DEATH IN DENTAL SURGERY
SOUTH DUNEDIN TRAGEDY
SPONGE LODGES IN YOUTH’S WINDPIPE
An inquest into the death of Gerald Potter Walsh, an 18-year-old electrician, who died under an anaesthetic in the dental surgery of Thomas James Moynihan at South Dunedin on February 27, was concluded yesterday. The finding of the coroner (Mr J. D Willis, S.M.) was that deceased died from asphyxia as a result of a part of a sponge lodging in the throat while the youth was undergoing teeth extractions.
Dr E. F. D’Ath, pathologist, said that when a general anaesthetic was administered for an extraction, as in this case, it was more desirable for the patient to be properly prepared in hospital. To Mr Gray, who appeared for the relatives, he said that the signs of death were those of asphyxia. If the patient had been promptly removed to hospital the restoration of life might have been possible. The signs of asphyxia would be apparent a minute or so after the lodgment of the obstruction in the trachea. He could not say whether or not a bronchoscope would have been successful in saving the life of deceased.
DENTIST’S EVIDENCE. Evidence that deceased had called on him for a full extraction was given by the dental surgeon, Thomas James Moynihan. He had arranged with Dr F. K. Rennie to give the anaesthetic. Dr Rennie commenced to administer the anaesthetic about 3.20 p.m., and Dr R. F. Allan arrived in connection with another matter during the induction stage. After the extraction, deceased’s breathing was laboured, and artificial respiration was applied, without success. Dr Rennie had administered anaesthetics for him on 14 occasions since January. He could not say how the piece of sponge got into the deceased’s mouth. He added that pieces of sponge were used for swabs. Some were attached to tapes and others used on a swab holder. During the operation he took the pieces of sponge from a tray held by his sister. If a piece of sponge were missing from the tray he would have noticed it immediately. The sponges were bought nine months ago. He had noticed nothing unusual during the extraction.
Oxygen was administered 10 minutes after he noticed the patient’s collapse, and a cardiac stimulant was also given. An ambulance was sent for on the instructions of Dr Allan. There was no oxygen at the depot, and the ambulance eventually came without it. He had done about 1,000 full extractions in the last six years, he said, and averaged 25 to 30 gas cases a week. During the operation he packed deceased’s throat with taped sponges, which he changed from time to time. In all cases the sponge came out taped. The sponges were as good as could be bought to-day, and were safe to use.
THE ANAESTHETIC.
Francis Knox Rennie, medical practitioner said that he began to administer the anaesthetic, ethyl chloride and ether, at 3.20 p.m. He later stood back and did not see who put the swabs in deceased’s mouth. When the oxygen was given to deceased he showed signs of recovery, but later his condition deteriorated for no apparent reason. He had administered several hundred anaesthetics during the last 18 months. He had inspected deceased’s throat by looking and feeling, and had decided his condition was due to blood in the larynx, a common occurrence. Suction equipment was required to remove blood in the larynx, and this equipment was not available in the surgery. To Mr Willis, witness said it was correct to say that the equipment was available only in a properly equipped hospital, and it would be prudent to have this type of operation always performed in a hospital.
To Mr Gray, he said that the patient’s colour led him to believe that the presence of blood or mucous. was responsible. It was his first experience of asphyxia. Dr Allan had agreed with his treatment.
Mr Gray: Since there were no external signs of blockage, would it not have been prudent to have rushed the patient to hospital?
Witness replied that he had come to that conclusion 20 minutes to half an hour after the deceased’s collapse. He did not think it possible that the obstruction could have been forced down the deceased’s throat. when he was feeling.
Mr Neil: Thousands of these extraction cases take place every year in Dunedin don’t they?
Witness: I believe so.
Mr Neil: Do you know if these thousands of cases could be accommodated in hospital?
Witness: With present conditions I do not think so.
He was satisfied with Dr Rennie’s treatment of the deceased, said Dr Ronald Finlay Allan. When the oxygen treatment was stopped deceased collapsed. When this had happened twice Dr Rennie rang for the ambulance. It did not occur to them to perform tracheotomy, an operation on the windpipe, as there was nothing in the patient’s breathing to cause a suspicion that he might have had a swab in his throat. He had experienced previous cases of asphyxia but none that had occurred under an anaesthetic, he said.
Professor J. P. Walsh, dean of the Otago Dental School, said he considered Mr Moynihan’s sponges safe but not efficient. He thought the use of single-induction ether anaesthetics not suitable for multiple extractions, although he admitted they were widely used. The only absolutely safe procedure was endo-tracheal anaesthesia, in which a large tube is passed down into the windpipe, thus providing continuous anaesthesia and permitting the throat to be absolutely packed.
She was certain that a piece of sponge did not come off the swab holder used, said Margory Hargreaves, a nurse employed by Mr Moynihan. She did not at any time use a loose sponge.
Elizabeth Moynihan, a dental mechanic, said she could not be certain whether or not she had changed a swab on the swab holder but if her brother had asked her to change it she would have done so efficiently. She had had 17 years’ experience as a dental nurse. -Evening Star, 27/3/1947.
DEATH IN SURGERY
ALLEGED NEGLIGENCE
DENTIST AND DOCTOR INVOLVED
PATHOLOGISTS EVIDENCE
A claim for £2000 damages, with allegations of negligence on the part of a dentist and a doctor while his son aged 18 was under an anaesthetic for the purpose of having 32 teeth extracted on February 27, 1947, was brought by John Nevin Walsh in the Supreme Court in Dunedin yesterday. The defendants were Thomas James Moynihan, a dentist, of King Edward street, and Dr Francis Knox Rennie.
During the course of his evidence Dr E. F. D'Ath, professor of pathology at the Otago Medical School, said that a considerable number of full dental extractions were done in dentists' rooms in this country, but it was desirable that in these cases, which were really major operations, the job, where possible, should be done in a proper hospital.
Mr Justice Hay presided, and the case was heard before a jury of 12. The plaintiff claimed that, in addition to suffering a loss of income from his deceased son, Gerald Potter Walsh, who paid £2 a week towards the upkeep of the home, he had suffered the loss of services of the boy in the assistance which he had given in the home.
Mr E. J. Anderson appeared for the plaintiff. The defendant Moynihan was represented by Mr A. G. Neill, and Rennie was represented by Mr C. J. L. White.
Counsel for the plaintiff said that on February 27, 1947, the deceased found it necessary to have 32 teeth extracted. This could be described as a major jaw operation. The general anaesthetic was administered by the defendant, Dr Rennie, at 3.20 p.m., and about 3.40 at the latest the operation was almost completed. Just before the last two stumps were extracted, the patient showed signs that were unsatisfactory.
"As far as we can gather,” Mr Anderson said, “some steps were taken, and the signal was given for the operation to continue. From there on it appears that there were lapses on the part of the patient and an administration of oxygen, which happened about three times.”
About 4 o'clock the father telephoned his home and then the dental surgery, counsel continued. He was informed that his son was well and would soon be home. Eventually the plaintiff discovered that his son had not arrived home, and a further communication with the surgery elicited the fact that the boy was “in a bad way,” and the ambulance had been called to remove him to Hospital.
“At seven or eight minutes to 5 o'clock, the ambulance had not reached the Hospital,” counsel said. “The father learned that the boy was dead, and he went to the rooms to find the boy dead in the chair. Upon the father saying to the dentist that his son’s death had been caused by suffocation, he was told that the cause was heart failure. A postmortem examination subsequently showed that the windpipe was blocked by a piece of sponge.
It would be stated, Mr Anderson said, that the safe place for a major jaw operation was in a properly-appointed hospital. In the present ease, the packing of the mouth was done by the out-moded sponge method. In the use of sponges, there was a danger of fragmentation. Counsel said that questions would be asked why the boy Walsh, after being in the dentist’s chair for about one hour 20 minutes, was not taken to hospital.
“One of the sponges, or part of one, got into a place where, in the hands of a careful dentist, watching and responsible, it would never have been. allowed to go,” declared counsel. He said that the sponges were not new, and were kept in a special solution between periods of use.
Concerning the anaesthetist, Mr Anderson said; "It is fair to say that he was a young doctor, no doubt fully and adequately trained, but confronted with an unusual and difficult position. From 3.30 p.m. onward, the anaesthetist, with Dr Allan, who had arrived in the surgery, endeavoured to revive the failing life of the boy. They thought it was a case of a failing heart and applied oxygen.
The plaintiff said that his son Gerald went to the dentist’s rooms at 3 o’clock in the afternoon At 3.30, witness telephoned his home and learned that his son had not returned. Again at 3.45 he telephoned and began to feel concerned. At 4 p.m. witness telephoned the dentist’s rooms and was told that “everything was all right” and that his boy would be home soon. At 4.15 p.m. his son had not arrived home.
When witness telephoned the dentist at 4.30 p.m, he was told that the boy was in a bad way and was being sent to hospital in an ambulance.
About seven or eight minutes to five he learned that his son had not arrived at the hospital and he telephoned the surgery again to be informed that the boy was dead. Witness said he went immediately to the rooms. His son was sprawled in the chair and was dead. The dentist said that “his heart had given out.” No doctors were present, but the nurse and the police were in the surgery.
Mr Neill: Is there any reason why you should bring this claim two years' after your son’s death? — The claim has been in court for 12 months.
Witness said he had decided to make the claim six months after the occurrence. “After thinking the matter over and examining just exactly what happened and realising the poor attempt that had been made to save my son, I considered it was my duty to make the claim," witness added.
Mr Neill: So it is not to make money? — It is to expose the danger? . . . — No. It was to recover pecuniary loss suffered by the death of my son.
Mr Neill: How do you make up the claim for £2000? — I calculated the loss on weekly contributions of £2 and the loss of services to me in the home.
Witness agreed that it would have been fairer to Moynihan had the action been brought sooner.
Cross-examined by Mr White, witness denied any question of vindictiveness on his part in connection with the doctor in the action.
Dr E. F. D'Ath, professor of pathology at the Otago Medical School, said that he had carried out a post-mortem examination. In the windpipe was an obstruction in the form of a sponge. From his examination lie formed the opinion that the boy had died from asphyxia resulting from the lodgment of a portion of sponge in the windpipe.
An exhibit showing the portion of the sponge in the body was produced.
Witness described the obstruction as lethal. The mere fact that there was a fraying of the sponge when it was used would suggest that it was not a new one.
”In reviewing things at leisure after the event, one can suggest what might have been done, but it was a different matter in making an emergency decision at the time,” witness stated.
A very considerable number of such dental procedures as full extractions were done in dentists’ rooms in this country, Dr D’Ath said, but it was desirable that full extractions, which were really major operations, should, where possible, be done in a hospital. The case in point was a major jaw operation.
Proper packing of the throat was part of such an operation for keeping foreign bodies from the windpipe, witness replied to Mr Anderson.
Mr Anderson: If that is not effectively done there is a potential danger to the patient? — Yes.
Dr D'Ath said it was the practice among more recently qualified dentists and among those who followed up modern methods to use gamgee tissue. However, older methods taught 25 or 30 years ago were still in use by some dentists. There was a potential danger in that practice. All the advances made in dentistry were directed towards increased safety.
“I can quite imagine that it was difficult to diagnose a partial asphyxia, which must have been the condition during part of the time,” Dr D’Ath said.
Cross-examined by Mr Neill, witness said he had no objection to a sponge as long as it was properly used. There was more danger in the use of a sponge than with gamgee tissue, however.
To Mr White, witness said that the doctors had to make up their minds on the spur of the moment. They had no opportunity to consult books or think the matter over.
“They had to make a sudden decision, and I think it was justified from the course of events, although we now know that the interpretation of that course of events was wrong," Dr D’Atli said. “I am perfectly certain that the average capable general practitioner could just as easily have come to the same decision.”
Re-examined by Mr Anderson, witness said that, according to the principles of medical jurisprudence, Moynihan was in charge. Looking at the event in an afterlight, the boy’s life might have been saved if he had been taken to hospital at 4 o’clock.
His Honor: What division of responsibility existed between the doctor and the dentist?
Dr D’Ath: We believe in the dentist having complete control of the dental side of the proceedings and general supervisory control over the whole operation. The anaesthetist is responsible subject to general direction from the dentist for the giving of the anaesthetic, and is responsible for keeping the airway clear. In the event of anything happening, it is the anaesthetist's duty to warn the dentist and take what action he thinks necessary. In other words, he assumes charge. The dentist could not have done anything further in this case.
At this stage the court adjourned until this morning. The case is expected to last until about Thursday. -Otago Daily Times, 1/3/1949.
NO NEGLIGENCE
VERDICT OF JURY
CLAIM AGAINST DENTIST AND DOCTOR
INVESTIGATION WANTED
Verdicts that neither defendant was guilty of negligence were returned by the special jury in the Supreme Court at Dunedin last night at the end of an action in which John Nevin Walsh had claimed £2000 from Thomas James Moynihan, a dentist, of Cargill’s Corner, and Dr Francis Knox Rennie. The defendants were engaged as dentist and anaesthetist respectively when the plaintiff's 18-year-old son died in Moynihan’s surgery on February 27, 1947, while under an anaesthetic for the purpose of having his teeth extracted.
The foreman stated that it was considered by the jury that an appropriate dental authority should investigate the question of throat packs and should formulate a policy for the guidance of dental practitioners.
Mr Justice Hay: I shall be pleased to see that passed on to the proper authority.
The jury retired at 4.5 p.m. and returned at 7.45 p.m. The foreman said that on the question whether Moynihan was guilty of negligence, the jury had found in the negative by a majority “in excess of nine to three.” There was no prospect of being unanimous on that question. The jury had been unanimous in finding that Rennie was not guilty of negligence.
By dismissing the charges of negligence, the jury did not find it necessary to find whether the plaintiff had sustained pecuniary loss by the death of his son, or to assess damages.
Judgment was entered for the defendants with costs according to scale, witnesses’ expenses and disbursements to be fixed by the registrar.
Mr E. J. Anderson appeared for the plaintiff, while Moynihan was represented by Mr A. G. Neill and Rennie by Mr C. J. L. White.
In his summing up, the judge referred to the fact that the nurse had brought a selection of sponges from the surgery to the Police Station, and that the court exhibits could not be regarded as the actual ones used in the operation. Dr D’Ath had said in evidence that the sponges appeared to be old, his Honor remarked, while the dentist and the nurse said that they were only two or three months old. At the inquest Moynihan had stated that the sponges had been in his possession for about nine months. That was an important point on which the jury should be satisfied.
His Honor next referred to the swabbing done in the surgery. Three witnesses had said that Dr Allan did swab, while both Dr Allan and Dr Rennie said that they did not swab with sponges. Was it probable that Dr Allan would have interfered at that stage when he was only looking on? the judge asked. That was a factor for the jury to consider when weighing up the evidence. Anything done by the nurse was binding on the dentist, his Honor remarked.
A wrong diagnosis had been made, his Honor continued. Once it was made, however, the evidence pointed to the fact that the treatment was correct. The judge referred to the “overwhelming evidence” given by expert witnesses concerning the diagnosis that had been reached. He had almost decided to withdraw that part of the case from the jury, but as it affected Dr Rennie’s professional reputation, also that of Dr Allan, he considered that there should be a finding from the jury.
Case for Plaintiff There were points manifest in the case which required no experts to explain, Mr Anderson said in his address to the jury on behalf of the plaintiff. “Do they do major jaw operations in 20 minutes?” counsel asked, “because at 3.30 p.m. another doctor was ready to administer an anaesthetic for another operation.
Counsel said that a substantial sponge obstruction in the windpipe killed the boy. If care had been taken in a dental operation of major proportions, how could a piece of sponge of that size and lethal in nature have got away unknown into the air passage and killed the boy? he asked. Such a large obstruction should not have got away unchecked.
Mr Anderson said it would not be disputed that Moynihan was an experienced dentist. What the court wanted to know was why, on this particular occasion, a piece of sponge caused asphyxia. The fact that a sponge was found in the windpipe pointed to negligence on somebody’s part. The sponge got into the windpipe, Mr Anderson declared, because a major operation was conducted with the pressure of short time on the operators. The sponges used were of an unsatisfactory nature.
“A piece of sponge got into the air passage because the sponges were not properly checked,” counsel said. “It is reasonable enough to ask that when sponges are used, operators should see that none get away. It is a breach of reasonable care not to know what has been put in the human mouth and what has been taken out.
“Had that piece been found early there would have been no puzzled doctors,” counsel declared. “There was a lack of reasonable care we are entitled to expect in a case such as this. I submit also that the steps taken were not active enough to get the boy to a place where there was more adequate assistance than in the. dental surgery.”
Mr Neill said there was a £2000 claim for negligence alleged against a doctor and a dentist. The jury was a special one, capable of realising the difficult questions arising in claims against professional men.
“Did Moynihan act as a man in his profession should have acted in this operation?” counsel asked. “Did he adopt a standard that could reasonably be expected from a dentist?”
Qualified witnesses had arrived at the theory that a piece of sponge had been torn off, probably from a throat pack, possibly from a swab, Mr Neill said. Moynihan was a dentist of 23 years’ experience and had used sponges in tens of thousands of cases. Moynihan knew that the sponges had to be in good order. The nurse examined the sponges and there could be no question that they were suitable for the purpose. They were not old sponges.
“Was this an accident?” asked Mr Neill. “That is the crucial point. Dr Dodds said that this was one case in millions in which a lodgment in the windpipe has killed somebody. One witness said it was possible to take every care, but an accident could happen. Here we have an incident happening to a man who is a skilled operator with a vast and lengthy experience. This odd incident must be accidental.”
Doctor’s Defence On behalf of Rennie, Mr White said that the plaintiff had suffered a distressing family loss, but that did not entitle him to damages until he could establish pecuniary loss.
“Dr Rennie is not expected to be a Harley street specialist, nor is he allowed to act in a reckless manner without due attention,” counsel said. “He was expected to act as a careful, average practitioner would have done.” Was there a particle of evidence that Dr Rennie did not act according to the standards and requirements of his profession? Mr White asked.
The two doctors were placed in a sudden emergency of a most puzzling description, counsel continued. The peculiarities of the case led them in the wrong direction. Everybody in the case was puzzled as to how the accident had occurred until the lucid explanations given in evidence by Dr Dodds and Dr Moody.
Mr White declared that no blame could be attributed to Dr Rennie concerning the cutting off of the piece of sponge which was found in the windpipe. Counsel submitted that the doctor did not know that a piece of sponge had become loose, and when a halt was called near the end of the operation, the patient recovered from a momentary lapse. Dr Allan had acted promptly and with considerable gallantry. Both he and Dr Rennie were misled about the symptoms. -Otago Daily Times, 5/3/1949.
