THOMAS KIRK CASE

Otago Witness, Issue 3673, 5 August 1924, Page 22

THOMAS KIRK CASE

HOSPITAL HOARD INQUIRY. A COLOURLESS FINDING. The death of Thomas Pettit Kirk, who was an inmate of the Dunedin Hospital from July 10 to 12, and who died at his own home on July 16, was afterwards the subject of an inquest at which the Coroner made pointed comment on the casual manner in which the deceased had been discharged from the Hospital. The matter came up for discussion at last meetiug of the board, when reports w T ere reeceived from the hospital’s radiologist (Dr Anderson), from the board’s architects (Messrs Mason and Wales), and from the medical superintendent (Dr Falconer), and others concerned. Various matterjj were raised in discussion by members of the board, and eventually it was decided, on the motion of Mr J. H. Hancock, to hold a speoial inquiry last evening. The meeting of the board on the 28th ult. was attended by Mr W. E. S. Knight (chairman). Mesdames M. Jackson, J. K. Maefie, Marshall Macdonald, Messrs J. W. Sou it, J H. Hancock, A. F. Queleh, J. W. Dove, W. B. Morgan, and Dr Newlands. The Chairman at the outset explained tile object of the inquiry. It was the desire of the board that every patient admitted for treatment in any of the board’s institutions should be treated in a kind and considerable manner. It was also expected of the staff that every patient admitted should be treated with every kindness and consideration. That was what they were out after, and if anything happened to the contrary the board itself should not be blamed; but when these matters against the interests of the board or any of the patients came to the knowledge of the board it was its duty to inquire into what bad happened and deal in an impartial way, even if it had perhaps a very severe bearing on any medical officer or any member of the staff. They hoped that night that they would deal in an impartial way in considering the evidence that would be given. It was to be sincerely hoped that the evidence to be given would clear the minds of the public to a very great extent. It seemed to him that it was somewhat unfortunate that an adjournment of the inquest had not been asked for, so that the coroner then would have had the whole of the evidence before him. As they knew, some of their staff were involved, and it would have beer, much tetter if the inquest had been adjourned so as to give an opportunity for those concerned to appear before the coroner and give evidence tneie. Nevertheless that opportunity had not been given, and the board deenietl it its duty to held this inquiry. In answer to the chairman, Mrs Kirk said she had no witnesses, and that she was not represented. , , ]p r r p Fergus, a member of the honorary staff Dunedin Hospital, said he was at the rfospital when deceased was admitted, and saw him shortly after, having assisted in the dressing of the fracture. He supervised the application of the splints. In his opinion the treatment of deceased was quite satisfactory. Witness saw deceased the following day, and he was comfortable and progressing satisfactorily. The Chairman: Did you give explicit instructions that the patient was to be discharged on the Saturday? Dr Fergus; No, sir. There was an understanding that deceased could be discharged when he was able to leave his bed and use the crutches satisfactorily When he heard of the patient’s discharge he thought that under the circumstances it was reasonable to let him go. The Chairman: Is this an isolated case where a patient had been admitted for a fracture and bad been discharged after so short a time? Witness: I could not say without eonsalting the records, although such patients are not retained for long periods. Tile Chairman said he understood that in london hospitals such cases were treated at the “door,’’ and were not admitted. Witness said that as far as he know that was the procedure at some London hospita. i. M s Jackson: Have you any idea when the patient was admitted? Witness: Some time in the morning. Mrs Jackson: When was he operated npor, ? Witness: About 4 p.m. Mrs Jackson: Don’t you think that was fc long time?

Witness said it was not under the circumstances and explained that in eases of fracture there was a great deal of swelling ■' hnt had to diminish, and it was sometimes several hours before an operation could be performed. To Mr Queleh, witness said he did not see the patient on the Saturday morning. To Mr Dove, witness said he could not say definitely whether he discussed the matter with Dr Champtaloup. The cases were of a routine nature, and had to be attended to. Mr JSeurr: Did you give explicit instructions to discharge the patient on the Saturday? W’itness: No. Mr Seurr: Did you say something to the house surgeon which would lead her to infer that deceased could be discharged? Witness: I have rather a difficulty in answering that question, as I have a large number of patients, and I cannot remember all I said. I may have made such a remark, but cannot say definitely. Mrs MacDonald: When you told the house surgeon deceased could be discharged I suppose you meant that to apply when he could use the crutches? Witness: Patients vary in their adaptability to use crutches. The Chairman then asked Mrs Kirk if she had any questions to ask. She wanted to know whai Mr Jamieson said to her when she came out of the office. The Chairman said that question would be answered at a later stage. Mrs Kirk then asked Dr Fergus if her husband were given any practice in the use of the crutches when he left his bed. Witness said he did not see deceased on ip, Saturday, and would not like to say. Robert Jamieson, hall porter at the Hospital, was the next -witness called. The written statement by him already published was read over anil also a report of the evidence given at the inquest by Mrs Kirk. Witness told the chairman he had nothing to odd co his written statement. Ho did not remember speaking to Mrs Kirk more than told Mrs Kirk to “get a wriggle on.” No matter who it was. everyone he dealt with at the Hospital got civility. He did not remember saying anything about hurrying up. Mrs Kirk repeated her statement that witness had told her to go back and tell her husband to “get a wriggle on.” Witness absolutely denied this. Mrs Kirlc: It is no use you standing there telling lies, because you know it is true. Mr Chairman, when I came back from the ward he said, “Has your husband arrived yet?” and when I said “No,” he saut. “Go back to the ward and tell him to get a wriggle on.” The Chairman said it seemed a deadlock as far as this point wa s concerned. It was just one word against another! It did not seem to be possible to elucidate it any further. Witness said the chairman could ask the other porters if they had over heard him use such an expression. He said M.'Kinlay was there at the time, and would have heard it. Mrs Kirk: Excuse me. You were alone at the tune. To Mr Morgan: Nothing had been said to him about a conveyance. They were there to do anything a patient asked and to ring for a conveyance if requested. To me Chairman : He was not there when Mr and Mrs Kirk left. Mr MTCinlay would be in charge of the door then. W’. M’Kinlay said he had relieved the previous witness at a-quarter to 12. Miami Mrs Kirk left at five minutes to 12 Witness remarked to the patient that they had fixed him jup pretty quick. He ought he might just be going to test the crutches for a little. Mrs Kirk said she did not see anyone at the door except the girl at the telephone. There was no one else there , Witness said that Mr Kirk replied to nim that he was being discharged that day and was to attend as- an out-patient later cn. Nothing was said about a conveyance Witness said to Mr Kirk that he could Mrs Kirk, in reply to Mrs Jackson, said she was sure no one spoke to her husband going out. There was no one at the door. lo tne chairman witness said that no nurse came through the door with Mr and Mrs Kirk. He did not see a nurse there at all. Mr s Kirk said that no nurse helped her husband. He came down the ward from tne screen by himself, and she alone took him to the front door. No nurse left the ward with him. Mrs Macdonald asked at which of the two doors the last witness was. Witness

said he was by the little table between ihe two doors. E. King, porter, said he did not know anything about the case. lie had been assisting the previous witness from 12 to 1, but he was not on the door till 12 and saw nothing of Mr and Mrs Kirk, tfrre ** €as J —there was plenty of Miss I •..Mi I.evland, patients’ inquiry officer, sum she had noticed Mr and Mrs Kirk- pass through the outer door about fu-e minutes to 12. Mr Kirk was on crutches, and his wife was with him. She dl m n °-, t r sse the witness M’Kinlay. q„4? Mr Dove: She did not see Nurse i uinerland, but she was looking straight ahead ana Nurse Sutherland might easily have been there. Sister Hunter had her written statement lead o\er to her. She said she did net ?? ve T^ n y thin g‘ *° ftdrj to the statement, -rr Kirk stooped down to get his boot, ra. atle an attempt to put it on. She told him to sit down, and Nurse Denford and she came and put his boot on for him. rnu° Dcnford lad dressed him. Ihe Chairman asked what had been said about a conveyance. Mrs Macdonald (rising hurriedly): I do not think that is a fair question to put to the Sister. That is a. point that should be decided by the medical officer. The Chairman said he thought it was a perfectly fair question They wanted to get exactly what happened in the ward standing order 12 directed that the Sister must satisfy herself that suitable arrangements were made by the friends for a patient’s removal, otherwise she would notify the medical superintendent. Mro Macdonald: I think you are placing too much responsibility on the Sister by that regulation. The Sister should not have to decide such an important point. The Chairman said he was endeavouring to find out exactly what happened in regard to the conveyance. It was quite a simple question, and could be simply answered. Continuing, witness said Mr Kirk told her he lived just straight down from the Hospital in Castle street. She told him to seo how ho felt when he got to the door. Mrs Kirk said witness stated she had assisted her husband to lace up his boot. It was an elastic-side slipper with no laces that .ihe took her husband. The Sister was talking to her at the door while her husband was hopping round trying to get on his boot. The witness said she just remembered asking the patient to sit down and she assisted him. Mrs Kirk said she did net see Nurse Denford at all. Her husband was hopping about outside the screen trying to put the shoe on with the aid of crutches. She did not see hew he eventually got it on. Witness denied that Mr Kirk was hopping about the ward floor. To Mr Seurr : She was quite certain that Nurse Sutherland took Mr Kirk down to the hall. Mrs Kirk: No one gave me assistance down the corridor, nor yet along to the front door. My husband came right down there himself. Nurse Denford said she assisted Sister Hunter in putting on deceased’s boots She was told by Sister Hunter to dress the patient, and she found that some of his clothing was missing. She left the room and told the sister about the missing garments, and when she returned the patient was sitting on the edge of his bed endeavouring to put his boot on. To the Chairman: It was a lace-up boot. To Mr Queleh: I w’as in tile ward when Mr ami Mrs Kirk left it. To Mr Dove witness said there had been a screen round the bed at the time the patient was being dressed. He was not hobbling about the floor. The Chairman: Was it on your invitation that deceased endeavoured to put on his boot? Witness: No. Mrs Kirk: Is it quite true that Mr Kirk had on a boot? Witness: Yes, and I put on a lace-up boot. Mrs Kirk: No, nurse, you did not; it v.-as a shoo. Mrs Macdonald: Did you dress him in the clothes lie was wearing when he was admitted? Witness: I did not seo him admitted. Mr Morgan: How- long did it take to dress him ? Witness: About 10 minutes. Mrs Kirk, in reply to Mr Morgan, said she was not present in the ward all the time occupied in dressing her husband. Nurse Sutherland said Sister Hunter instructed her to take the patient to the front door. She escorted him along the corridor leading from the ward, and left him in the quadrangle where the seats were She did not notice anyone standing near the main door at ihe time. The Chairman. When deceased was using the crutches did he get along all right? Witness: I thought he w’as getting along quite well. The Chairman: Did you have any conversation with deceased or his wife when walking along the corridor? Witness said she spoke to Mrs Kirk when she (witness) was taking her to the office to see about the paper for her husband’s discharge. Mrs Kirk then asked her why her husband was being discharged so soon. Witness had replied that he would not have been discharged unless the medical superintendent had said so. As far as witness could say, Mrs Kirk said nothing to her regarding the walk home. Mrs Kirk: Aie you quite sure you came down the ward with Mr Kirk and myself? Witness: No, but I came down the corridor with you both. Mrs Kirk: It’s no use telling lies, nurse, because you did not do that. To the Chairman witn .s said she was practically level with deceased as they were walk-inn- along the corridor. To Dr Newlands: She went hack to the ward after leaving Mr and Mrs Kirk in the quadrangle. . . To Mr Sou it : She had no conversation of any importance with them during that Dove: Did you notice what kind of boots deceased was wearing? Witness: No, sir. To the Chairman: I was not present in the ward when Sister Hunter and Nurse Denford were dressing deceased. Mrs Kirk persisted that witness did not walk down the corridor with her husband. The Chairman said that was another difficult question the board had to decide. Mrs Kirk had said the nurse did not accompany her husband and herself down the corridor, while Nurse Denford said definitely that she did. Dr Champtaloup said she assisted m reducing the fracture when deceased was admitted on the TL.rsday. After receiving attention deceased seemed quite well, and

such was the case until he was discharged on the Saturday. With regard to the question of the discharge of the patient, w.tness said that from a conversation she had with Dr Fergus she had gained the general impression that she was at liberty to discharge the patient as the fracture belonged to a class which did not require special treatment. She could not remember all the details of the conversation, but that w’as tne impression she got. The Chairman: Do you understand the provisions of rule II regarding the discharge of patients? Witness : Yes; I have read the rules. The Chairman : It seems to us that you did not actually receive explicit instructions from the honorary surgeon, but wo gather from your conversation with him that he approved cf the discharge. Witness: He would have approved of it. From the conditions I thought the patient could be discharged without the possibility cf trouble arising. Mr Dove: Wbaf time was it when youlast saw the patient cn the morning of his discharge? Witness; I saw him between 8.30 a.m. and 9 a.nr. After that I was in the operating theatre until 1 p.m.. Witness could not remember whether she looked at the splints. Deceased did not complain to her. She told him he was to be discharged, Kit she could not remember the conversation on the matter. She had told him the day before that he could leave the hospital when he could use his crutches. At that lime she did not know ho would get them on tn e Saturday. Deceased had seemed cmite satisfied with the arrangement, and said he lived near the hosnital and could be an out-patient. Mr Dove : Do you know of a similar case where the patient has been discharged so soon I Witness: Yes, we had a case of a fracture which was discharged in less than two davs. Mr Dove: In rule 11 it says that the assistant medical officer will visit all pat ents. Did the assistant medical officer visit deceased on the Saturday? Witness: As far as I know he didn’t Mr Dove: Don’t you know it is the duty of the house surgeon to tell the assistant medical officer? Witness said she had given instructions that the patient was to be discharged when fte got his crutches. She gave the order for the crutches on the Friday. When she saw the patient on the Saturday morning they had not arrived, and she went to the operating theatre and did not know when he left. The Chairman: Did any conversation take place between deceased and yourself whether ho could get to his home without a con veyanco ? Witness: No, but had I known the crutches were to arrive so soon, I would have considered whether he should have walked home. It usually took a week for crutches to come to hand. To Mr Hancock, witness said she had about half-a-dozen patients under her charge. Mr Seurr: If you had known the patient had the crutches on Saturday morning would you have permitted him to go? Witness: Yes. To Mr Dove witness said she did not sign deceased’s discharge papers because she had been in the theatre. Mr Dove: Then he left without having his papers signed? At this stage the chairman produced the papers in question, and said they had been signed by Drs Falconer, Perry, and Champtaloup. To the chairman, witness said she could not say when she signed them. It might have been on the Saturday. Mr Dove: Then you must have told Sister Hunter the man could be discharged? Witness: Yes, certainly I did. Dr Falconer stated that in this case the sister had received instructions from Dr Champtaloup, and knowing she was in the theatre, and anticipating that she would get her signature afterwards, she allowed the patient to leave. That was not according to the rules laid down, but it could be understood that this occasionally occurred. Dr A. Perry, assistant medical officer, said he did not see Mr Kirk when ho w-as admitted or at any time after. He was notified of the case on the night of Mr Kirk’s admission. He might have seen the case, but he did not definitely remember it. The Chairman: What would that mean ? Dr Perry said that if the house surgeon was in doubt at all about a case he would notify W’itness, and he, if he thought fit. would notify the hen. medical officer. If he were not called to the case it would mean the house surgeon was not in any difficulty. He did not see the patient before discharge because he had not been notified for reasons explained by DrChamptaloup. He had know’ll of other eases of simple fractures discharged within 48 hours of admission, and- no complications had followed. He could not remember any definite case of such a patient being discharged on crutches, but if the natient’s home was very close he himself would have given instructions for the patient to be discharged on crutches. Seeing Mr Kirk lived 300 or 400 vards away he thought it would have been better to get a conveyance, but there was evidently some misunderstanding about the distance. If he had been instructed that the patient lived “just round the corner” he would have sanctioned the discharge. To Mr Hancock: A telephone message would have brought the ambulance. Mr Seurr asked if the cause of death in this case was a common one. and if the death would have occui-red if Mr Kirk hail been kept in hospital. Dr Perry: If you want my personal opinion the fact that the man walked home with crutches had nothing at all to do with his death. Mrs Kirk said she told the sister that Mr Kirk lived in Castle street. It was along in King street that Mr Kirk said he was feeling tired. Between Cumberland and Castle streets he seemed very faint and in danger of foiling, and she had *to get the assistance of _ a passer-by. He had no strap to assist him. and was striking his toes as he went along. In answer to Dr Falconer. Mrs Kirk denied that the sister had told her to sea at the Hospital door how her husband felt. Dr Fergus said it was thought inadvisable to put a strap round the foot in the earlv stages of a fracture. It tended to reproduce the displacement. The Chairman said Dr Falconer was willing to answer any questions members of the board would care to put. Mr Dove: About the X-ray plant? Mrs Macdonald: It is a smoke screen. Leave it alone! Mr Dove: Is it a smoke screen? Mr Morgan asked who had the right to say whether a patient was to have a conveyance or not? Dr Falconer: The doctor. Mr Morgan: Which doctor?

Dr Falconer: Tbe house surgeon in charge of the case would know whether a conveyance was required or not, and would tell the sister. A case that was entitled to walk would be presumed to be a walking case. If there were any doubt the sister would consult the house surgeon. The massage department was practically halfway between Blanket \\ ard and the patient’s home. Mrs Macdonald asked whether the last rule framed about the discharge of patients after another little episode had been carried out in this case. Dr Falconer said he knew of no rule about the discharge of patients Mrs Macdonald said the b-oard had diseased the haphazard way in which patients were sent out after the Mosgiel incident, and it had asked that some responsible officer should see every patient before discharge. Dr Falconer: I have received no letter Mr Dove: But you were present! Dr Falconer: Let me finish. Dr Falconer went on to say that instructions were given that the house surgeon had to see the patient on the day of dischai-ge. Afterwards it was ruled that a patient could not be discharged by a house surgeon until seen by the assistant medical officer, but that did not apply in this case, because the man had been seen by the honorary staff. Ho himself had framed a rule that every patient had to be seen before discharge by tho medical superintendent or the assistant medical officer. Mi- Dove said Dr Falconer had only been doing his duty when he framed such a rule. Dr Falconer read the various rules that had been framed bearing on the question of discharge. Mrs Maefie said it appeared that tho Hospital was run on standing order linos, not on humanitarian lines. Mr Dove asked if he would be allowed to discuss the matter of the X-rav plant with Dr Falconer later. —The Chairman said he could do so. Dr Fergus, in reply to Mr Seurr. said that an X-ray examination in this case would have made no difference. Had tho man remained in the Hospital he did not think it would have made any difference in regard to his death. He might have died from tbe same trouble in the Hospital. Mrs Smith, on behalf of Mrs Kirk, said it was an elastic side shoe that. Mrs Kirk took over to her husband. The boots first taken were too heavy and were sent hack home 10 Dr Newlands: It was elastic side shoes he wore on his way home. Tho Chairman said that concluded the inquiry. It would be necessary for the board to go into the whole matter. Ho thought the best course would be to go into committee. Whether they would have time to come to a finding that evening he did not knoiv. He had to thank" the witnesses for the evidence they had given. In a number of cases it was somewhat contradictory, but members would do their best to unravel it as far as was humanly possible. He assured Mrs Kirk that members if the board sympathised very deeply with her in her trouble. Tho hearing of evidence closed at a quarter to 10, and the board went into committee. At a quarter to 12 the board adopted the following resolution in open board: After making full inquiry into the circumstances of the discharge of the late Thomas Pettit Kirk from the Dunedin Hospital on Saturday, Julv 12, the board finds (1) that in view cf the directly conflicting evidence it is unable to arrive at a definite conclusion as to the various incidents alleged against the members of the hospital staff, and (2) that the regulations laid down for the discharge of patients wero not strictly adhered to in this case in so far as the house surgeon had only an implied instruction from the honorary surgeon. The board will issue instructions for a more rigid compliance w’ith the regulations with the object of avoiding any grounds for possible misunderstanding on the part of patients or their relatives. Mrs Jackson and Mrs Macfiie voted against the motion, and had their dissent recorded.