GIRL'S DEATH FROM MORPHINE POISONING

Chronicle (Levin), 13 March 1947, Page 6

GIRL'S DEATH FROM MORPHINE POISONING

Coroner Criticises Use of Students As Air Force Medicos

The action of the Air Department in contimting the wartime emergency praetice of employing final-year medieal students in positions of responsibility, was> condemned by the Coroner (Mr, 0. L. Mowlem) in a rider added to the verdiet wliich he returned at the inquest held in Palmerston North yesterday into the circumstanees surrounding the death of a 17-year-old girl, Audrey Enid •Giirr, of 113 Moxham Avenue, "Wellington. Mr. Mowlem found that Miss Gurr. had died at the Palmerston North Hospital on Deeember 23, 1946 as a result of morphine poisoning due to an overdose of morphia administered by Graham Alexander Shanks, an unqualified final-year medieal student employed by the Air Department as a temporary medieal officer at the Ohakea Air Foree station.-

"I think it is well understood that an inquest is not a criminal or civil trial, and is not the proper oecasion to try or consider questions of negligence or criminal liability," the rider stated. "The law provides appropriate tribunals for settlement of questipns of personal responsibility. However, I feel in.such a case as this, it is regrettable that the wartime emergency i>ractiee of employing students m positions of responsibility should have been eontinued by ihe Air .Department for sueh a lengtly period after the cessation of the war. ' ' Although he did not give evidence, Wing Commander A. H. Marsh, Director of Medieal Services, Air Department, Wellington, in answering a question by the Coroner from the body of the eourtroom, said that so far as he' knew the regulations regarding the appointment of medieal students had not been revoked, and he hoped that the regulations would eontinue in force because of the desperate shortage of medieal staffs. He informed the court

that lie had sought special permission from the Government for the appointment of four students this year, although they would not have provisional registration as practitioners. The inquest yesterday was a continuation of the inquiry opened on Deeember 24 when evidence. was given that Miss Gurr had been staying with her un'cle, Flight Bergeant F. J. C. Morgan, and his wife, at Bulls. . On the night of Deeember 21 and the following morning she had comjjlained of severe toothache and her face had begun to swell. On the evening of Deeember 22 she was taken to the Air Force station at Ohakea where she was given injeqtions of morphia and had three teeth extracted. Later that night she collapsed and in the early hours of the follovving morning she died in the Palmerston North Hospital. Deteetive-Sergeant J. G. Long conducted proceedings for the police. Mr. H. R. Oooper appeared for the Air jDephrtment, Mr. G. Crossiey for G. A, Shanks, a final-year medieal student now employed at the Christchurch Hospital, but formerly a cadet officer at Ohakea, and Mr. A. M. Ongley represented Captain H. P. Armour, New Zealand -DentaPCorps. The relatives of the deeeased girl were not represented. In evidence, Shanks said that on the night of Deeember 22 he visited the lionie of Captain Armour on the station. Armour said he had a patient requiring dental extractions, that she was in pain and would require a pre-operative sedative, suggesting either a nembutal or an A.P. codine. Witness had said he thought a general anaesthetic would be desirable, but he did not consider he liad sufficient experience to administer one. "In the workroom of the dental seetion, after the dentist had examined the patient, I suggested giving morphine," said Shanks. "I thought it was the best treatinent we eould give her in the circunistances. The ordinarv dose is l/8tli to l/3rd of a grain. After discussion we agreed -J of a grain would be given. We then went to the medieal section and wliile the dentist put his instruments in the steriliser, I looked for some preparation morphine." Dangerous Drugs. The key of the dangerous drugs cupboard was in the loelt. He found a. eardboard box labelled on the outside "solution of morphia hydro-ehlor, 23 ampoules". This indicated to liim that there should be 23 separate containers. The first bottle he examined had a blaek tvpe-written label on which he read morphine hvdrochlor, grains 1/4, aq. camphorae, miuims 15". On top of the label" was printed 5 c.c. which indicated the total contents of the ampoule. 'He knew that was not wliat he wanted because the aqna camphorae was not -required. He then picked out a bottle with a red printed label which read ; "solution of morphine hydro-ehlor, 1/4 grain. He did not remember reading the individual words on the label as he assumed from the label on the box and from the description on the first ampoule he had inspected that this ampoule contained 1/4 grain of morphia. He assumed it to contain 5 c.c. In cpnipany with Dr. Benson, of Marton, he later measured the contents of the bottle and found it contained 100 minims. Another ampoule produced from the cardboard boy by the detective sergeant had writt.en on it in ink "dose 1 c.c.". This would indieate, said Shanks, that the bottle contained five doses of 1/4. grain morphia. The bottl he had use# had had no such instruction written m it, and the label he had read gave liim to believe the bottle contained onlv 1/4 grain of morphia. At the time he had thought it a weak solution. "When I went to the cupboard I did not know what. solution I was looking for," said witness. ' T did not have in ' miucl any fix'ed preparation,"

Deteetive-Sergeant Long: Yet when you found this bottle you did not exereise sufficient care^ to read the label properly? Witness: I saw "morphine hydroehlor." I did not see 'that 10 minims equalled 1/4 grain. Highly Nervous Patient. As the steriliser had not boiled, said witness, he obtained from a first aid pack a metal tin labelled v "sterile syringe". The reasoif he /ised it was that iie wished to avoid delay in wait ing for the water to boii as the patient was in a highly nervous state. He ex tracted the contents of the bottle with the syringe which had a metal barrel. . This handieapped him as he could not see how much of the fluid had entered the syringe. In the process some of the fluid was spilled and more was lost when he tested the syringe for air. He then administered to the pa+ient.the contents of the syringe, bur, he could not be sure how much from ih.e bottle the patient received. He -rhougK she might have received betweeu 1/2 and 1/3 of it. He told Captain Armoui that he thought the patient had receiv ed a negligible quantity of the first injection, and he thought they agreed upon that. Witness said he f'elt the patient required . still further preparation for the operation. The dentist and he returned to the medieal section where Captain Armour picked up his

instruments which had not boiled. While there witness read an article on morphia. When he returned to the dental surgery the patient was not reacting to the anaesthetic as he would have expected. She was still extremely nervous and in answer to his question she said the pain was ' ' avvful ' '. He had another diseussion with the dentist as to the adminislration of further morphia. ' ' I strongly .recommended f ui'ther morphia, but the actu.al decision was not mine, " said Shanks. "Although 1 wak administering the morphia, 1 was only a medieal student and had no authority to adininister the anaesthetic except under supervision. The girl was not my patient, and tlie decision really rested with the dentist, who was strong-. lv in f'avour of.u/OT giving a further injection b§cause he maintained^ it wouid mean a further delay, and this entailed keeping a very nervous jiatient in the ehair." Shanks said he had brought a second bottle of morphine from the medieal section to the deqtal surgery. Between the iirst and the second injections he did not read the whole of the label on the bottle. He did not check the cardboard box of. anyjkoul'es to see whether there were mOre ■ thatn two different types of solutions. When getting the second bottle he had picked up an ampoule with a red label. Deteetive-Sergeant Long: What care did you exercise to make sure you had the right type'? Witness: 1 selected a bottle with a red printed label. and I assume I read that it contained morphine hydro-clilor. For the second injection 1 used the syringe with the glass barrel and it held the full contents of the bottle. Second. Injection. * The patient did not get the whole of the second injection, eontinued Shanks. She received the contents, less about oue half c.c., which was equal to aboui a tenth of the bottle, or oue quarter of a grain of morphia. In leaving this amouut, he thought he would allow for the amount the girl might liaye received on the first injection. To the Coroner witness said the patient wmuld have received approxiniately three-quarters of a grain on the first injection, and approximately two and a quarter grains on the second, a minimum total of nearly three grains. He knew now thafreach bottle contained twro and a half" grains. Shanks said he was present when the dental operation w*as carried out, later returning to his own private quarters. At midniglit he was called to go to Morgan's house at Bulls -where Miss Gurr was staying. Ai'inour and Sister Davidson were already there. Dr. Benson, of Marton, arrived at about the same time as himself, and assumed charge of the girl. He subsequently learned she had been removed to the Palmerston Xortli Hospital at about 2.30 a.ni. At a final lecture on dangerous drugs at the medieal schooi, eontinued Shanks, the students had been told they could not administer s'uch drugs until they wrere registered medieal practitioners. They had been told, however, that they could administer eertain drugs under qualified supervision. The medieal officer at Ohakea, Dr. Ballantyne, was a registered practitioner. Shanks said that when he arrived at Ohakea he feeeived no instructions 'as t6 what his duties would be. He had received no instructions ' that he was to take over as medieal officer during absences of Dr. Ballantyne, -tliough he understood that he was to attend to sick. parades, act as port officer of health, and give ■aiedical treatment when. required. Question of Status. Oross-examined by Mr Ongley witness said he did not have the same status as i students who previously had been pro- ! visionally registered. His powers were J strictly limited. He could not -issue death certificates, order prescriptions or ' handle dangerous drugs wuthout superj vision. In the absenee of Dr. Ballan- ! tvne there were 'no medieal officers on l fc'he station. He was the' only xnedical

student on the station ;s medieal stafE. At this stage the witness deelined to answer questions by Mr Ongley regarding the availability of dangerous drugs to wituess dr to Captain- Armour, the Coroner a'dvising Shanks that he need not answer any question which he felt might incrimmate himself. ' ' I am just wondering how far I can allow this eross-examination to go," 'said Mr. Mowlem. "This court -is not here to apportion the blanie. Other tribunals exist for that purpose. -It is my duty to find the eause of death, and much of this /cross-examination appeajrs to be outside the scope of my jurisdiction. " " . "I submit that it is.the duty of tliis court to ascertain who aud wliat were responsible for the death of the. gipl, and that the court will want to- go so far as to prevent a recurrenee of this happening," remarked Mr. Ongley. The Coroner: I agree with .that en,tirely. Oontinuing under cross-rexamination by Mr. Ongley, Shanks said- that when , Captain Armour asked him what. dose would be necessary, he ha.d replied very definitely one-quarter of a grain. The only inistake was his failure to realise the quantity of the drug in the bottles. He could not recolleat the dentist saying he would extract the teeth of the girl as she was before the second injection. Witness again deelined to . answer .a question when Mr. Ongley put it to him that after strongly recommendihg a tuiti! er administration of morphia, h'e had finally persuaded 'or convinced Captain Armour to agree to a second injection of morphia. The Coroner: You do not have to ; answer the question if you don't want to. Mr. Ongley: It is a strange thing that he can answer the question one way when it suits himself, but refuse to answer when it does not suit him. 1 submit that he should aimwer the question in fairness -to Captain- Armour. In his evidence, Shanks- has endeavoured to sliow that it was not his responsibility to administer the drug, and this question is important to Captain Armour. The question was not answered. To further questions Shanks said that in • his judgment the use of morphia for the ; oecasion was eorrect, but a inistake had been made in the quantity administered. He deelined to answer whether Captain- Armoui had been responsible for that inistake. Dentist 's Evidence. , Captain Hugh P. Armour, said he had "been at Ohakea as dental officer for about 14 months. He said he had agreed to examine Morgan's niece after' the had been assured that she was in aeute pain and could ,not receive civilian treatment. Shanks .and Charge Sister Davidson were at his house that evening, and witness said he remarked that nitrous oxide should be usqd for the operation, but none was available at Ohakea. He had previously asked Sister Davidson for some nembutal. The medieal and dental sections were entirely separate, and he had no nembutal or A.P. codine. Nembutal was given to a patient through the mouth and was commo'nly used by dentists. He had no access to the drugs of -the medieal section. He was famiiiar with the use of nembutal. During the discussioji on what drug should be used Shanks had oft'ered to give a general anaesthetic, said witness. He had asked Shanks how many general anaesthetit's he had given and Shanks lrad replied 12. Witness had not then seen the patient and said he did not think a general anaesthetic would be necessary. At the surgery it was extremely difficult to examine tlie. patient because she was in extreme pain and would not open her mouth. However, it was" clear to him that three teeth would have to be extracted on the lower left side. A sedative was discussed and Shanks recommended inorphia, Witness said he again suggested nem butal. He had never used morphia for dental purposes but it was frequent.l}' used by doctors for sedative purposes He had heard of its use-as a loCal appli cation to teeth for the extraction 'of a nerve. Teeth Extracted. Armour said he did not examine the bottle of drug when Shanks obtained it from the cupboard. After giving the injection Shanks had said "she didn't get any of that ' but witness "had replied that he would make the extractions in any case. While witness was waiting for his instruments to be steriiised, Shanks had administered the second injection. Witness gave the patient a local anaesthetic and extracted the teeth. He assisted the girl into Mrs1 Morgan's -car and saw thein drive away. To Mr. Ongley witness said his experience of linal year medieal students extended considera-bly over his service with the Air Force. During his finalyear at Lniversity .65 "final-year- mediea'i students went out with provisional re gistrations, some as regimental medieal officers, some as loeuin tenens in private praetiees and others in hospitals. He had coqsidered Shanks to be medieal .officer on the station in the absenee of Dr. Ballantyne. Shanks, as port officer of health, had granted pratique to an overseas aircraft, and witness knew of no restrictions on Shanks ' duties. He did not know that the regulations gran ting provisi.onal registrations had been revoked. Corroborative evidence regarding the diseussion of drugs in Armour 's house before the operation, and events at Morgan's house after the operation, was given by Charge Sister Joan David son. She thought Slianks had full powers as a medieal officer. "In my opinion there is no donbt that death was eaused by. acnte morphine poisoning," said Dr. T. H. Pullar, pathologist at the Palmerston Nortli Hospital, who couducted the post-mor-tem examination. There had been no evidence of disease of the heart, and other organs were norma!. Ambiguous Labels. To Mr. Crossiey witness said in, his opinion the labels on the black bottles were ambiguous because tliey did • yot indieate tlie dose. Taken at; their .f§ice value, they would mean they contained one quarter of a grain of morphia to tlie whole bottle. An ampoule usually 'con- . tained only oue dose. The label on the . cardboard box containing the ampoules

had been cofrect. Personally, he had not seen morphine hydro-ehlor put up in that type of bottle before, although he had heard. of the solution being preyared. [t_was.the, habit of hospitals to have morphine tajilets and dissolve them as required. To the Coroner, witness said he thought 1/4 grain of morphia adequate for -a girl of deceased's age. Morphia would not be described as a general anaesthetic. Three grains of morphia would be eonsidered a fatal dose. In answer to a question by Mr. Cooper, witness said aqua camphorae could be used as a drug but iu !tjiis in; stance .it was probably used only as a preservatiye. Bottles of the type pro: duced were used extensivelv in the -u-med. forces during the war., It be'.ame a standard praetice to have morphia in rubber capped bottles during the air raids in England. The fonn of the bottle -was unfamiliar to him. The norma! ampoule contained oue dose only. R would bo broken apavt aitd

' then discarded. He would agree thafc tlie general rule was the rubber cappedbottles were used for multiple doses. A verdiet as. stated was returned.