HOSPITAL ENQUIRY.

Press, Volume LXI, Issue 18415, 23 June 1925, Page 9

HOSPITAL ENQUIRY.

THE DUNEDIN CASE.

OTAGO BOARD'S FINDINGS

CPEI33 ASSOCIATIOS TCLKOHkU.)

DUNEDIN, June 22.

The adjourned enquiry by the Hospital Board into the circumstances concerning the death of James Eobertson, who died in Dunedin Hospital cm April 26th when about to undergo an operation for the removal of a dental plate from his throat, was concluded this evening. The following the Board's finding:—

(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 which did occur was not responsible for the death of the patient, nor did it accelerate tho fatal ending of his 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 cvidenco at this enquiry, 'ihe practico 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. The 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 tho Medical Superintendent and Assistant Medical Officer. It is not expected that the Medical Superintendent should personally examine every patient in hospital, but it is expected that he should be sufficiently in touch with what goes on to know it the regulations are not being complied with or if any patient is not receiving proper attention. (3) The Board finds that Dr. Ivcrach 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, that is, at 12.30 p.m. on Saturday. The fact that three of his subordinates had alroadv seen the patient did not relieve him of that responsibility, and_ tl).; Board is unable to accept as valid his repeated assertion, "Once an honorary surgeon is made acquainted with the ease under his charge I do not think I have any responsibility in seeing to the case."

(4) Mr Buttc'rfield, in going flown the harbour on Sunday, April 26th, when ho had received dofinite instructions from Dr. Anderson to remain en call jn cased of emergency, definitely disobeyed orders. .Mr Butterfield should understand that he must be absolutely to be relied upon in future and obey implicitly instructions given to him by his superior officers. (5) It is regretted that Dr. Bathgato was not communicated with earlier, and that when she did know of the case, noC being able to attend to it herself, and Dr. Carswell not being available, that she did not suggest the 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 tho dental plate she committed an error of judgment in not having tho case transferred to Professor Bell immediately, instead of instructing the houso surgeon to notify him on tho following morning. (6) The Board was not favourably impressed by Dr. Marshall's evidence. Accepting his statement that ho was called at 5.30 a.m. on Saturday, not as Dr. Miller's senior, but as Professor Bell's house 6urgeon. the Board is of opinion that Dr. luarsball either should have .seen the patient himself or should have advised his junior colleague to inform the A.M.O. (7) Dr. Reid (house surgeon) failed to yisit Mr Robertson at 5.30 a.m.. on Saturday, when informed by Dr. Miller of the patient's admission under Dr. Bathgate, and also failed to report either immediately or at i all to the A.M.O. In the opinion of the Board, this was a serious omission on the part of this house surgeon and was the initial cause of much of the subsequent delay. ___ (8) That the following matter&"De referred for an immediate report to a joint meeting of the Hospital Committee, and the committee of the honorary medical staff: (1) The duties of modfc cal superintendent. (2) The duties and )status of the A.M.O. (3) The question of tho revision of the standing orders of the resident staff, including all special departments of the hospital.