latch be opened if the piece of composition was removed from the door? —Yes. Is it a fact that other films were missing from time to time?—Only those I mentioned. Have you been in the habit of giving doctors films? —For consultation. Are you careful that they are always returned? —Yes. Mr Foden: Films could be missing until you put the new lock on the door without your knowledge?—Yes. I would not notice unless I went for one. SUGGESTION REPUDIATED Strong repudiation of the suggestion that he knew something of the disappearance of the X-ray films was voiced by Dr William Douglas Fitzgerald. He mentioned that when he visited the hospital to see films they could not be found. He had never had occasion to take films away from the hospital. Mr Foden: You were definitely accused of having these films of Rells? Dr Fitzgerald:' I was rung up by the Doctors Berry, but I regarded the matter as " leg-pulling." What was your reply to them'.—l told them to have a look round their own place. To whose interest would it be that the films should not be available?—l do not think it would be to anyone's interest. The whole thing seemed to me to be silly. Dr Frank N. Harvey, radiologist, stated that he had not been a party to the disapoearance of the films. He considered that if Rells's claim for damages was based on the presence of disability and the X-ray films disclosed that there was no such disability, then it would be to his advantage if the films were missing.. To Mr Grant, Dr Harvey stated that he was aware that the Hospital Board was planning to provide more adequate X-ray'accommodation than that available. Wherever films were allowed to leave the hospital trouble was experienced in securing their return. , , Mr Mosley: Do I understand from you that-any doctor in Napier can get films relating to his patients? Dr Harvey: We have had no instructions to the contrary. Have any honoraries removed films from the hospital?—They might have. Dr James Joseph Foley, medical superintendent, referred to the tightening up of the film recording system. Mr Foden: Did you know about the broken piece in the door? —Yes. Suspicious, is it not?—Yes, it might be made use of. Those films would not be of use to anyone but medical men?—That is so. THE MISSING KEYS Mr Grant: Are these films of any value that we should be making such a stir over them? Dr Foley: Yes, they are. To whom are they any worth?—Only members of the medical profession. Dr James Allan Berry gave evidence that he knew nothing about the disappearance of the films, nor had he gained entrance to the X-ray room while no one was about. He had never had the key to the room. Mr Foden: Have you ever removed films from the hospital? Witness: I may have years ago. It would strike you as being a rather rare coincidence that three sets of missing films were all in regard to your patients?—lt looks almost like a conspiracy. "Almost like other conspiracies m connection with the Napier Hospital." Mr Foden observed to witness. Dr Berry said that over the period for which the films were missing he had not seen them. The first time he saw them after they were lost was when they were produced in court. Mr Foden: A committee decided that the matter of the missing films should be placed in the hands of the police? —Yes, that is so. And the films were returned next morning?—l understood so.

Suggesting the presence of fear?—l should say so. The information that the aid of the police had been sought travelled very rapidly to whoever held the films?— Yes. ' I suppose you know nothing about the pieces of broken asbestos near the lock on the X-ray room door?—No. Mr Bate (for the Hawke's Bay Hospital Board): We know that these films were returned in an envelope without any indication of who had taken them?

Dr Berry: Yes. We can assume, therefore, that some kleptomaniac was responsible for the disappearance of the films?—You can assume what you like. I have no explanation to offer either for their disappearance or for their return. The disappearance indicates that some definite action should be taken to ensure that there is not a recurrence? —Yes, certainly. Mr Mosley: Do you know anything about those keys?—No. Was it not rather a coincidence that Ihose films and keys should have been returned at about the same time?— Yes POLICE AID SOUGHT Christian Lassen, chairman of the Hawke's Bay Hospital Board, said that the matter of the missing X-ray films had come to his notice first when men tioned by Dr Berry at a board meeting At the following meeting there was before the board a letter from Mr C. W. Nash, solicitor for Mr Rells, and a sub-committee had been set up to investigate. 'The board decided later to place the matter in the hands of the police, believing that the films must have been stolen. The board also decided upon additional precautions in connection with allowing X-ray films to leave the hospital. . Mr Lassen said that one of these precrutions was that honoraries should sign for films which thev took away. Dr Berry was the only person who objected to this lr.easure. Mr Bate: Plans are under consideration for a new X-ray department?— Yes. And vou will be in possession of an excellent X-ray department very soon? —Yes Mr 'Foden: What did the police report about their investigation?—That our system had broken down owing to the fact that the medical superintendent allowed honoraries to take the films away. Mr Mosley: And you withdraw the matter from the hands of the police?— Yes. Mr Lawry (for Dr J. Allan Berry): After the decision to place the matter in the hands of the police the press got hold of it, did they not?—Yes. I suggest that the press report would let anyone know what action was being taken'?— Yes, but I did not give any statement to the press. Mr Mosley: Oh, they get hold of these things. This concluded the evidence under the fourth item in the order of reference. "That is as far as I can carry the matter," Mr Foden said to Mr Mosley. " The matter was put into the order of reference so that this commission could recommend a water-tight system" "And we are going to do that to the best of our ability and it will be pretty radical. I can tell you." said Mr Mosley. CONDITIONS FOR NURSES Giving evidence of the conditions existing for nurses, Dr Foley said that the nurses were not so well off as elsewhere. They had a seven-day week. There was no 40-hour week. Although the hours were long, the nurses were not worked hard. A serious effort had been made to provide better conditions. Late leave was limited to 11 p.m. for certain girls. Some nurses would not report sick too readily. The matron said that the nurses had two lawn tennis courts, a library, silting room, etc. As soon as ill-health was detected the nurses were sent to bed. They were weighed every two months, and those missing a meal were noted.

Mr Foden: So that if a certain disease were present in a ward the same sister would be nursing her sick companion as well as the diseased children. A nurse's sick bay would be preferable. The matron: If the sickness was of a minor nature the patient was expected to tell her own parents, otherwise witness would write to the nurse's parents. Nurses worked 58 hours one week and 50i hours the next week. There was an" insufficient staff to grant all that the nurses required. Mr Foden requested that if a nurse was called to give evidence there should be no victimisation.

Mr Mosley: You need not be afraid. The commission will safeguard them. Some nurses will be called. Continuing, the matron said that extra accommodation was to bo provided, permitting an increase in the staff and one clear day off a week. The nurses had been encouraged to form clubs, etc., for recreation. One pint of milk a day was allowed for each nurse. Her reports to the board were addressed to the managing-secre-tary. Sir James Elliott: And the medical superintendent ignored?—No; we discuss it, and nothing I send to the board is objected to by him. Some nurses went six weeks with only one day off, but the best was done with the available staff. The mother of a nurse complained that her daughter did not receive proper treatment during an illness. If that were possible, she asked, how would a patient fare?