SOME STRONG CRITICISM

Hawke's Bay Herald-Tribune, Issue 157, 21 July 1937, Page 6

SOME STRONG CRITICISM

LAXITY IN ADMINISTRATION Triple-Control System Not Satisfactory DR. ALLAN BERRY SEVERELY CENSURED Strong eriticism of some aspects of the administration of the Napier Hospital and of the conduct of Dr. J. Allan Berry are the principal features of the report of the Royal Commission which recently inquired in the affairs of the hospital. The report has now been preseated to his Excellency the Governor-General, Lord Galway, and has been made available for publication by courtesy of the Minister of Health, the Hon. P. Fraser, by arrangement with the New Zealand Press Association. The report comments upon the failure of those responsible to "take such prompt and vigorous measures as the situation demanded" when dealing with the out- > break of an infectious disease in the Shrimpton Ward, The Commission remarks upon the unwarranted conduct of the ward sister in giving the hot bath treatment to children without the authority of the patients' medical , pzmctitioner and without proper supervision. The re- ; port characterises the conduct of Dr. Berry, on the evidence before the Commission, as "such as to merit the f aeverest condeynnation." The organisation, control, and supervision and training of nurses in the Napier Hospital was considered by , . the Commission to be unsatisfactory and it was found that excessive hours of duty had been worked by nurses. The Commission views with disfavour the system of triple control by Superintendent, Matron and ManagingSecretary, and recommends that the Superintendent should be given much more direct authority. That a person should at the same time hold office as ,. . a member of the hospital board and as a member of the honorary staff is regarded by the commissioners as contrary to proper administration and discipline, The report also discusses the nationalisation of hospitals, the Commission's opinion being that th^ authority and powers of the Minister of Health should be much greater.

The commission eongisted of;— Mr E. D. Mosley, of Wellington, Principal Stipendiary Magistrate, ehair■tam Sir James Elliott. M.D., medical practitioner, of Wellington. Miss Ce&ilia McKenny, B.N., refcired, of PaMatua, formerly matron of Wanganui Hospital. During the hearing of tlie inquiry, which occupied tliirteen days, fiftyfour vritnesses were heard, and tlie •vidence required. 784 foolscap pagea. In the first place, the Conmiisaioa was asked to inquire dnto and report upon generally the eircumstanees in which, between May and October, 1§36, certain children, being patients in the Shrimpton Ward of the Napier Hospital, contracted the disease known as vuivo-vagmitis resultlng from infection, and all matters relevant to the discovery, control. and treatment of the' disease in these patients. The Commission fcund tliat the first patient was, in its opinion, iufected before being received. into the Napier Hospital, but the fact that the patient was so infeeted was not discovered, the patient having been admitted for anotner complaint. Subsequeut cases were infeeted within the Napier Hospital from the first ease and iroin oue another by a breukdown m supervi-s-on apd nursing techniquo. "fcjuch infeeted eases of vuivo-vagin itis may be inadvertently received into any hospitalwken tiie infection i*. present in chHdren who are admitted for an entirely different complaint, such as pneumouia,"etc.,"*states the- Commission. "The medical evidence we received was unanimously to the effect that the making of a microseopical examination of all children brought "for admission to a hospital to detect the possibility of tliis disease and guard the hospital againsc t.his infection is not an absolute safeguard, and it has other objections. However, when" a case of this kmd in a children ward is detected or suspecled, it is of the utmost importauce that vigorous steps should be taken to prevent the spread of this dreaded infection to other children. "In the case under revievv, the ward sister segregaled the patients by removing tlieui to side-iooms, uo more aultabie accoiumodaSicm being available in the hospital The ward sister did not 'reeeive adequate directious necessary to nieet the situation. . *• wnen an infectious disease breaks out * in a general hospital, it is the immediate duty of the niedtcaa superintenaent to take charge and act with promptness and vigour. In our opinion. Dr. J. «T. Poley did not take such prompt and vigorous measures as the situation demanded. "The duty of making sure that the nursing technique is " sound and effeetive tkroughout the hospital, and partieulariy in the ward concemed, :$ & VMponsibility which belongs to the Mtron. She failed to realise what might reasonably have been erpected •tf her in this situation, and put too much dependence on the ward sister. "The ward sister^ on her part, did Mcewe sufficienfc direction from >tgher anthority. The umTiiier in tifkb thermpm.siefs were used, and

other obvious defeets in nursing technique, such as insuffieient constant supervision of junior nurses and insuffieient faeilities for disinfection, eannot be condoned, and were prime factors in the spread of the disease of vulvo-vagjnitis in the children 's ward. "If the matron, as requested by the ward sister, or on ner own initiative, had provided special nurses to care for the first group of infectious patients, probably there would have been no second outbreak of the disease. "One of the vulvo-vaginitis patients was under the - care of Dr. J. Allan Berry. while four othera were under the care of other members of the honorary staff. Dr. A. D. S. Whyte was pe'rfectly satisfied with some form of local treatment of this complaint in the belief that the natural course might be tedious, but that ultimafely1 sach tieatment would sueceed. Dr. J. Allan Berry adopted an experimental method of heat treatment by means of very hot baths. "We recognise that medical treatment by means of heat (pyrotherapy) is a fully recognised method of treatment if given with suitable appliances, for suitable complaints, under

o the control of a highly teehnically trained staff, and having regard to Ihe age and resistance of tho patient. 4 4 U nwarranted, DangerouB. 4 ' "We have no doubt that Dr. J. Allan Berry ?s method of treatment of his patient was crude, not properly supervised, and not supported, as any special investigation should be, by proper records. It was proved to be unwarranted and dangerous. " We are satisfied that the treatment of the first series of patients, other than the one under the care of Dr. J. Allan Berry, was not in accordance | with the instructions of the medical ; practitioner in. attendanee on such patients. The ward sister gavo evidence that, without any authority Whatever. she had adopted a very unusual course. She subjected Dr. A. D. S. Whyte 's patients to the same dras-tie-hot bath treatmeut that Dr. J.' Allan Berry 's case was reeeiving. This ward sister alleges that her cours© of acfcion wae uahsyown to Dr, .J, Allan

I Berry himself, to the medical super-4 intendent. or to the jpatron. 44 We think that the unwarranted,. and perhaps unprecedented conduct of the ward sister was instigated directly or indirectly by Dr. J. Allan Berry, who did not consider it his business to consult Dr. Whyte, 44 It is, an our opinion, the duty of the medical superintendent, in consultation with the honorary medical officer attending to the particular case (if necessary) to notify the parents of the children, without any unnecessary delay, of the fact that they have contracted an intercurrent and infectious disease. The medical superintendent, probably in the belief that this contagious disease of vulvo-vaginitis might soon be cured, and with the knowledge of the state of public opinion in regard to venereal infection, unduly delayed his notificafcion to the parents. For whatever reason, he departed from the correct prineiple and committed a serious errpr of judgment. " Advising the Parents. Eeferring to the question of the steps that were taken to acquaint the parents with the nature of and any dangers attached to the treatment proposed to be given to patients, and to obtain the parents' prior consent thereto, the Commission states that it was well aware that it was not necessary in every changc of treatment that the doctor in charge should notify the parents or friends. "As regards the treatment adopted by Dr. J. Allan Berry, however. a new element is introguced," it continues. "The treatment that he adopted had never been applied to young children before. It required a staff with special te-chnical training, and wais undoubtedly dangerous. Therefore, we strongly condemn the failure of *Dr. J. Allan Berry to obtain the parents' prior consent. He was also eulpable in not notifying the medical superintendent or any other doctor of the staff .of the treatment he proposed. ' ' Present Safeguards.

Touchiug on the measures that have sinco been adopted to guard against the untoward xecurrence of the aisease in the hospital, .the Commission states: ,4fc3inee this outbreak of vulvo-vaginitis, there has been a very great pubiic outcry, a Hospital Board inquiry, and tho institution of a ltoyal Commission. These f acts have greatly assisted in the adoption of inore vigilant safeguards in . the hospital against the spread of recurrent and infectious diseases. At the Napier Hospital now, all female children for whom admission is sought for any disease are tested mieroscopicaily for the presence of the germ that causes vulvo-vaginitis. If Uhe result of this examination is posi- ! rive, it is a complete safeguard. If, On the other hand, the result of the inicroscopie examination and culture is negative, it may give rise to a feeling of false security. It is weil " Known that in positive cases the causative germ cannot always be demonstrated. 44In our judgment, on the evidence. while it is a matter of great impoitance to prevent the admission of a child infeeted with this disease into a general ward, it must be conceded that such a case may be inadvertently received into the most efficient hospital. "We'wisli t'o emphasiso again that it is xnost important to take steps to liniit the disease to the initial case and to prevent any of the other patients from being contaminated. We considor that rdne cases of this disease in one ward is an excessively large uumber. " Disappearance of X-Eay Film. Circumstances surroundmg the takmg of certain X-ray iiims which could not be produced tor reference wnen required were dealt with by the Com- « mission, which states in tnis couneetion; 4 4 The e vidence reveals the toilowmg facts:— The film which led to Lhis inquiry was one of three relating to three patients all under Dr. J. Aiiau Berry 's care, and all of these films at one time or another were removed. They were all of considerable importanee, parfcicularly in connectjon with certain contemplated litigation or claima for compensation. They were mystcriously returned to the X-ray room after the board docided to eall in the aid of the police. The evidence suggests that the iilms were abstracted by some medical practitioner or nurse. However, each person examined denied all knowledge of how the films were abstracted or returned. The methods oi . recording, handling, storing, and earing for X-ray films are quite satisfactory. It is important that X-ray films should b'e readily accessible for medical purposes at all times." Health of Nurses. Coming to the question oi the health of the nurses, the Commission finds that the general principles adopted for the detection of symptoms of ilJ :ealth in nurses (including pupil-nursea) are recognised in the Napier Hospital, but the question arises as to whether these are strietly and constantly adhered to in practiee. 4 4 The large proportion of youthfui and inexperienced pupil-nurses, a condition of under-staffing, the difficulty :n prpviding suitable accommodation for (lie nurses, and perhaps the want of more adequate recreational faeilities, are some of the special considerations which cause difficulties in this hospitII," comments the report. "Long hours of duty without adequate relief have also an important and detrhnental effect on the health of the nurses. 'Under such circumstances, nurses are reluctaiit to impose an inevitabiy additional burden on theil fellow-nurses by reporting*sick; henee we have evidence of nurses who have continued ou duty when they ought to have been having medical attention. 44 Excessive hours of duty have been worked by nurses in the Napier Hospital. The hours assigned for pupil-nurses were 59| in one week and 48 hours the f ollowing week, though these hours were seldom adhered to, heing often exceeded. As many as from 60 to 70 hours were at times worked with no weekly day off duty, and for considerable periods — in some cases as long as slx to ten weeks.. "The fact that legislation providea .that no junregisterefl nurss Jbe kept on ,

duty for uiorci than 56 hours in any one week was unknown to the matrou or to anyone else conneeted with tho hospital. This legislation was enactcd in 1909 and re-enacted with addit'ions in 1932. ,4Ae long, exhcting hours worked by the nurses had such an important bearing on their health, the matron should Uave been more emphatic in her reprusentation of the situation to the board. The matron would thus have appeared to have acquiesced in the unfortunate situation. The board allowed the increase in the number of hospital patients to outpaee the accommodation provided for the nursing staff. Both the matron and the board thus failed to appreciate their responsibility in the provision of what de necessary for the health and welfare of the nurses in an e-stablished hospital training school. "Tests for diphtheria, tuberculosis and scarlet fever are routinely carried out. Weighing is done regularly, and nurses are directed to report symptoms of ill-health immediately. Ward sisters are instrueted to observe pupil nurees carefully and to report signs of illhealth to the matron. There is evidence that the medical examination of nurses was less thorough than it should have been, on the assumption that the patients, being nurses, should be able to report their symptoms, and perhaps help to diagnose their own cases. 4 'One of the first necessifies for the proper care sick nurses is a self-. contained ward with cubicles or rooms for that exclusive purpose. The Napier Hospital is not provided with these. The nursing staff caring for sick nurses do so with diligenee and sympathy, but full accommodation is "lacking,, ' ' Two good tennis courts are provided for the nurses. Apart from this, tho hospital site is too small to permit of arrangements being made for other forins of outdoor recreation. There da much need 'for improvement in encouraging indoor recreation and entertainment by organisation for this purpose. Working of the Board. ' "The evidence discloses that the working of the Hawke's Bay -Hospital Board has not been harmonious, and the board has been divided into two rival sections, broadly representing Napier, and Hastings and surrounding

dietrdcts," continues the report. 4 4 The board has also been sharply divided on the question of Dr. J. Allan Berry 's dismissal from the honorary staff. The. situation is further eomplicated by tho fact that Dr. Berry is both a mcmboi of the board and of the honorary staff; he thus acts in the dual capacity oi employer and employeo. 44 The board has held special inqu:ries, reports of which have appeared in the newspapers; this has not tended to promote harmony. This unrest with its resultant lack of effeetive co-operation, must necessarily have permeated the whole administration of the hospital throughout its various branches, aud was detrimental to the discipline of the. nursing staff. "Dr. J. Allan Berry's resistance to a majority of the board in reference to his proposed dismissal as a member of the honorary staff was entirely suhversive of discipline, and this, together with other factors, helped to, divide the nurses „ into two camps. The evidence given hefore us also proves that Dr. Berry's conduct, both as a member of the honorary staff and as^ a member of the board, was* such as to merit the severest conaemnatiou. c, "Dr. J. Alian Bsrry is the only member of the honorary staff whose conduct calls for adverse cQmment. Dr. J. Allan Berry's personal association with some members of the nursing staff has been of such a very serious nature that we have no option but to recommeii'd that the evidence in reference to this be placed before the Medical Council of New-Zealand for consideration of what disciplinary aetion within its province it might consider necessary. "In reference to the heat treatment given to his own and other patients suffering from vulvo-vaginitis in tha Bhnmpton Ward, we have the f ollowing observations to make: His want of candour, to put it mildly, in his relationships with his professiouai brethren on the honorary staff, with the medical superintendent, tho matron, the child 's parents, the Ooroner, ' aud with the board, was detrimental to the discipline and co-operation of the nursing staff. ' "Apart from tha board, there ara in the Napier Hospital three administrative heads, naniely, the medical super■intendent, the matron, and the manag-ing-seeretary, eaeh with a certain degree of independence. The disorgauisation in this hospital as a result of such triple control is opposed to the maintenance of satisfactory discipline and co-operation. . . . 4 4 The system of control is full of possibilities for the creation of difficulties. There should he only one head, clearly defined, namely, the medical superintendent, and he should be the head of the institution not only in theory, but in fact. The matron should he responsible to the board througb the medical superintendent. 4 4 yimilarly, tho managiug-secretary, who should b6 desiguated by the word , 'secretary ' and not 4 managing-s6e*G-.

lary,' should be responsible to the board* except as to his secretarial duties, through the medical superintendent. ' ' Training of Nurses Dealing with the organisation, control, and supervision of the training of nurses at the hospital, the report says: "The duty of a hospital board establishing a training school is to provide the means of giving pupil-nurses adequate training in nursing. Pupil-nurses, under supervision, perform a substantial part of the nursing service. The matron, as the head of the training school, is responsible for the requirernents laid down by the Nurses' and Midwives' Eegistration Board being fully met. It is the duty of the matron, therefore, to advise the hospital board of requirements for the training school. "In our opinion, dissatisfaction aniong the pupil-nurses might have been averted if the temporary nature of the situation had been more fully explained to them. In the case of the outbreak of vulvo-vaginitis, the need for extra supervision was not suffieiently appreciated. "In this connection the conduct of two registered nurses, one in substituting unauthorised treatment, the other in carrying out such treatment for patients, should, in our opinion, be referred to the Nurses' and Midwives' Eegistration Board, ana we recoramend accordingly. " The commission finds that the teaching of the theory of nursing, medical and surgical, by the medical staff ajipears to have been fairly met, though on tho nursing side the teaching is - inadequate. Oue part-time tutof-sister cannot do all the work. "A full-tihie tutor-sister is an imperative need at this hospital," at says. 4 4 The very essential whole-time training period of nurses (held for one month or less at Napier Hospital) should, according to present-day practiee, extend over three months. " - Summing up on this question, the Commission considers that the organisation, control, and supervision of the training of nurses in the Napier Hospital is unsatisfactory, and should be reviewed by the Nurses ' and Midwives ' • Eegistration Board. The Administrative Side. "In regard to matters relating to the management and administration of the Napier Hospital your commissioners. are convinced that it is contrary , t« proper administration and discipline that any person should at the same time hoid office as a meniber of the Hospital Board and as a member oi" the honorary staff. 4 ' Wo are also of the opinion that, for obvious reasons, it is wrong for a member of 'the Hospital Board to act as Coroner with respect to any patients who have died in the hospital. "We consider that it is improper that a member of the honorary staff should retain his positiqn as sach when a majority .of the board members deeire to dispense with his services. If legislative authority is • necessary it should be taken to give power to 'prevent such occurrences. ' ' Where the Minister desires td exercise his authority with respeet to aetion or contemplated aetion by the board he should be possessed of full power to enforce such authority.

s. "There appears to be lack of statutory authority enabling a Minister effectively to deal with the po- . sition where a hospital board makes unwarranted or arbitrary decisions, which may not he in the hest interests of the institutions under its control, or consistent with the hest hospital policy for the Domlnion. 4 ' The position of the medical superintendent, Dr. Foley, restrieted as it was by by-laws, custom, and other disturbing influences, has been very difficult. We thihk that a medical superintendent whose experience has been limited to the Napier Hospital might be given necessary study-leave, on pay, to enablo him to visit hospitals in Australia and in New Zealand to observe standard principles and practiee in medical administration. "We think that the honorary staff generally should be transformed into a part-time part-paid visiting staff. Hospital practiee and private practiee are inter-related and complementary in anv community. "Plans for the lay-out of the new Napier Hospital, formulated by the Department of Health with a view to present and future requirements, were not accepted by tho board, aeting, so we were informed, under local prossure." the report continues. "Fifty general and fourteen maternity beds were provided for the Hastings Hospital, and it »is proposecl in part to staff the Hastings Hospital from the Napier Hospital. The rew Hastings Hospital is a model hospital, with all faeilities for expansion. The operating block is suitable for a hospi. tal as large as the pf esent Napier Hospital; It seems inevitable that the Hastings Hospital must expand while the Napier Hospital becomes relatiyely restrieted. "We are not here eoncerned with the propriety of establishing two hospitals twelve miles apart under the one board, but with the state of affairs that has already been established. "Tho difficulties of finance for necessary buildings in Napier was too much laboured by the board in view of the adequate loan made available by the Government for such purpose. 4 4 The building plan adopted by . the board was extremely unsatisfactory, and has made subsequeut building improventents diffieult and in some respects almost impossible. "It is obvious that thi3 Eoyal Commission cannot regard the Napier Hospital, together with the Hastings Hospital, both under the control of the Hawke's Bay Hospital Board, as separate and distinct units, but as they are, an essential part of the hospital system of the Dominion of New Zealand. " Nationalised Hospital. 4 'There is much to be said for the contention that the hospital system in New Zealand should be, in a large measure, nationalised," says. tho report. "It might well be under the control of commissioners responsible as regards broad policy to the Minister, and through him to Parliament. Such commissioners Would not be infiuenced by politieal or local1 pressure to the same extent as. a hospital board, or by the

ill-effects of rivalries and jealousies. as exemplified in Napier and Hastings. Certain it is that hospital boaTds, if r etained, sliould have their powers clearly defined and strietly limited. "It would not be unreasonable, also, that the Government (seeing that it generally provides as xruuch money foi hospitals as do ratepayers) should have direct representation on local hospital boards or committees of management. "The very extensive and efficient system of hospitals under the control of the London County Council is ,administered without hospital boards. Under ' effeetive and independent central control, hospitals could be propecly graded and co-ordinated. The opportunity as at present for hospital boards to increase the status of what should in a proper system be minor hospitals, and perhaps over-heavily burden ed ratepayers, should not occur. In other words, expenditure and „ expansion, should be controlled. To lessen overirowding of expensive hospitals, grad ing'of hospitals is essential. - " A centrally-organised system of district nursing is an important auxiliary of hospital service and materially le3sens unnecessary pressure on costly hospital accommodation. Combined with this, there should be an organised medical service for such people as are unable to alford private medical attention and nursing, many of whom ean be treated cheaply and satisfactorily in their own homes."