ACID POISONING.

Star (Christchurch), Volume LXIV, Issue 939, 8 December 1933, Page 4

ACID POISONING.

Cause of Woman’s Death at Kaikoura. HOSPITAL TRAGEDY. A verdict in accordance with the medical evidence, that the cause of death was due to paralysis of the vital brain centre as the result of poisoning with carbolic acid, was returned by the Coroner, Mr James Davidson, at t’he adjourned inquest into the death of Airs Lilian Rhoda James, which was resumed at Kaikoura yesterdav. Mrs James died in the Kaikoura Hospital on October 22, shortly after the administration of an enema. Detective J. Ilalcrow represented the police, while Mr J. W. Anderson appeared for Mr James. Mr W. R. Lascelles appeared for Sister Francis, matron-in-charge at the time of the death, and Mr W. R. Teape for Nurse M’Coombe. The Hospital Board was represented by Mr D. E. Wanklyn. Dr F. J. T. Grigg, Government Analyst for Canterbury and Westland, stated that he had received a box from Dr Pearson containing seven jars. He had examined the contents and drawn up a report showing the result of the analysis. The report was handed in to the Coroner as an exhibit. Dr Grigg’s report stated that six organs had been examined and 643 mil‘igrams of phenol detected in one organ and a total amount of 1405 milligrams in the blood. The quantity of phenol fikelv to cause death by introduction | into the body cavities would be 1000 [to 3000 milligrams, which might be regarded as a fatal dose by the method |if injection used. A bottle was produced. labelled “Poison,” and handed to witness by Detective Ilalcrow. On November 2, 1933, the bottle was in a sealed condition. It contained lloz of phenol liquefaction and also 80.9 per cent phenol by weight. “Phenol” was the technical name for carbolic acid. The reports produced were duly signed and no qxiestions were asked ._

Dr A. B. Pearson, pathologist, in reply to Detective Ilalcrow. stated that on October 23 last he had made a postmortem examination on the body of Mrs James, and his report was submitted in writing to the Coroner. He had removed certain organs, and also a quantity of blood specimens were taken under his personal care, and handed over to Dr Grigg on October 24. They were then in the same condition as when removed from the body. He had heard Dr Grigg’s evidence, and was of opinion that the death of Mrs James was due to carbolic acid poisoning. This opinion was based on his own examination and partly on the. evidence of Dr Grigg. Constable’s Evidence.

Constable W. M’Lennan, of Kaikoura. said that he took possession of the basin used in the case. The matron, Sister Francis, was quite trank when giving him the basin, stating that she had found it in the cupboard when she went to prepare an injection for the patient. He also took possession of the bottle of carbolic from Nurse M’Coombe, who said that she had used

some of the contents for making carbolic solution. Nurse M’Coombe said that she had left some . of the solution in the basin, which she placed in the cupboard, since she had j not finished with it. t To Mr Anderson the constable said |! that, when interviewed. Nurse M’Coombe had only mentioned carbolic solution as having been used in the * basin. She had made no mention of ’ pure carbolic. ' Detective Ilalcrow said that a super- ' ficial examination of the basin had been made by the analyst, but it had not been chemically examined. At the request of Mr Anderson, who said that at the opening of the inquest it had not been made clear as : to what the basin had the Coroner read the evidence of Nurse M’Coombe, who had said that the basin had contained pttre carbolic acid. Nurse Recalled. Nurse Marian Elizabeth M’Coombe was recalled at the request of both Mr Anderson and Mr Teape, the latter stating that in the earlier inquest proceedings there had been an obvious misunderstanding about the cupboard in which the articles referred to in the inquest were kept. The witness then j gave detailed evidence of the situation and use of the cupboard, in a portion of which, she said, were kept all the appliances used when giving an injection. In the other portion, which witness indicated was deary defined from the other, were kept all the cleaning utensils. The basin containing the carbolic acid solution had been placed by her in the cupboard in which the cleaning utensils were kept, in the bottom of the cupboard, and well behind the other articles. She regarded that part of the cupboard as her cleaning cupboard, and it was not the practice for vessels tised in the treatment of patients to be taken from it. Counsel Object. Mr Teape was proceeding to examine witness about the practice in regard to the cupboard, when Mr Lascelles suggested that he was going beyond the limits cf an ordinary coronial inquiry. The coroner agreed with the objection. It was correct, he said, that Mr Teape had addressed questions which were rather of a “fishing” nature. It was right to clear up points referred to in earlier evidence, but not to bring up extraneous matter. Mr Teape proceeded to ask another ; question about witness’s use of the ( cupboard, when Mr Wanklyn rose and j said that he would like to add his pro- * test to that of Mr Lascelles. lie j I thought that the examination had gone j ! a long way past the cotirse of an ordi- J 1 nary coronial inquiry. ! “ This has been an unfortunate affair j 1 and I have given all possible latitude ‘

in the inquiry,” replied the coroner. “It is an extraordinary case, and sol that no one can say that he has been baulked and not allowed every opportunity, I have extended that latitude. Access to Poisons. The coroner added that the question ■ of the movements of the bottle of j poison was one which he thought j needed clearing up. It had struck him j forcibly that there had been too much i freedom of access to the poison in the theatre of the hospital, and the ques- j tion arose: Whose responsibility was j the control of the poison? llow did Nurse M'Coombe obtain the bottle 5 Tlie two questions were put to the . witness by Mr Davidson. Nurse M’Coombe said that she went into the theatre to secure the poison. She had not asked the matron for permission and had not done so on any previous occasion. She secured the bottle herself and made the solution, leaving the remainder she did not use in the bottle. To Mr Lascelles, witness said that she did not suppose that any person would expect to find poison in the cupboard. In her duties she would not put anything away which was in a dirty state. To Mr Wanklyn, witness said that it was part of her ordinary duty to go to the theatre to obtain carbolic or other chemicals necessary for nursing, with the exception of drugs, which were kept locked up. She obtained ordinary antiseptics for making up everyday lotions herself. Carbolic acid solution was a very common form of antiseptic. It was suggested by Detective Halcrow that no good purpose could be served by recalling Sister Francis, but the latter asked to be allowed to explain what she alleged was a misunderstanding conveyed in the evidence of Nurse M Coombe. Mr Lascelles put the ; request to the coroner, but Mr David- j son ruled that lurther evidence from j the sister was not necessary. Mr Davidson then returned his verdiet.