THE CASE OF THOMAS KIRK.

Otago Witness, Issue 3672, 29 July 1924, Page 5

THE CASE OF THOMAS KIRK.

AX INQUIRY TO BE HELD. Several matters connected with the aafortunate death of Thomas Pettit Kirk came before the Otago Hospital Board at its meeting on Thursday. The meeting was presided over by Mr W. E. S. Knight. Dr Falconer, medical superintendent, wrote forwarding a report by the radiolpgist in regard to the recent breakdown in the X-ray department, and recommended the approval of a suggestion by Dr Anderson that a stand-by X-ray plant be provided at an estimated cost of £340. The writer reported that the under-pinning for the large X-ray plant was unsatisfactory, and should be immediately replaced by concrete pillars on a concrete base. The following is the report by the radiologist (Ur Anderson): — With regard to the therapeutic apparatus, the breakdown in this case was caused by a broken resistance wire in the Collidge heating circuit dropping in the frame of the resistance, and thence allowing a leak to earth through the retaining screen. This screen came in close contact with a nail holding up the lead lining of the treatment cubicle, and we were most fortunate that a fire did not result, as the wood of the cubicle roof was actually charred around the screen The leak was sufficient to fuse the end of the screen. With respect to the diagnostic set, Newton and Wright, this apparatus failed in the middle of an examination towards the end of the morning’s work on Monday, July 7. Mr Butterfield was unable _to locate the fault, and the hospital electrical staff also failed to relieve the position. On Wednesday the apparatus was dismantled, and the Collidge heating transformer and the main transformer were taken to Messrs Turnbull and Jones for thorough testing and investigation. As a result of this it was discovered that the current from the small Collidge transformer was leaking directly to earth as a result of a fault in the insulation, and probably as a result of this several leaks had taken place to earth from me big transformer. I have been assured by Messrs Turnbull and Jones that the big transformer is all right and that the little transformer is completely repaired, but the fact remains that the big transformer has failed, momentarily, it is true, and is consequently liable to fail again at any time in the future. A contingency which it will be impossible to guard against. There can be little or no doubt but that the trouble can be traced to the vibrating floor, which has thrown an undue strain on all parts of the apparatus. The plant has been in operation for some four years, during which it has given satisfaction, despite adverse conditions, but during that period it has been subject to strains that the manufacturers had no intention of allowing for, and the wonder is that the plant has functioned so satisfactorily until the present. The point that has been raised by this unfortunate occurrence is that fact that ir« the event of a breakdown it is impossible to carry on the department. Had the more serious fault developed in the main transformer we should probably have been unable to carry on any work until the apparatus had been replaced, which would have meant a wait of at least three months. Of course, a hospital can get along without an X-ray department in a sort of a way, but it means a considerable dislocation in the routine of the hospital with subsequent depreciation in the eyes of the public, a contingency which is strenuously to be avoided. In view of past occurrences and the fact that these will quite probably occur again, it is my duty to recommend to the Otago Hospital Board that some provision should be made for a stand-by X-ray plant at the Dunedin Hospital in case of further breakdowns which are liable to be even more serious than the last. Since it has been repaired the plant does not appear to be running very satisfactorily. There has been far too much fluctuation in the output of radiation from the tubes, so much so that it is exceedingly difficult to do screening work satisfactorily. The trouble appears to be located in the small Collidge transformer, and though it may settle down eventually, actually the trouble appears to be becoming worse each day, and, I am afraid, is the prelude to a further breakdown. Messrs Mason and Wales wrote that they had suggested to Dr Anderson the advisability of removing the large X-ray machine to the basement and set it on a concrete foundation. The nature of the ground was such that unless tne concrete foundation was taken down to a solid bottom the whole of the vibration would not be eliminated. It was not possible to say how deep it would be necessary to o-o; probably from 12ft to 14ft. The removal of the machine to the basement would mean an alteration to the position of the several fittings, and the writers had requested the board’s engineer to obtain the cost of this work from Messrs Turnbull and Jones, and also the time it would be necessary to close down the X-ray plant. Mr Dove said this was a matter of great importance. No fault had been found before, and there must be someth ini- radically wrong when they heard that they would have to lay down a duplicate plant. He was opposed to that, and thought the difficulty could be got over. Instead of removing the plant and having to dislocate the whole concern thev could put in standards and out out the floor where the machine was situated. Mr Wales had said that if they cut the floor away they might get over the difficulty. He had it on good authority that the suggestion would work out all right, without going to unnecessary expense. They could get telegraph poles and sink them in. If they put in that foundation they would get rid of vibration. The Chairman: You are still carrying on with that plant? Dr Falconer: Yes. Mr Dove then moved that the matter he referred to the Finance Committee, the architect, and engineer to report to the chairman of the board as to the elimination of vibration, and the chairman to act up to the cutting out of the vibration. The motion was agreed to. The following communication was received from Dr Falconer:—l beg to draw the attention of the Hospital Board to the remarks of the coroner in the inquest on Thomas Pettit Kirk, who was an inmate €>{ this Hospital from July 10 to 12, 1924, and who died on July 16, 1924. The coroner stated “that the circumstances of the discharge of this patient was, to say the !east, casual.’' With regard to th 0 standing «rders concerning the discharge of patients,

standing order No. 11 for house surgeons is as follows : The house surgeons shall initial the charts for a patient’s discharge from Hospital only after having the approval of the honorary medical attendant. All cases must be seen on the day of discharge by the house surgeon. The A.M.O. will also initial the charts before the discharge of patients. Tho A.M.O. will visit all patients for discharge who have not on the day been visited b” the honorary medical officer. Standing order No. 12 for sisters in charge of wards is as follows: On the discharge of any patient, old, infirm, or in weak health, the sister will satisfy herself that suitable arrangements are made by tho friends for the patient’s removal from Hospital, otherwise she will notify the medical superintendent or the house surgeon on duty. These regulations have always appeared to be sufficiently detailed to meet the position.” Robert Jamieson, hall porter, forwarded the following statement: —“Dr Champtaloup told me in the morning about 9 a.m. that Kirk was being discharged. A few minutes later a boy came to the door of the Hospital inquiring to get Mr Kirk’s boots. He was then told that the patient was being discharged, and to ask Mrs Kirk to send in his clothes. Mrs Kirk came to the Hospital about 10.30 to ask if it was correct, and I told her it was so, and to get clothes. She arrived back about 11 a.m. with clothes, and went to tho ward With them. As to the statement in regard to ‘getting a wriggle on,’ the word was not used hy me. It is a statement I never use. I have asked the porters who were in duty at the time if they used the expression, and they say no. The patient was not at the door by 11.45, at which time I go for dinner, and I believe he left the Hospital at 3 minutes to 12 (noon).”

The statement by Sister M. Hunter, in charge of Plunket Ward, was as follows : “I remember Mrs Kirk coming to Plunket Ward. She seemed surprised that her husband would be going out, and I told her it was unnecessary for a patient to remain tn hospital if he could be treated as an outpatient. I certainly said nothing to justify any impression that we desired to get rid of the patient. He was quite a nice patient. When Mrs Kirk brought the patient’s clothes I directed Nurse Sutherland to take the clothes to the patient’s bed. In a few minutes I went up the ward and asked Nurse Denford to assist the man in dressing. The screens were round the bed, which was in the centre of the ward. I saw him stand up on his good leg and try to pick up his boot. I then went up and asked him to sit down, and assisted Nurse Denford to put his boot on. Mrs Kirk was in the corridor. Slhe would probablv have seen her husband stand up, but would not be able to see Nurse Denford and myself putting the boot on. While the patient was being dressed I sent Nurse Sutherland with Mrs Kirk to the office to arrange the discharge. Both Mrs Kirk and the patient informed me that he lived only a short distance from the Hospital, and Mrs Kirk asked if a conveyance would be necessary. I did not instruct her not to get a conveyance. I told her to see how he felt when he got to the front door. Nurse Sutherland took him to the front hall. The time would be nearly 12_o’co!ck. I considered it would not he against the medical officer’s treatment of the case to allow the patient to walk a short distance home if he felt quite able to do so.” Dr Champtaloup wrote : —“On admitting the patient I informed him definitely that it would not be necessary to retain him in hospital for more than a few days. On my visit to the ward on the Friday morning Mr Kirk greeted me with the remark: ‘Well, doctor, I live quite close to the hospital, and there is no need for me to remain in hospital if I can he treated as. an outpatient.’ I replied: ‘Well, Kirk, you pan go out as soon as yo-u have your crutches and can use them, and if you can be looked after outside and attend the hospital as an outpatient.’ I explained that there might be some delay in obtaining the crutches. He said he could pay for the crutches immediately if that would facilitate his going out. I considered that from my previous consultation with Dr Fergus he would permit me to discharge the patient without further consultation. I visited the ward early on the Saturday morning—about 8.30 a.m. From 9 a.m. to 1 p.m. I was busy in the operating theatre.” ,

Mr Scurr, prior to the reading of the documents, moved—‘That the board go into committee,” to which proposal several members objected, stating it was a publio rqatter. The Chairman : We have nothing to hide. Mr Seurr: But there may be further developments. Mr Quelch expressed the opinion that the board should hold an inquiry into the matter.

The Chairman: Well, we can read the correspondence. The first letter (from Dr Falconer) was referred to the Hospital Committee, and the remaining correspondence was read. The Chairman: These communications seem to be from those in charge of the patient. Mr Hancock: In the meantime I don’t know what more we can do. The reports have been handed to the press. Mr Quelch said he would move —“That the board inquire into the matter.” Mr Dove said he was agreeable to that, but he wanted to ask a question. Was it correct that the X-ray was out of order for four days, and was it impossible to take a photograph of the man’s leg? Dr Falconer replied in <*the affirmative. The X-ray plant was out of order, as stated in the reports. Mr Dove: What about the standby plant? Dr Falconer: There is no standby plant. Continuing, he said that Mr Dove probably meant the treatment set, which had been turned into a diagnostic set. Mr Dove : Yes Dr Falconer said he did not know that it could be used. Mr Dove: The other man used it, and it was in the position of the present set. Mr Morgan: Could it not be shifted? Mr Dove: It would only be a matter of two or three hours. Dr f alconer said he would get a report on the subject from the radiologist. Mr Quelch pointed out that the board had sent a letter some time ago to the superintendent notifying what might he done m future as to discharging patients. He would like to see how far that letter had oeen given effect to. One of the most important matters was the discharge of a patient by a senior officer.

Mr Hancock then moved —“That an inquiry be held by the board.” —This was agreed to, and the inquiry was held last evening.