DEATH OF PATIENT.

Hokitika Guardian, 24 June 1925, Page 4

DEATH OF PATIENT.

I) GNEDIN HOSPITAL IXQnj.IV DI'XEDIX. dune 22.

The adjourned iiKjuiry by the Hospital Board into the circumstances ot the death of James Robertson, who died in Dunedin Hospital on April 20, when about to undergo ait o]K*ratiou lor the removal of a dental plate from bis throat, was concluded this evenThe follow illg was the Is,aril's fiiiilino. The hoard finds: (I) There was unnecessary delay in the ease of the late James Robertson, ami has noted the opinion of the honorary medical staff, subsequently supported |>v the evidence of Professor Bell that the delay which did occur was not responsible tor the death oi the piitieiiL. nor did it accelerate the latal ending of the case. The board desires t., express its crave concern reward in <5

the atmosphere provailng among ecri,iin members of the resident siaff as revealed by tlieif own evidence at Ibis inquiry. The practice of bare compliant e with the letter ol the regulations u quite foreign to the ordimtry spilit always believed to exist among the resilient medival staff, and the lack of

■vidcnce of mutual helpfulness. espeei allv from senior to junior is very re

gret. table. The board believes this -pirit to be quite a recent growth. and 1, insistent on its repression that the written regulations should be the minimum and not the maximum demand on tin* liniiso surgeon's service*.

(■>) The board is not satisfied with the measure cl control and supervision exercised by the medical superintendent and A..M.0. ft is not expected tire, the medicid superintendent should personally examine every patient in the hospital, but it is expected that he should be sufficiently in touch with what woes on to know H the reguhi- • inus are not heine complied with, 01 il ;,„y patient is not receiving proper attention. ( :tl The board finds that Dr. Tveracb l"!U!( 1 dto realise Ibe full responsibilities of bis idliee ill nut visiting a case of thi» nature at tin* earliest opportunity alter be learned of its presence i.c.. a

12.50 pi.lll. on Saturday. The tact that lj,i-ce of bis subordinates liad already the |.itient does net- relieve him ol that responsibility, and the board is unable to accept- as valid bis repealed assertion that “once an hmiorarv surge-m is made acquainted with Hie ease under bis charge T do not think I have any responsibility in seeiUp! the ease."

(Il Mr Butterfield in going down the harbour on Sunday. April 2n. when he had received delinite ilist met ions from Dr. Anderson to remain on call in rase of emergen y. definitely ihsobeye.l orders. Mr Butterliehl should understand that and In*, must he absolutely 1,, |,e relied upon in lot lire to obey impliei 1 ly, instructions given to him lit Ib- -u| erior ofiicers. (, w ,i || (s regretted that Dr. Rat ligate wa- not com.immirnted with earlier, and that- when she did know of the ease, and not being able to attend to il herself, and Dr. far,-well not being available she did not. suggest the transfer of the ease to another member of the special department instead of de--1;,.. in,,- for several hours. ! 1 be board I'nriher considers thill when Dr. Bath-

eale realised that she could not rc--111;:V1 * the t'Hitll plate, she eolnlllitted on error of judgment- in mil flaring the rase I rallsl'el'reil lo I’rolessor I'.ell immediately. instead of instructing the hens" surgeon i-i notify him the I*l- - morning. Oil The hoard was not favourably impressed by !>r. .Marshall's evidence, tie cpling bis >t:iler,ueu 1 bat lie vas , 11,.,J : :;o a.m. oil .Saturday, e.ot ie. Dr. Miller'.-, senior, hm as I'rofes-

Kell's holme MU-eon. The hoard m of i.uimoii that Mr Alar-hall -houi.: cither have s.en the patient h i in-ml f nr should hare advised his junior mlleimile to lilt..till the A.M.O. 17l 1)1-. It.-id (house -u roe .lit tailed to visit Mr I*..hortsoii at A.(Ft a.m. on Palimlav. w b-n infermcd l.v I>r Miller lII' i lie patient's admi-minu under Mr. V.al ligate, and also failed io report either immediately. er at all, to tin\.M .(>. 11l tile opinion of the In aid ihi- \v;i - a sol ion- ..mi ion on tin- part of this In use -urycan. ami it was tlm * initial eaime ol much of the MlW-■|ii.-ut delay. Co That the following matters ha refer.v.l for immediate leporl to a jej ui meeting of the Hospital ( ontmitt:l., and a committee of the lifiiairnr.v medical stall: - (It Duties ol tiem.'ilieal siipeii l. 1.-nde/U : tJi tile duties and status nl' the A.M.O. : (-1) the question of the revision ol' ihe standing er.hr- ol the residciu -tali', including ail -p.-ial departments of the hospital.