DENTAL PLATE SWALLOWED
INQUEST OPENED
Sitting as coroner, Mr H. W. Bundle, S.M., opened an inquiry at the Dunedin Hospital yesterday afternoon into the circumstances surrounding the death of Jas. Robertson, who died in the institution on Sunday evening as the result of swallowing a dental plate the previous night.
Sergeant Gilligan represented the police.
Alexander Robertson, engineer, residing at 190 Leith street, a brother of the deceased, said that the latter was a single man, and had resided at Blueskin road, near Port Chalmers. Deceased was a carpenter, and lived by himself. About 11 o’clock on Saturday night witness received a message from his mother that deceased was missing. Witness motored to Port Chalmers and went to his mother’s residence, where he was told that deceased had gone home about 10.50 o'clock the previous evening, and his mother had heard nothing of him up till that time. On Saturday morning deceased’s nieces visited his house, but as the blinds were down they called a neighbor, who broke in the door, but deceased was not in the house. The next morning a party of friends and neighbors commenced a search, starting in the vicinity of deceased's house, but they found nothing. On Sunday afternoon a message came from Dunedin stating that deceased had been admitted to the Dunedin Hospital in the early hours of Saturday morning, but that his condition was not serious. Witness came into town, and, on seeing Dr Marshall, he was informed that deceased had swallowed his dental plate. At the time deceased had been admitted the doctors endeavored to locate the obstruction, but were unsuccessful. Witness’s brother had stated that on Saturday morning he woke up and found that he had swallowed a dental plate with four teeth. Deceased then dressed and called on Dr Edgar at Port Chalmers, but the doctor was unable to remove the plate, and pushed it further down so as to facilitate his breathing, and sent him to the Dunedin Hospital, arriving at Dunedin about 4 a.m. on Saturday. The hospital authorities had not operated on him but intended to do so about 8 p.m. on that day.
The Coroner said that he did not propose to hear any further evidence at this stage, and adjourned the inquest sine die. -Evening Star, 28/4/1925.
DEATH IN HOSPITAL.
MAX SWALLOWS DENTAL PLATE
INQUEST CONCLUDED.
The adjourned inquest into the circumstances surrounding the death of James Robertson, who died in the Dunedin Hospital on April 26, was concluded before the coroner (Mr H. W. Bundle, S.M.) in the Court House yesterday morning. Mr B. S. Irwin appeared for the relatives of the deceased, and Dr A. R. Falconor (medical superintendent of the Hospital) watched the proceedings on behalf of the institution. Sergeant McCarthy represented the police.
FURTHER MEDICAL EVIDENCE.
Dr Kenneth W. Miller, house surgeon, Dunedin Hospital, said that he saw the deceased on his admission at 5 a.m. on April 25. He complained of having swallowed a tooth plate and of suffering from discomfort. Deceased came from Port Chalmers, where he had procured a note of admission from Dr Edgar. Witness could detect nothing abnormal about his gullet. He was not in distress, and could breath, speak, and swallow. Witness admitted him to Hospital, and informed Dr Marshall. About 5.30 a.m. witness made a further examination, which confirmed his previous opinion. By this time witness had also informed Dr Read that the patient had been admitted. Deceased had pointed out a region in his neck where he considered a foreign body remained. Witness did not consider this was an abnormal swelling. The man was quite normal.
The Magistrate read Dr Edgar’s evidence, which stated that the man drew the doctor’s attention to a swelling in his neck, just below the larynx.
Dr Miller, continuing, maintained that his (witness’s) opinion was correct. He could not tell by an external examination whether the man had swallowed anything or not.
To the Coroner: he would say that the patient was not in distress. In the event of a person swallowing anything it was not necessarily advisable to have a full examination straight away.
To Mr Irwin; Sometimes it was necessary to examine immediately, and in other cases it was not. In witness’s opinion it was not expedient to operate at once in this case. His previous opinion was that the man had swallowed a plate, and that as he was not in distress it was not necessary to operate.
To Dr Falconer: The site of the obstruction was not immediately below the larynx as stated in Dr Edgar’s evidence. The obstruction might have moved during the period between Dr Edgar's and witness's examination.
Dr Falconer remarked that that would account for the discrepancy between witness's and Dr Edgar’s statement.
To the Coroner: Witness stated that deceased had said that the swelling was in the region immediately below the larynx. A layman would be easily deceived whether there was a swelling or not.
The Coroner: Dr Edgar is not a layman. It is peculiar that there should be such a curious discrepancy in the statements of Dr Edgar and witness.
Dr Charles David Read, house surgeon, Dunedin Hospital, said that about 5.30 a.m. on April 25 he was informed of deceased's admission by Dr Miller. Witness saw the patient between 8 and 8.30 a.m. Deceased was in no pain whatsoever. He complained of slight discomfort below the voice-box. He told witness that he had just previously swallowed a cup full of tea and some gruel or porridge. Witness examined the inside of his mouth and throat, and also his neck, and found no abnormality whatever, either internally or externally. As far as witness could make out, there was no swelling whatever on the neck. Witness did not consider the case was urgent. He saw some other patients, and about 9.30 a.m. he spoke to Dr Marshall concerning the case, and the latter said he would ring up Dr Anderson, the radiologist, which he did. Witness saw the patient again about 10.30 a.m., and he was in an exactly similar condition as when he first saw him. Dr Miller, on first seeing him, had to decide whether the foreign matter was in the gullet or stomach, but like everyone else, he could not be certain. The X-ray examination was completed almut 11.45 a.m., and the result showed that there was a foreign body in the gullet considerably lower than the region referred to by the patient. In consultation with Dr Marshall, the senior house surgeon then on duty, they considered it useless to notify Dr Bathgate till the foreign body was located. Witness was informed of the result of X-ray examination, and between 12.30 and 1 p.m. he rang Dr. Bathgate to whom he said that they did not consider the case urgent. Dr Bathgate asked him to ring Dr Carswell, who was her assistant. Witness did so, but found that Dr Carswell was out of town. He immediately rang Dr Bathgate again, and discussed the case over the telephone, which she, like himself, did not consider urgent. Dr Bathgate said that she would come down at 7 p.m. and attempt to remove the denture. She came down at that time and witness believed that an operation was carried out. Witness saw the patient on the operating table, when he was not suffering the slightest discomfort. Witness did not think that deceased’s chances of recovery would have been improved if he had been operated on earlier. He was in no pain, his breathing, speaking, and swallowing being quite normal.
To Mr Irwin; The plate may have shifted since Dr Edgar's examination and prior to Dr Miller’s examination. The case was not an urgent one. The swallowing of semi-solids and fluids would not cause the foreign body to move more than the ordinary swallowing of saliva. Dr Bathgate, had she considered the case urgent, would have ordered an operation straight away.
Dr Winifred Bathgate, honorary throat and nose specialist, Dunedin Hospital, said that Dr Read had rung up about the case at 12.30 p.m. Witness said she could not come down till the evening, but suggested that if Dr Carswell could come down he would carry out the examination. Witness questioned Dr Read very carefully whether the man was in distress, and the doctor had assured her that he was quite comfortable. She went down nt 7 p.m, and found the man cheerful. Witness inquired about the denture and was informed that four teeth with a broken clasp on one side had become lodged in his gullet. She felt no swelling in the neck. After an anaesthetic had been administered witness examined the gullet with an aesophaguscope, and she saw the denture, but could not remove it. If the man had been in discomfort or had not been able to swallow witness would have asked for Dr Bell or a surgeon to be sent for as she would have considered the denture would have to be removed from the outside. Wutness gave instructions that Dr Bell should be told about the case. The patient was comfortable and returned to bed.
To the Coroner: There was no possibility of any septic trouble owing to the delay.
To Dr Falconer: If plate had gone into the stomach it would have been moved much more easily.
THE CORONER’S REMARKS. In reviewing the evidence the Coroner said that the circumstances surrounding the death were a little unfortunate in certain respects. It was a most peculiar result of a man living by himself that there should be an unfortunate delay in notifying the relatives of his admission to hospital. He had lived about a mile from Port Chalmers, and on Dr Edgar examining him he had ordered him to the Dunedin Hospital. Deceased had told the taxidriver to notify his relatives, but he had failed to do so. The result was that the relatives did not know that anything had occurred until the brother went to Port Chalmers on the Saturday evening when he found deceased was missing, and he was naturally worried at his disappearance. The brother called at the police station, and at deceased’s residence, and then again at the police station. On the day after deceased’s death the brother complained somewhat of what he then considered was the dilatoriness of the police. No doubt in his then greatly excited state he had made statements which he would not have done otherwise. The Coroner was quite sure that Constable Oswell, Port Chalmers, had done everything reasonably possible, and had said that a search would be made for deceased. It was unfortunate that any suggestion should have been made that the constable had not carried out his duties. The deceased had swallowed a dental plate with four teeth attached by a wire. Dr Edgar had noticed a lump in deceased's throat, or at least, the patient had pointed out a lump. As there were no instruments at Port Chalmers suitable for dealing with such a case Dr Edgar had put a finger down deceased’s throat. He had ordered the patient to the Dunedin Hospital, and, on his admission there, he had been examined by Dr Miller, who saw him about 5 a.m. He could detect nothing abnormal about his oesophagus, and his breathing, speech, and swallowing were normal. Dr Miller had reported to Drs Marshall and Read, and the latter had taken charge of the patient. Deceased was in no pain whatever, and between 8 and 8.30 o'clock when Dr Read examined him there was no evidence of swelling. After consulting Dr Marshall, Dr Head was of opinion that there was no need to consult a specialist until an X-ray photograph had been taken. The X-ray photograph, which was taken about 11.45 a.m., showed that there was a foreign body in the gullet in a considerably lower region than that stated by the patient. It must be remembered, however, that it was Anzac Day, and the doctors would not attend unless the matter was urgent. Dr Bathgate had stated that Dr Carswell would attend to the man, but, on finding that he was out of town, she said she would see the patient at 7 p.m. Dr Bathgate had come to this decision after consulting Dr Read. Her examination confirmed her previous opinion that the case was not an urgent one. She examined the denture with an aesophaguscope, but found that it would be necessary to make an incision from outside in order to remove the plate. At that time no particular urgency was necessary. Possibly if an aesophaguscope could have been used successfully the foreign body could have been removed by an immediate operation. Although the medical evidence in this case showed that an immediate operation was not urgent there was no question that where a foreign body was lodged in the throat or gullet an immediate operation was desirable and advisable. Dr Bell saw the deceased on Sunday between 10 and 11 a.m., and the operation was later carried out as described by Dr Marshall. Dr Bell did not think that the delay which had occurred had prejudiced deceased in any way. The only possible trouble might arise from the decay or erosion of the plate, which might cause ulceration. It was unfortunate that there had been delay in having the X-ray plate developed. It would have been more unfortunate from the point of view of the relatives if any apprehension was a contributing factor to the death of deceased. From the medical evidence, and particularly that of Dr Bell, the coroner was unable to think that that was so. Although Dr Bell’s statement definitely expressed that the delay did not affect the deceased it should be impressed that no delay should take place in public institutions. In view of Dr Brennan's evidence he (the coroner) could only find that deceased died from asphyxia, due to pressure on the windpipe, caused by the dental plate which had become impacted in his gullet. The Coroner added that he did not propose to add any rider to his verdict. -Otago Daily Times, 19/5/1925.
Dunedin Hospital
CITIZENS DEMAND FULLEST INQUIRY.
(From "Truth's" Dunedin Rep) It has often been said that the citizens of Dunedin are slow to anger, but at the present time there is widespread evidence of their being in that state as a result of circumstances surrounding the death in hospital of a man who had swallowed a denture.
On Friday of last week a representative deputation waited on the Mayor and placed the following resolution before him: — "That this meeting of citizens views with grave apprehension the lack of efficient administration at the Dunedin Hospital, as revealed in the case of the late Mr. James Robertson, and desires you to summon a public meeting for the purpose of setting on foot an independent and searching inquiry in order to fix the responsibility and to deal adequately with the question in general."
The Mayor said he would call the meeting as requested and is now taking steps in that direction.
With the inquiry pending, comment must be withheld, but if it be found that a human life was sacrificed because of delay then there must be no sheltering of officials, whatever their positions. -NZ Truth, 6/6/1925.
Dunedin Hospital Scandal
Disquieting Revelations — Responsible Officer Out Yachting — Orders Definitely Disobeyed — Medical Superintendent and A.M.O. Censured — Muddling and Mismanagement Disclosed
Inquiry Into John Robertson's Death
(From "Truth's" Dunedin Rep.)
Though John Robertson's body lies peacefully in the grave, the scandalous details of his treatment in the Dunedin Hospital were not allowed to be buried with him.
The unfortunate man was admitted to the institution for the removal of a denture containing four teeth, which he had swallowed. Anzac Day intervened, an officer, required to be on duty in the X-ray department was out yachting, and not until 36 hours had elapsed was an operation commenced, but the patient died under the anaesthetic.
The coroner's inquest revealed such startling derelictions of duty on the part of certain members of the medical staff that an influential deputation of citizens waited on the Mayor and requested him to call a public meeting to demand an independent inquiry. The Mayor consented, but later recommended that the calling of the meeting be held over until the Hospital Board held its projected inquiry. This was duly held last week.
Those who persistently affirmed that they "would never go into the hospital to be practised on by mere boys" now contend that their arguments have been strengthened considerably.
The primary objects of the inquiry were to ascertain the following:
(1) The reasons for delay after admission pf the patient.
(2) Whether any officer of the board was guilty of negligence and, if so, to what extent.
(3) Whether the standing orders or staff rules of the hospital were adequate for the purpose for which they were intended.
(4) If any person was found responsible for delay or neglect of duty, or if any superior officer was guilty of neglect of duty, what disciplinary action should be taken against such person.
(5) Generally, how could the board best provide against a recurrence of such a happening.
HONORARY MEDICAL STAFF REGRETS DELAY.
The secretary read the following letter from Dr. Charles North, hon. secretary honorary medical staff, date June 12:
In reply to your, letter of June 9 re Robertson case, I have to report that the medical superintendent's report thereon was considered by the staff at its meeting this evening. I am directed to supply your board with the findings of the staff as follow:
(1) The honorary medical staff wishes to express its regret for the delay that occurred, in the case of the late James Robertson, though the delay which did occur was not responsible for the death of the patient, nor did it accelerate the fatal ending of the case.
(2) During his stay in the hospital there were no urgent symptoms and he suffered no distress. His breathing was normal, he could talk quite well, take food, and walk about.
(3) The patient died of asphyxia under anaesthesia, and this might have occurred if an anaesthetic had been given at any period m the history of the case. After the anaesthetic, given on Saturday night, it was undoubtedly wiser to wait till next day before attempting further operation.
(4) After the board has held its inquiry into this case the honorary medical staff will be glad to have an opportunity of making recommendations which will more effectively co-ordinate the duties of the stipendiary and the honorary medical staffs. I have further to state that Dr. Batchelor, as chairman, will represent the staff at the inquiry on Monday.
TREATED AS A JOKE!
Dr. Edgar, at whose residence at Port Chalmers deceased called at 2 o'clock on the morning of Anzac Day, said he had nothing to add to what he said at the coroner's inquiry.
The Chairman: Did the patient seem to be in any distress or discomfort when you first saw him? — No. He was rather inclined to laugh at the matter and treat it as a joke.
His conditition was such as would lead you to think he could reach Dunedin without trouble? — Yes, quite.
Mr Larnach: Didn't you think the case was dangerous? — Yes, that was my reason for sending him to the hospital.
Then there was danger? — Yes, there was always the risk of the plate shifting into a position of danger.
Dr. Kenneth William Miller said he admitted the case at 5 a.m. on Anzac Day and conferred with Dr. Marshall, informing him of all the signs and symptoms life had elicited. He didn't consider the case an urgent one.
The Chairman: Why didn't you communicate with the assistant medical officer? — Mostly because I did not think of it.
Mrs. Jackson: Was the assistant medical officer m the hospital at the time? — Yes.
Mr. Quelch: Did you think it an urgent case? — No. I have looked up the records and found that of five cases of persons admitted to the hospital in recent years, complaining of foreign bodies lodged in the throat, in only one case had a foreign body been discovered. I had no proof that the foreign body was in the man's aesophagus beyond his own statement.
Dr. Batchelor: It is by no means certain that a doctor can always accept a man's statement that there is a foreign body in his gullet. I have seen several cases of persons claiming that there was something in their gullet and they were proved to be mistaken. In the case of a man showing no signs of distress it would be impossible for a doctor to be certain that a foreign body was there without further examination. It is perfectly obvious that Dr. Miller could not be certain.
SENIOR HOUSE SURGEON'S ACCOUNT
Dr. Marshall, senior house surgeon, said he was informed by Dr. Miller of the patient's admission at 5 a.m. on April 25. Witness asked Dr. Miller the nature of the case, questioned him concerning the symptoms, and said the case should go to a specialist. Witness told Dr. Miller to waken Dr. Read. He saw Robertson next morning, but did not examine him. About 9.30 on the Saturday he rang Dr. Anderson to ask him if he would come down to take an X-ray of the case, and that was done. Dr. Read and witness went out for a walk later on, but returned shortly after the X-ray had been completed, and Dr. Read, in the presence of Dr. Iverach, witness and some others, rang up Dr. Bathgate about half-past twelve. Witness had nothing to do with the case that day. Next morning he was told that an unsuccessful operation had been performed the night before, and that Dr. Bathgate wished Dr. Bell to see the case with a view to removing the obstruction. When Dr. Bell arrived witness explained to him that Dr. Bathgate had handed the case over. He said he would not be prepared to do anything till an X-ray was taken. For all Dr. Bell knew and all he could deduct the plate might have been in the stomach by then. Witness was told by Dr. Iverach that Dr. Anderson (radiologist) had rung up to say that if any urgent work was required at the hospital that day Mr. Butterfield would be on call. When Dr. Bell asked for the X-ray witness said they could get one right away as there was someone on call. He rang Mr. Butterfield, who was out. He rang a number of times, and was told that Mr. Butterfield would not be back till 3 o'clock. Somewhere about 5 or 6 o'clock witness rang Dr. Anderson. The first time Dr. Anderson was not there, but later witness got him and he said he would come right away and take the X-ray. This was done and the operation was proceeded with at once.
The Chairman: Didn't you think it was your duty to see the case when Dr. Miller reported it to you? — No, I don't think so.
Dr. Newlands: There was evidently a hiatus between the time when Dr. Bathgate asked that the case be handed over to Dr. Bell and the time when Dr. Bell's house surgeon was made aware that the case was under his chief? — All that I know is that I was not notified till 9 o'clock on the Sunday morning.
HIS WEEK-END OFF.
Dr. Charles David Read said he was Dr. Bathgate's house surgeon. He was informed of the patient's admission by Dr. Miller, who assured him that the case was not urgent. He saw the man at 8.30 and found him to be comfortable, and at 8.45 informed Dr. Marshall, who came to the conclusion that an X-ray was necessary. Witness was busy in the theatre till 11 a.m.., but saw the case then and discovered that an X-ray had been taken. When he heard the result of it at 12.30 he rang Dr. Bathgate, who asked him to ring Dr. Carswell. Dr. Carswell was not in and he rang Dr.Bathgate again. She said she would be down at 7 p.m. Witness informed her of the result of the X-ray examination and also told her that the patient was comfortable. Other experts could have been communicated with, but it was not part of his duties to do that. He was not present when Dr. Bathgate attempted to relieve the patient. It was his week-end off and a special doctor was put on operation duty.
Mrs. Jackson: Was the assistant medical officer in the building? — I understand he was not.
Mrs. Jackson: Are you aware that the medical superintendent is always on duty when the assistant medical officer is away? — No.
Mrs. Macdonald: There must have been some reason you all thought Dr. Iverich was off duty? — Witness replied that there was no roster to show whether the medical superintendent or any of the house surgeons were on duty. The medical superintendent made no claim to attend to the clinical side, but only the administrative side.
Dr. Newlands: Who is your definite substitute when you go off duty? — The casualty officer.
In answer to a further question witness said that Dr. Champtaloup, who assisted Dr. Bathgate, had left him a note stating that an attempt had been made for an hour and a-half to extract the plate, but that it had failed.
REFERENCE TO "JUNIOR" RESENTED.
Dr. Bathgate told of her connection with the case from the time she was rung up at 12.30 p.m. on Saturday. She instructed her house surgeon to hand the case over to Dr. Bell and let him know in the morning. She wanted the case to go to a surgeon because the plate was so impacted that she did not think anyone could get it out with the oesphaguscope.
The Chairman: It would have saved time if Dr. Carswell had been available? — Yes, but I would have gone myself if it had been urgent.
Why did you not ask Dr. Ross? — Because I thought it would be a difficult case and I thought it hardly fair to ask a junior to take such a case.
Dr. Batchelor (warmly) It is most unfair and unfortunate to say Dr. Ross is a Junior man.
Witness: I do not mean that Dr. Ross can't do operations, but it was a difficult case, and the more senior the man the better.
THE X-RAY EXAMINATION
Dr. Colin Anderson, radiologist, said he was notified of the case on Saturday morning. He stated that he would come in and see the case and arrived between 10.15 and 10.30. The examination was completed at 11.45, but he did not consider it necessary to develop the plate, which was for special reference. He understood that his assistant, Mr. Butterfield, would be at home over the week-end and he asked him if he would do substitute duty for him and he replied that he would. He was surprised to learn that the hospital had been ringing him. He saw the patient at about 6 p.m. on the Sunday. During the eighteen months' he had been in Dunedin it was the first time Mr. Butterfield had been asked to do substitute duty. The trouble had arisen because Mr. Butterfield did not realise that he should have been on call.
NO VITAL URGENCY.
Professor Francis Gordon Bell recounted his connection with the case and explained the necessity for a second X-Ray examination. Although the case was passed on to him on Saturday evening he was not aware till he visited the hospital on Sunday morning that it had been passed on to him. He was quite satisfied that there was no vital urgency for an operation and he did not think it was necessary that the case should have been, passed over to him after the first X-ray examination.
Mr. Quelch: It is desirable that a foreign body should be removed within a reasonable time? — On general principles, yes; but as a matter of fact the plate did not choke the man. His breathing was not distressed.
Is 36 hours a reasonable time? — In this particular case it did not in any way prejudice this man's chance of recovery.
JOINED A LAUNCH PARTY.
Mr. H. Butterfield, assistant radiologist, read a statement in which he said that he must decline to accept full responsibility for the delay in the Robertson case, of which 80 per cent, had occurred before he was communicated with. This particular day was the first time he had been asked to be on call, as the call system was inaugurated only the previous week. Had he been informed at the time, as he was after the incident happened, that being on call really meant that he should not be out of hearing on his 'phone until going on auty next morning, he certainly would not have left his residence. If he had been communicated with before 11 a.m. on Sunday he would have been available. At 10.45 a.m., he was invited to join a launch party on the harbor, his host intending to return to the boat harbor at 3. p.m. The day being fine, the launch went further than was at first arranged. On arriving home at 5.30 p.m. he received a message to the effect that he was required at the hospital, and immediately went down to find that Dr. Anderson had preceded him by a few minutes. For reasons of efficiency he was in the habit of spending as much of his time as possible in the open air, acting on the recommendations of the X-ray and Radium Protection Committee, which that board had endorsed. The board had confirmed the principle that Sundays should be free from duty. He was not engaged to do Sunday work. He had in the past, on several occasions, given his services on Sundays, and would do so again, but that had been purely voluntary on his part. In view of this he considered the term "dereliction of duty," which was used in the medical superintendent's report, not only unduly, harsh, but scarcely correct.
After reading his statement, Mr. Butterfield said he would like to add that Dr. Anderson had telephoned him at 9 a.m. on the Sunday asking him whether he would be within call if needed. He replied that he would, and asked if there was any likely case in the hospital. Dr. Anderson replied that he did not think so.
The Chairman: Are you aware of the medical superintendent's instructions regarding emergency duty?— No. There are no such instructions posted in the X-ray room.
Mr. Morgan: Do sou consider you did wrong in leaving? — No. I intended to be back by 3 p.m.
"TOO MUCH RESPONSIBILITY."
Dr. Iverach, assistant medical officer, said that it was at 12.30 on Anzac Day when he first learned that Mr. Robertson was in the hospital. He heard Dr. Read ringing up Dr. Bathgate. Witness did not see the patient at all. Dr. Bathgate having been informed, he did not think any responsibility rested upon him. According to rules laid down he should have been notified of the case.
Mrs. Macdonald: Is there any arrangement whereby Dr. Falconer is in charge while you are away? — I see that there is a senior house surgeon in charge before I leave. That means that the hospital is left in charge of men with about eighteen months' standing. We are expecting too much of them and put too much responsibility upon them.
MEDICAL SUPERINTENDENT'S STATEMENT.
Dr. Falconer (medical superintendent) said that he was first informed of the case by Dr. Marshall after the patient had died.
In answer to questions witness said that returns came to him from the hall porter each morning. He did not see the cases as a routine unless his attention was drawn to them. He tried to see the dangerously ill cases each day and special cases that he was asked to see. He attempted to see each patient once a week and took a ward at a time. James Robertson was never on the dangerously ill list. Witness was not in the hospital on Sunday but was in Batchelor ward on Anzac Day and saw several of the infantile paralysis cases. It would be impossible to see each patient in respect to diagnosis and treatment. The assistant medical officer reported to him at 10.30 each morning There were no written rules bearing on Dr Iverach's position. The assistant medical officer would straighten out the difficulties of the house surgeons of whom ithre are at least three on duty at all times. It was the duty of the assistant medical officer to see the new cases.
Mrs. Jackson: Who is responsible while you are away? — The assistant medical officer. One of us is always on call.
Mrs. Macdonald: Do you think it a fair thing that patients should be left to the care of mere boys who have had only eighteen months' experience? Why didn't the house surgeons communicate with the medical superintendent? — I understood Dr. Iverach was aware of the case.
But Dr. Iverach left at 1.30, and left the patients under the case of these young doctors. — I have recommended that there should be two assistant medical officers.
Don't you think you should know something about the human side of the hospital? — I attempt to see each individual patient each week.
Mrs. Macdonald: We don't want you to know anything about diagnoses, but we do ask that you know something about the patients.
This concluded the evidence. -NZ Truth, 27/6/1925.
DECISIONS DELIVERED
Board Not Satisfied With Control and Supervision
House Surgeon's Serious Omission.
The findings of the Board, delivered later, are as under:
(1). The board finds that there was unnecessary delay in the case of the late James Robertson, and has noted the opinion of the honorary medical staff, subsequently supported by the evidence of Professor Bell, that the delay was not responsible for the death of the patient, nor did it accelerate the fatal ending of the case. The board desires to express its grave concern regarding the atmosphere prevailing among certain members of the resident staff, as revealed by their own evidence at this inquiry. The practice of bare compliance with the letter of the regulations is quite foreign to the ordinary spirit always believed to exist among the resident medical staff, and the lack of evidence of mutual helpfulness, especially from senior to junior, is very regrettable. The board believes this spirit to be of quite recent growth, and is insistent on its repression. Written regulations should be the minimum and not the maximum demand on house surgeons' service.
(2). The board is not satisfied with the measure of control and supervision exercised by the medical superintendent and A.M.O. It is not expected that the medical superintendent should personally examine every patient in the hospital but it is expected that he should be sufficiently in touch with what goes on to know if the regulations are not being complied with, or if any patient is not receiving proper attention.
(3) The board finds that Dr. Iverach failed to realise the full responsibilities of his office in not visiting a case of this nature at the earliest opportunity after he learned of its presence, i.e. at 12.30 p.m. on Saturday. The fact that three of his subordinates had already seen the patient does not relieve him of that responsibility, and the board is unable to accept as valid his repeated assertion: "Once an honorary surgeon is made acquainted with a case under his charge I do not think I have any responsibility in seeing the case."
(4) Mr. Butterfield, in going down the harbor on Sunday, April 26, when he had received definite instructions from Dr. Anderson to remain on call in cases of emergency, definitely disobeyed orders. Mr. Butterfield should understand that he must be absolutely, to be relied upon in future, to obey implicitly instructions given to him by his superior officer.
(5) It is regretted that Dr. Bathgate was not communicated earlier and that when she did know of the case and not being able to attend to it herself, and Dr. Carswell not being available, she did not suggest a transfer of the case to another member of the special department, instead of delaying for several hours. The board further considers that when Dr. Bathgate realised that she could not remove the tooth plate she committed an error of judgment in not having the case transferred to Professor Bell immediately, instead of instructing the house surgeon to notify him the following morning.
(6) The board was not favorably impressed by Dr. Marshall's evidence. Accepting his statement that he was called at 5.30 a.m. on Saturday, not as Dr. Miller's senior, but as Professor Bell's house surgeon, the board is of opinion that Dr. Marshall should either have seen the patient himself or should have advised his junior colleague to inform the A.M.O.
(7) Dr. Read (house swrjjeon) failed to visit Mr. Robertson at 5.30 a.m. on Saturday when informed by Dr. Miller of the patient's admission under Dr. Bathgate's care, and also failed to report either immediately or at all to the A.M.O. In tha opinion of the board this was a serious admission on the part of this house surgeon and was the initial cause of much of the subsequent delay.
(8). That the following matters be referred for immediate report to a joint meeting of the Committee and a committee of the honorary medical staff: (1) The duties of the medical superintendent; (2) the duties and status of the A.M.O.; (3) the question of revision of the standing orders of the resident staff, including all special departments of the hospital. -NZ Truth, 27/6/1925.
The New Zealand "Truth" went on to report the resentful response of the medical staff who were criticised by the Hospital Board, and repercussions of the revelation of similar conditions in one or two other hospitals. Mr James Robertson rested in the Port Chalmers New Cemetery.
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