A Chloroform Tragedy

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 4, 1 October 1923, Page 172

A Chloroform Tragedy

The Question of Responsibility

(To the Editor.) Sir, — According to the press reports of a recent inquest, a patient about to undergo an operation lost her life owing to the anaesthetist using- a chloroform inhaler the tubes of which had been wrongly connected. It would appear from the report that the woman doctor succeeded m shifting the responsibility for this on to the theatre sister, for the jury added a rider to their verdict that m future the theatre sister should be responsible for all apparatus and instruments m the operation theatre. This rider does not define the extent of responsibility, and, strictly speaking, the words would appear to mean "responsible for safe custody," but from the context it is clear that the jury meant to imply that the theatre sister should be responsible for the proper putting together and proper working of the apparatus. It this be so, it is not common sense, and, 1 venture to suggest, is not good law. As to the action of the doctor m shielding herself by blaming inferentially her subordinate, I express no opinion; but the rider of the jury should not be allowed to

pass unchallenged. The theatre sister's duty is to keep the various instruments and apparatus clean and m proper order During the operation she is under the direction of the surgeon, and so she can hardly be held responsible for the way m which the various instruments are used. The position is somewhat analogous to that which arises when at an operation a swab is left m the abdominal cavity. The responsibility is the surgeon's. He may delegate the checking of the swabs to the sister, but the responsibility still remains his. "Qui facit per alienus, facit per se." A surgeon, like any other mortal, may make mistakes, but any attempt to put the blame for errors of this kind on to the nurse is not only unfair but unjust, and should not receive either moral or legal sanction. — I am, sir, yours faithfully, HERBERT J. PATERSON. Lon., W., April 14, 1923.

Note. — This letter, published m the "Lancet," is of deep interest to nurses, coming as it does from a well-known member of the medical profession.