THE HOSPITAL.

Gisborne Times, Volume XXV, Issue 1977, 12 January 1907, Page 3

THE HOSPITAL.

PUBLIC INQUIRY. A public inquiry by the Gisborne Hospital Trustees into a complaint liiado by Air John East of inattention to his late son Gordon while a patient at the Hospital was hell yesterday at ■ the Hospital. Present : Captain Tucker (.chairman), and Messrs A. F. Matthews, F. J. liysnar, A. Tuohy, J. A. Hardin", J. ~\V. Bright, AY. I). S. Macdonald, and T. A. Coleman (secretary). Mr Lusk, solicitor, represented Hr. Morrison, and Mr Mann, solicitor, appeared for Mr East. The Secretary read Mr East’s letter of complaint. Mr Mann asked the Trustees to judge the case on its merits. He knew that they had reason to be proud of the institution, and that they had an excellent matron. Hethen proceeded to state the facts of the caso in regard to the boy East, who was admitted to the Hospital suffering from an injured limb. While in tlio Hospital the boy’s limb* was not looked at for three weeks by the doctor, according to the boy’s own statement. East’s sister visited him and saw the limb, and stated that it was in an awful state. Mr Mann was commenting on the certificate of death, and the cause of death therein stated, when The Chairman remarked that Mr Mann was taking them out of their depth, and asked him to confine himself to evidence of neglect at the Hospital . Mr Mann, in the course of further remarks, said that while in the Hospital the boy’s temperature was very high. He (Mr Mann) had asked Mr Coleman for the temperature charts, but they could not be found. Before the accident the boy was healthy and had been accepted by an insurance office as a first-class life. Mr Mann then called witnesses. Dr. Cole said that when the boy was 'admitted to the Hospital lie was suffering from inflammation of the bone, with suppuration. There wore two openings in the leg, and a tube running through, leaving a channel. There was also pus. The pus cavities were opened and everything washed out. Next day the boy was greatly relieved. The temperature which had been 101, went down considerably. Witness saw him five days after that, and he was progressing. The temperature after that was rather above normal. The boy had a-delicate constitution. He was very pale, very thin, anaemic The case was a serious ono when it came into the Hospital. Mr East said the boy had been as strong as a bullock. By Mr Lusk: The doctor stated that in the case of such a constitution as the deceased had the trouble might break out somewhere else and result in death.. Tile Chairman: In a good constitution the disease would probably not have arisen. Pr. Cole: It might have done. Mr Husk: If the boy’s leg was improving in appearance you would not consider amputation necessary? Witness: No. The Chairman : What time do you refer to. Pr. Cole: From the 23rd to 2Gth January the case was going on favourably, and amputation was not then necessary. John East, farmer, and father of the. deceased, said his son was 19 yoar3 old at the time of his death. As far as he could judge the boy was in a good healthy state when liis limb was injured. The boy complained to him about his leg about tile 13th January of last year. A fendays afterwards lie said his log was very stiff. Witness took him home, and he was placed on the sofa. His wife said she did not like the look of the boy’s leg, aiid she sent for Pr. Schumacher, who operated on the leg, and every attention was given to the lad night and day. They afterwards took the boy to the Hospital. After ho saw him comfortably in bed he came away. That was -at the time when Pr. Cole was in charge. He never saw Pr. Cole himself. Witness visited the lad, but he made no complaint. He was a boy who never complained. The Chairman said the question was whether the lad received proper attention at the Hospital. Witness, continuing his evidence, said he went to the Hospital afterwards in answer to a telegram, and he noticed that a great change had taken place in him. He saw Dr. Morrison, and said that whatever he did he was to save the boy’s leg. On the following day lie went to tlio Hospital again, and found the lad in the place where Mr Hill had died. Tho boy said they had put him there to die. It was then sottlcd that the boy should be shifted, and on the 18th April he was taken away. While the boy was in the Hospital ho had taken notice of his temperature. It was never lower than 100, and sometimes 105. By Mr Lusk : He could read a temperature chart when he saw it. It was stuck up on the side of the wall. The boy was getting on well with a temperature of 105. Ho did not know that if he had any complaints to make he should have made them at once to the Hospital Trustees. Questioned as to why he had not made complaint at once, witness explained that he was away a good portion of the time Continuing, witness said that after what lie had heard lie said ho -would not stand another dressing there. Mr. Lusk: And that’s the reason you took him out? Yes. You say that tho boy’s leg was giving pain? Witness: My boy tokl me before ho left the Hospital that he could feel thumping up tho leg. If I could have pulled the boy through there would have boon no complaint. I made that up after what I saw in the paper. Mr. Lusk: Yon never thought it worth while to niako complaint for eight months ?—No. What did Dr. Morrison tell you should be done to the leg? Did he not tell you it should be taken off?— No, he said the doctor had asked himif ho would like to have it taken olf. 1 wanted to save the boy’s leg if there was any possibility of doing it. By Mr. Bright: The doctor had not suggested amputation. Witness was questioned as to how first arose in his mind the_ thought of amputation?—He said his family had told him ; but not Dr. Morrison. Mr. Matthews said it was only wasting time going on with this. The members of tlio family would be ablo to give their evidence. Continuing, witness said ho had not received word from Dr. Morrison that either the boyV leg must come -off, or ho would ha’ o to be removed from the Hospital. Further questions were put, but it was found that Mr. East could only reply, from what he had hoard from others. In reply to Mr. Mann, the witness said his complaints wore _ based on what lie had heard from his family. Mr. Mann: AY by do you say that if the boy had got well no more -would have been heard of it? Is it not because you would have been so happj in your boy's recovery? Witness :Ycs, I would .have been sc !■ pleased that I would have had nc more to say. I have no desire foi a public inquiry. It is tho'first feu I hayo had to do with anything o tho sort. Mr. Bright: Do you menu- by wha you say you heard as to the boy’ screams that you think his log wc not properly- dressed ? _ Witness: Yes, that is what I d think. ‘ , , , , Tressed ns to why ho had remove tho hoy, witness said he had remove him bocauso he believed that lie coul bo Treated bettor in a private ho: PJ Mr. Bright: What .did. you thin ... Pr. Scott meant by saying that : you removed tlio boy it would be u your own tisk?. . ; ./V

■ Witness: I thought tlio boy wouh be bettor looked after at a private hospital. To Mr. Bright: The boy always ox- *' pressed liimsctf as pleased with the 1 nurses and matron. a Dir. Mann: I have admitted the hoj > laid ho liked the nurses and matron. Mr. Matthews: If you had nol - soon tho complaint ro Miss Olsoi p would you havo brought this up? Witness :Well, that put mo on inj " mottle. s Tho Chairman said that ho luu ■ taken it down. “I only complaint", becauso I saw a report of an enquiry ■' in the newspapers, in which my boy’s 5 name was mentioned.” Mr. Mann : But is that corroct? In reply to Dir. Lysnar, witness said, peoplo had been conti l-iady 1 sticking lum up in tho street and ask- ’ ing him to make complaint. Mr. Lysnar: How is it, tlion, if yon > wero so dissatisfied you waited eight | months, and only complained after seeing something in tho paper? ' Dir. Mann said Dir. East was smart--1 ing under tho matter. Tho boy was buried on the day of tho other enquiry, and ho was naturally very 1 grieved about it. Mr. Bright: Certainly ho would bo. Dlrs. East, mother of tho boy, was next called, and was informed that she would bo specially asked ns to tho doctors. She said her boy hail been sent to tlio Hospital on tho advico of two doctors. Sho had seen Dr. Colo after tlio operation, and asked him about it. Ho snid it was a very bad >og; they had scraped tho bone and done wliat they could; tlio boy seemed to bo doing well, though tho leg might havo to be opened up again, l’ho boy was very fond of tlio nurses. Eight days before she left for Hi ex’Bay, on tho 18th February, sho had come to tlio Hospital and spoke to Nurso Warniington, asking how Guidon was getting on. Tlio nurso replied, “Tliero is the first improvement to-day that wo havo seen in him. Witness again heard lie was doing .wall, but lied no direct conversation with the matron. On returning from Hicks Bay, 12 days later, sho was met by Mrs. Jnmos East and another lady, who were crying. She had expected tho boy to be tliero to meet her. On March 23 she had a wire that tho boy was doing well. Dlrs. East l.a 1 expressed sorrow at tho poor condition of the boy. Mr. Lusk said lie did not want to interrupt this, but it was going a long way beyond the charge against Dr. Morrison. Continuing, witness said sho had gono straight to the Hospital and was informed that an opertaio.i mast bake place. This was on Friday. Slio went to see Drs. Scott, and Schumacher, to ask them to como up, but had not seen Dr. Scott. She had told Dr. Schumacher she wanted him to como. The boy said to her, “If you only knew wliat I have suffered, mother, .you would let me have tho ieg taken off.” Witness told the boy “You shan’t have it taken off here;you shan’t die here—if I can help it.” Sho told Dr. Schumacher that if he saw tho slightest chance, not to allow the leg to come off. She had not seen the doctors after the operation. She had seen the boy next day. He .vas very low-spirited. Ho was in a corner screened around,' and witness 1 thought he had been put there to die. ; She knew there had boon two men die 1 there. ■ That affected both her nerves 1 and that of the boy. He said, “I’m | sure I’m going to die.” Slio had not seen the bedsore, but saw tlie blue I mark on him after lie came homo. i Dir. Lusk said be had no question lo ask Dlrs. East. She had said no- | Aiing implying want of attention. In reply to Dir. Dlatthews, witness said she felt aggrieved at the boy' oeing put in tlio corner, as it seemed to her, to die. In reply to Dir. Lysnar and Mr. Alann, -witness said the boy had not complained. She liad felt it much that after tho boy had been there so long she had been asked to make up her mind in a very short time as to whether the leg should come off, Continuing, witness said she had not noticed the chart. Replying to Mr. Harding, witness said, tliough the boy had complained, she had not seen anything to ieel dissatisfied about and complain then. The Chairman: We have tho fact that Dlrs. East did not complain. In reply to Dir. Bright, witness said the fact that the boy had gone back so badly in so short a time gave hor the impression that there had oeen. lack o 1 attention. Her opinion was that as he had gone back so rapidly it was not safe to leave him in tho public Hospital. Slio thought ho would receive better attention in a private hospital than in a public hospital. The fact that the leg, had gono back, in her opiiron, showed chat ho had not received proper attention. '

Mr. Matthews suggested that it might. save time if they could focus the questions on the points they wanted clear. , Mr. Bright said they should have any information out that anyone wanted. Mr. Harding considered it better to let the witness go on. Dir. Dlann said he had four witnesses within call, but could not tell whether they would bo wanted until alter he had heard Dliss Stewart’s evidence. Miss Eflio East, sister of Gordon East, said she had not seen her brother in the Hospital until after her mother left, but after that saw him every Saturday and Sunday. Ho made no complaint until the 4th Dlarch, when he seemed poorly and complained that the doctor had not seen his leg. On Thursday, the Btli Dlarch, her young sister brought amessage that Gordon wanted some clothes, as he might be out any day. On the Saturday it was a cold, wet day. On Sunday, the 11th, she went and found Gordon on the verandah. He was very poorly, and complained very much that his leg had not been examined for that week. She had not seen the leg up to then. On Friday, tlie 16th, her younger sister brought a message that Gordon’s leg had been examined. On Sunday she expected to have heard something about tho examination or operation. Gordon said jocularly that the doctor had asked him if he would like the leg off. “I think the boy Stanton’s death must have frightened the doctor about mo,” Gordon had said. On the.2sth, she had seen her brother’s leg. Ho was worrying about it all tho time. She was much concerned about tlie appearance of it, and had got her aunt, Mrs. James East, to ring up on tho Monday. The message was that she had no need to be alarmed; there was no pus in the knee, and the case was doing well. She did not know who the message was from. Her brother did not get out of bed after that. There was another examination before her mother got home. She -was not sure how she got this information. She heard that the bone would have to bo scraped again. DDritness was hero closely questioned by Dir Lusk as to why she had not made complaint to anyone, and replied that she had only complained in a general way. DYlio did you make tho complaints to ? Witness; I never used to talk about it outside our own family. Dr. Dlorrison: But you never oven told your father? DYitness: I did not want to worry Jlim ’ . .. . . Continuing, witness said her brother told her that the examination on the 16th also included probing. She did not think it was very serious as hor brother saw she was getting upset, and said the doctor was only joking. Mr Lusk: You arc making a very serious charge against tlio doctor, and yet though mention was made to you that the leg would have to come oil vou told no one? " DVitness said that tlio boy had told her the doctor was only joking. The first complaint she had made-to her father was on March lGt-h. iherc was on examination made between the 25th Dlarch and April G. Sue had given her father some of the information appearing in the lettei published, but -found out aftorwaids that it was mistaken. Dir Lusk: If Dliss East says there was a mistake I do not want to pics)

that. . . . By Mr Dlann: Her anxiety had been taken away by what the boy had said as to the doctor only joking, and therefore sho thought there was no need to make alarm. Replying to Mr Bright witness said sho did not think her brother had complained to the authorities. She was not there when the screams were said to have taken place. . Replying to Mr Lysnar, witness said her brother had not complained to the nurses. Ho was not a boy to complain. . ' Dir Lusk • questioned witness closely as to the dates, which she stated she mado sure of from her brother’s diary. Howard East, brother of the deceased, said be helped to take liis brothor to the Hospital, and lie went there to see him nearly every Sunday. His brother went there on the 23rd January. That month ho seemed to be going on fairly well. He mado a complaint somewhere about the 11th of March. He complained that ho was not going on well. DDritness did not take any action. On tho 6th Dlarch witness, visited him, and found him bad then, lie did not seem to' be getting on so well as witness thought bo should, and it put him on the alert. Deceased com-

plained to him about March lltli tlin I tho doctor had not visited him for tw > weeks. Witness noticed tho tompon turo chart whan deceased was in bet Gonorally deceased was out on thovoi i aiulah when witness visited him. I Captain Tucker: Well, wliat abou • the tompovaturo chart. Witness: I took particular noti: : of tlio temperature chart, and I noti: ed that it was generally above 100. A ono time it was 105. His tempore turo was high at tlie end of February and also in March. It was soldo) I boloiv 100 beforo tlio lltli Macdi i Witness'wroto to his father on iff lltli March, and told him that Got don was not getting on well. On rh 25th March ho visited his brotho again, when ho complained of a lot o pain. During tlio time witness wa tliero deceased had a very bad tur.i and ho had to hold him up. Tin nurso camo niul took him from tin vornndah. On tlio following Wodnos day, tlio 28th March, witness visitoc him again, and Gordon then told hill that tho doctor had oxamiuod him Witness saw him again on Sunday April 4th, when ho seomod to bo ir great pain, and was thinner. Oi: April sth ho went to sco Dr. Schumacher, an daskod him to oxaiiii.': liis brother. Dr. Schumac u-r saw him on April Gth, and tho doctor toll! him that liis brother’s leg was in a very bad state. Witness told liis mother about it, and deceased was taken homo. When at homo deceased told him that ho would not havo been in that condition if the treatment at tho Hospital had boon bettor. By Dir Lusk: What my diary shows is the dates when I visited tho Hospital, and nothing more. I am relying entirely on my memory as to what took place on tlioso dates. On tho lltli March my brothor complained to me that the doctor had not examined his leg for about two weeks. Ho did not tell his father that in the letter he wroto him. Dir Lusk: Why did you not report it to tho Matron or nurso? DVitness: I thought tlioy know thoir business. Dir Lusk: Did you speak to the doctor about it ? DVitness: No. Dir Lusk: And you did not reporttho matter to any of tho Hospital authorities ? i DYitness: No. Mi- Lusk: Can you give us any date when your brother’s temperature chart was 105. Witness : No. i Mr Lusk: DYere the temperatures of 102, 104, and 105 on consecutive days ? Witness: They were on days at intervals. Tlio temperature varied very much. Dir Lusk: DYlien your father camo back on tlio 17th -Marcli did you tell him that your brother had complained that tlio doctor had not seen him for about a fortnight? Witness: No, bu-t I told him that some time afterwards. Dly brother complained that he felt very weak oil April 1. Dr. Schumacher said he thought tliero was a chance of saving my brother. Dly brother made another complaint after he had got home ,but I cannot give tlie date of it. It was after lie had lost his leg. It was later than June. Captain Tucker: It would ho about July or later that .lie made the complaint? DD -itness : Yes. Captain Tucker: Tell ns as near as you can tlie words lie used. DD r itness: He said if he had been attended to better in tho Hospital lie would not have been in that e. ndition ? Captain Tucker: Did lie. mean that if tlie medical treatment had been better lie would not have been in that condition?. DDritness: Yes. Dliss East: It was Dr. Morrison’s fault. Captain Tucker: DD r c will hear you afterwards; but you must not interrupt. Witness: If I had known how things would havo turned out I a onkl have taken detailed notes. Captain Tucker: Did you not see a largo placard in tho Hospital containing instructions as to how to proceed ill a caso of complaint? DDritness: No. If i bad seen it I would nu h-.vo complained because I was hoping for the best. In icply to Dir. Harding, witness said he had not complained to Dir. Johnson nor to any of the trustees. Dlis East said she bad not wished to bring the matter up at all. Sho liad lost her boy, and could not bring him back. The Chairman: But on seei ig in the papers what Dr. Morrison had said they decided to take action ? Dlrs. East: DD r e decided to move because we thought the statement reflected on other professional men l)r. Sif'lmmafilii'P n fiTi-a t,orl t.linl. lip

liad been called in to see tho case. There were indications of matter about tlie knee, and lie judged it necessary to operate, which lie did. Dr.-DVilliams then took the case over. He (witness) had explained it might be necessary to again ojierato. Judging afterwards the boy would not be a good subject for operation. He was called in again by Dir. Howard East, who wanted him to see the caso. He said he would be willing if Dr. Dlorrison agreed. The latter was communicated with, ’and witness saw the case next day. - The leg was in a serious condition. If lie remembered right it was a question of amputation. Later on he had seen Dlrs. East, who wanted him to see the boy. She said, if she remembered rightly, that ail amputation was proposed, and she asked -him to see if there was a chance of saving it. He was present at tho operation. There seemed to be a possible chance of saving tlio leg, and if that treatment was not successful amputation could havo been done some days later. The operation was to remove a dead bone. He had never advised removal from tho Hospital. Dlrs. East had consuited him about it. She liad de~ scribed tlio case; the boy did not like beng in the Hospital, and she did not like that. It was through no initiative of his that the boy was removed, He liad seen the boy in the private hospital. The nurse had told him there was a bed-sore on the hoy. He knew that the boy was kept on an air jiillow for some time. That was a remedy for bed sores. Mr. East wished to ask Dr. Schumacher some questions. Tlie Chairman: You can only do it through your counsel, or take it out of his hands. Mr. East thanked the Chairman, and then sat beside liis counsel. Continuing, witness said such cases were always serious, and this was one from which serious results might at any time occur. It did not differ from other cases of tlio kind. He had examined this boy 12 months before, and classed him as a first-class life on liis family history; that he liad no lung or heart affection. He looked upon him as a robust, healthy lad. Mr. Mann: Do you wish to add anything? Witness: No; those arc the facts. I have nothing to add. A question here arose as to the lad’s health being robust, tho doctor saying that any man, though robust, might, when run down, catch microbes floating around. Tho Chairman said then he would leave out the statement as to robustness, „ , , , Dr. Dlorrison : Docs he look as robust as his' brother. Dir. East, senr., interrupted at this stage, and said that he (the boy) was robust. Dir. Lusk said that it the boy was oniy as robust as bis brother he did not look very strong. “I have been at work since I was nine years old,” said Mr. East, heatedly, “and I can work you out yet.” The Chairman called for order, but as Dir. East still remained standing, Captain Tucker said he would adjourn tiie meeting ten minutes until thev got cool. Dir. Ease, before resuming, apologised for interrupting, but ho said his feelings had overcome him on his boy being referred to. In reply to Mr. Lusk, Dr. bchuniacher, being asked if it was necessary for a medical man to examine such a wound every (lay if the nurses’

reports were favorable, said no, unless there was evidence of suppuration. Ho thought the operation oil April 7 was skiliu-.y performed, and a proper one under the circumstances. No charge, in liis opinion, could be made against Dr. Morrison in reference to that. He considered the amputation 1 necessary in the cir- ■ cumstances. ft did not follow that! being on an air pillow meant the lad had bed sores. It might bo used just to prevent them. I3y Mr. Bright: When lie saw the lad prior to the major operation there was no evidence of neglect. By Mr. Lysnar: If there were a bed sore one could not necessarily say it indicated neglect. By Mr. Matthews: To produce a bed soro a patient would have to be lying in one position for several days. A great dealovould depend on the tissue ,not altogether on the constitution. The boy would not bo able to vary bis position much. It would he hard for him to give an opinion when ho had not seen the progress of the case in the Hospital. By Mr. Bright: When he had seen the boy in the .Hospital on April 0 Ik saw liim alono; the hoy then made no complaint, nor had lie ever done so. By Mr- Mann: • Negligent nursing would produce a bed sore,.

Tlio Chairman: Might not a bed sore arise, ovoii with careful nursing, under tho condition of this boy? DDritness: Yes. Dir. Matthews said tho ovidonco was that tlio hoy was constantly out on tlio vornndah, and thoreforo liis position must havo been varied. Mr. Dtann: My ini press ion was ho was in bed for a good portion of tho latter period. Air. Harding said they had hoard nothing about bod sores, oxeepting in a suppositionary way. Dir. Bright: I took it from Mr. Mann’s original stutomout. To tho Chairman : A bed soro might bo caused even with good nursing in tho caso of a patient lying long in ono position, though it would bo mitigated by good nursing. To Mr. Lusk: Nurso Smith had reported to him of tlio bod soro within tho first day or two of tlio boy boing taken to tho private hospital. Mrs. Harnoy stated that sho had

a private hospital, to which tho boy East had boon taken. She had seen a bed sore on him; about the size of a two shilling picco on tho buttock. This was shortly after tlio boy camo in. The soro seemed to bo commencing to lieal. Dliss Stewart, tho matron of tho Hospital, said sho lmd a cloar recollection of tho caso of Gordon East. He was in tho Hospital for about ten weeks, a good doal of which ho was in bed. Ho was soon to regularly by tho medical attendant. It would bo necessary after an operation for a doctor to seo a patient onco a day, but not so ofton as tlio, caso progressed. Sho referred to the operation after the boy camo in on January 23. She did not consider tlio boy had been neglected. If the boy made tho assertion that there was an interval of a week or a fotnight during which tlio doctor liad not seen the leg, would that bo incorrect?

DDritness: Yes. Continuing, tho matron said the temperature was taken regularly at least twice a day . These charts were generally put away in a desk by herself. She was aware that tlioso charts wore missing. They had apparently boon laid asido by mischance. Sho had some charts for seven years back. She believed the majority of tlie charts about the time tlio boy was in tho Hospital were available. Slio had put tho charts of tho boy in tlio desk, but sometimes there was a cleaning out, and evidently -they had gone. She liad looked for and could not find them . Sho was quite certain that the boy had no bed sore on him, and the statement that lie had was incorrect. By Mr. Lusk: There would be an average of 250 patients go through the Hospital each year. Dr. Morrison had been Dledical Officor for five years. Sho had not heal’d any complaints to the Trustees about him, except in those cases. Mr. Lusk repeated Dlrs. Harney’s evidence, and asked witnoss if she still maintained there was no bedsore on tho boy ? DDritness : I do. - Continuing, witnoss said Dr. Morrison usually visited ail the patients He liad seen the boy Gordon East daily. Tlie doctor liad done a second small operation on the boy, who continued to improve until the end of Dlarch. The wound was healing and the pus disappearing. Reports wero given to the doctor from day to day. Tlie doctor would see the boy every second or third day after ho began to get well, and he was informed every day of his condition. Do you think tlie doctor did everything possible for him?—Yes. You are quite satisfied that nothing more could be done for the boy? -—Yes. Continuing, Dliss Stewart said tho charts were mainly for the doctor's use as reports. The boy was happy and seemed very fond of them. He never fretted. The boy never made complaint to them. DVas ho sorry to go out of the Hospital?—Yes; he cried because lie had to go . Is it correct that for a fortnight tho boy was not attended to by tho doctor ? DDritness: No. By Mr. Mann: There was a second smaller operation, but she could not remember the date. It was nearly twelve months ago. Dir. Tuohy: DYere you awav from tlio Hospital while the bov"East was here ?

Dliss Stowart: I was not away a whole day during the time the bov was in the Hospital. B3' Dir. Dlatthews: There would not have been a week without the bandages being taken off; tliero might have been throe days. Tlie bandages would bo taken off by tlie nurse in charge— not a probationer—and any change would bo at once reported.

By Mr. Bright: In the earlier part of the case the. temperatures would have been high, as stated by Mr. East, but not as tho ease progressed. By the Chairman: There are two copies of tho rules in each of the large wards; these showed how complaints couhl be made. Any complaints made to her must be entered in the book (produced). Tho Chairman: Tho last date of complaint hero is in 1880. Mr. Mann: What has this to do with tho East case..

The Chairman: A lot. If no comlaints have been made.

In reply to Mr. Lysnar, Miss Stewart said the book was always available to make complaints. Mr. Bright: I notice by the book that most of-these “complaints” arc expressing satisfaction with the Hospital. You say the last complaint was in IShfi. That is not so —it is an eulogy. (Laughter.). Mr. Mann said he was calling the nurses simply to have all tho information in, not by way of complaint. Tho Chairman said they could see through it all now how it had come about, through things being said. Complaints, to be effective, should be made at the time.

Mrs. Bruce (formerly Nurse Warmington) gave evidence that she had attended to tho case of tho hoy, dressing the leg twice a day, and once as it got bettor. It was her duty to go round to the patients with the doctor. The doctor saw the hoy’s leg every day while at jts worst, for weeks.

Mr. Maim; J)o you think lie wan liogloctod by the doctor? Witness: It is not right to question a nurso about a doctor. Mr. Mann: That is for the Chairman to say. ■Witness: No; ho could not linvo neglected tho boy when lie saw him every day. Mr. Lusk: Wo wish you to state anything you know, whether it concerns tho doctor or not. Continuing, witnoss also said that any statement that tho boy had not boon soon by tho doctor for a fortnight would not bo correct. There was a bod sore* on tho hoy when ho camo in, but none when ho went out. Sho was quito sure of that. The doctor had dono a minor operation on tlie boy ,who continued to improve. By Mr. Lusk: Tho boy’s temperature suddenly went up, and tho doctor attended to him at onco, and said ho must bo operated on. Tho boy had got on so well that they got his clothes, thinking ho would get out on crutches. Was there any neglect in the easo during tho timo ho was in tho Hospital ?—No. Continuing, witness said she had been fond of tho boy, and ho of them, so much so, that when ho was leaving ho cried. Alter tho hoy had leit to go to a private hospital, sho hoard rumors that ho had been moglectcd in the Hospital. She went and spoke to tho boy himself ,nnd asked il he had said sho had not attended to his bandages. He said that ho luul not been neglected in any way. Nurse Edie was with her at tho time. “Is it truo, Gordon,” sho asked, and ho replied “No.” Asked wny no uni not deny tho rumors, ho said, “Pooplo will talk.” Asked why ho did not deny tho reports, he said there was no use noticing everything said. Tho Chairman: Hid lie deny that ho made any assertions of neglect? Witness: . Yes, ho did deny it. Mr. Mann: In tho presence of Nurse Edie?—l T os. Mr. Matthews asked ns to tho statement as to bed sore. Witness positively said tlioro was no bedsore on the boy when he loft the Hospital. Ho was washed on the morning ho loft by Nurse Reed. Ml'. Matthews pointed out that tlioro was a complete contradiction in thoso statements. In reply to a question, Mr. Mann stated that unfortunately Nurse Smith was at Whnngarei. Mrs. Humphreys, nurso, stated that sho had seen Gordon East on the day ho camo out of the Hospital. Sho saw in September, at his own homo, that ho had a bedsore; she would say it was a long-standing sore. She had not seen any sore on him when lie left tlm Hospital; glip had not seen his body then . Dr. Scott, examined by Mr. Lusk, said lie first came into tho case on tho removal of the boy to Mrs. Harney’s house. He had examined the boy and consulted with Dr. Schumacher, agreeing that amputation was desirable. Ho had hoard nothing then of a bedsoro. Mr. Mann: You aro not prepared to say lie had not a bedsoro? Dr. Scot: No, my attention was not called to it . Continuing, Dr. Scott said hq would not think it necessary to examine tlm boy overy day if the nurses’ reports were, favorable. It would all depend on tho circumstances. In reply to Air. Bright, Dr. Scott said ho had told Mr. East that if there was ffny doubt about the case as to amputation, that doubt could well bo left to Dr. Morrison. He had not soon the case then, and just spoke from a professional standpoint. Nurse Edie, examined by Air. Mann, stated that she had charge of the case of Gordon East for the first fortnight. Tlm doctor had seen him every day for that fortnight, She,, only had to do with the ease on night duty. Sho could only speak as to him during tlm fortnight. By Air. Lusk: She had seen the boy afterwards with Airs. Bruce. Tho latter had asked if she had hoard tho reports, and if lie had made them . He said that lie had made no complaint, and had not thought it worth while contradicting them. J3y Air. Matthews: Tim boy had a bed’ sore when ho came in, but she knew nothing of one when he went ■ out.

At the request of Air. Matthews, Airs. East was asked if she knew of the boy having a bed sore when ho came in. She said Aliss Stewart had called her attention to it; ho had been hiarked by tlm seam of tho trousers. Site did not know, beyond being told of a bed sore, when lie went out. Nurse llecd corroborated tlm evidence as to tlm attention of the doctor during the.time slm had to do with tho case. Questioned as to tho bed sore, witness positively said that there was nothing in tlm nature of an abrasion or bod sore when he left tho Hospital. She had had to do with tlie washing of him. In reply to Air. Harding, Nurse Reed said slic saw the boy regularly while on night duty . Tie made no complain t. Air, Harding: He was a nice, quiet boy, on good terms with all of you? Tcs. Air. Harding: You wore on such

intimate terms with him that you think lie would have made any complaints to you ? Yes, we were very fond of him. Miss Stewart, re-called, said she had no knowledge of any bedsore, and absolutely denied that' the boy left the Hospital with a bedsore. Dr. Morrison, Medical Superintendent of the Hospital, said he had occupied that position for four and a half years. About 300 patients passed through his hands every year. lie had never had a complaint against him before. The temperature charts wore koj)t for his use, so that lie might see how the temperature varied. In most hospitals it was the lule to keep temperature charts. As far as he knew it was’ the custom of the matron to keep the temperature charts. No one regretted more than he did that the temperature charts relating to the deceased had not boon produced. Had the inquiry been held within a reasonable time, they could have been produced. The mark on deceased when he came to the Hospital was simply an abrasion on the skin. He had never heard of the boy suffering from bed-sores. If such sores had existed it would have been reported to him. The boy was a peculiar looking, delicate sort of a boy: He did not think the injury would have ended fatally in a healthy boy. He thought he had a tuberculous or syphilitic tendency. About a fortnight after the boy came in he again operated on him, but it was not a severe operation. He had another medical man with him to administer anaesthetics After that operation the patient progressed fairly we! . and his temperature came down to less than 10(J. "Witness exmained him frequently aftoi the operation, and when he was convalescent and en the verandah ho used to examine him twice a week. He also watched his temperature chart. He did not let a week go past without seeing the boy. On the 25th March,', the lad's temperature. rose, and the log was much swollen. He was kept in bed. The leg started to pain him a great deal more, and the boy said lie would like to have it off, and have done with it. At that time ho examined the limb every day. He sent word to the lad’s parents that another operation was necessary. Mr. Hast suggested that Dr. Schumacher should have a consultation with him. Witness had a consultation. The question discussed was whether we should have an amputation there and then or have it scraped. Owing to the parents’ desire; that there should he no amputation, it was decided to scrape the hone thoroughly and see what would come of it. The following day this operation was performed. The ope ation did no good, and the hoy’s su lerings were terrible. Ho told M

liast that if lie would not allow him to amputate the leg, he would like him to sec the leg when lie was dressing it, and the terrible sufferings his son had to undergo. The day following, Mr. East took the hoy out of the Hospital. Ho did not attribute the taking the boy out to Dr. Schumacher, hut to the parents. During the time the boy was in the Hospital he gave him all the attention required, and much more than was given ordinarily. No one felt the lad's sufferings more than he did. The

nurses were conijietent and carried out his instructions. He had no knowledge of any patient having a bedsore after coming into the Hospital. It was absolutely impossible that the lad could have had his temperature up to 10-5 and feel comfortable and happy. By Mr. Mann: Dr. Schumacher agreed with him when in consultation that in all probability the boy’s leg would have to come off, and the decision to scrape the bone was ill deference to the wishes of the parents. He was himself jiersonally in favor of taking off the leg there and then, because ho diiT"ftot believe that scraping would do any good. ' Mr. Mann said lie saw discrepancies between Dr. Morrison’s statement, as reported in the papers, and the statement lie made there that day.

Dr. Morrison said the report of their proceedings which had appeared in the paper that day was not absolutely correct; so that they should not tako his statements as reported in the paper, but as made at the inquiry, , 13

Afr. Mann: Tho wholo inquiry had arisen out of tlm statonmnt of Dr. Mo prison .which had appeared ill one of tho papers. . ' Further cross-examined by Air. Maun, Dr. Morrison said": Ho had stated that tlm lad seemed to have a tuberculous or syphilitic tendency. Ho based that belief on his oxpormneo and tho boy’s own appearance. Tho operation hook was now produced, but it did not contain any record of tho operation whom another medical man was called to administer tho anaesthetic. By Air. Mann: Witness had nothing to do with tho book. . Mr. Mann: That was an important operation, and it ought to liavo boon roeorded in tho operation book. In reply to further questions, Dr. Morrison said that a day or two after tho operation oi : scraping tho hono ho saw tho log must como oil. It tho matter had been loft entirely to him ho would liavo taken tlm leg oil some timo previously. ... Air. Lusk said that this inquiry was a gravo matter, as it affected Dr. Morrison and tlm matron. Jhe Trustees must have absolute proof that tlm complaints wore well founded before they could sustain them. Tho main charges woro that Dr. Morrison, in tlm treatment of tho hoy ,was so careless and inattentive that lie had caused tlm death of tlm boy Gordon East. In general, when thov had a heavy charge against a man tlmy had direct evidence against him ; but there was no direct evidence in this caso. There was simply hearsay evidence. All that Howard East’s diary showed was that lio had made visits to tlm Hospital, but there was no entry of any complaint. Howard East never reported any of tho complaints to his father. Surely, if there had been a complaint it was his duty to report it to his father or mother; but, according to his own statement, ho had not done so. It had not been suggested that Dr. Alorrison had shown want of skill. The only complaint against Dr. Alorrison was that ho had not examined tlm lad for a weok, according to one witnoss, and a fortnight according to another witness. If tho nurses’ story could bo believed there was absolutely no ground whatever for any complaint against Dr. Morrison, If they behoved tlie oYideimo of Airs. Bruce and Nurse x.tllo, whore-woro tho charges. Tlioy were most fortunate in having that evidence. Ho was not going to say anything as to tho temperature charts, which were simply kept l>y the nurses to assist tho doctor: The fact that tlm charts were not kept was no fault of tho doctor’s. Tho matron and all the nurses said that tlm boy had not bod sores when he came to tho hospital. There was absolutely no evidence to support tho charges against Di>. Alorrison. It was not a fair thing that charges should ho brought against a medical man on such flimsy and ridiculous statements. It amounted to an attempt to wreck the doctor’s reputation, and without any proof to support tlm charges. Air. Mann also addressed the trustees, and contended that his clients wore justified in asking for the inquiry. They had been quito honest in tlm matter. They were not people to stir m> strife j blit they felt that in this case there ought to ho an inquiry. Tho East family had not concocted their story, but had acted up to the liglip they had. Tho evidence in tho case was very conflicting, and lm was glad that lie was not on the jury. Air. East thanked tlm trustees for their hearing of tlie evidence and careful investigation. Tlie room was then cleared for the Trustees to consider the evidence and come to a decision in the case. It was half-past ten o’clock when Air. Coleman, the secretary, informed the reporters and solicitors that the Board had arrived at a decision, the consultation having lasted over an hour. Tho Chairman read the finding of the Board, as follows:

“That the Trustees after investigating the evidence in the inquiry as to the treatment of the late Gordon East, who left the Hospital on the 10th April, 1906, are of opinion that tho weight of evidence goes to establish that ho received all jiroper and necessary medical and nursing attention whilst in the Gisborne Hospital,”