POISONING CASE

Hokitika Guardian, 30 September 1926, Page 4

POISONING CASE

IXQ l-JSST COX CL U DED. EVIDENCE OE VALUE TO .MEDICAL PROFESSION. i TI.MAIiC . Sept. 28. f At tin* Tintimi Courthouse to-night i Mi- E. D. .Mosley. District Coroner, re- t opened the- inquest held last week into c the circumstances r»t the death ol \ Patrick McCann at the Tiniaru Pnhlic : Hospital. _ ' The interests of the Smith Canter- ; horv Hospital Ih.Mrtl were watched l>y ; Mr Finch, while l)r I. C. Fraser was - represented l.y Mr Ulrich. ■ The on- t qiiiry was conducted by Sviiioi-bci-geant Fahey. MEDICAL Sl PERIXTEXDEM b> 1 Dr Parr. Aledieal Superintendent at the Hospital, in continuation of the evidence he had previously given. said ; that he Hid not fully examined the deceased. Patrick McCann, when lie hrst came into the Hospital on September 22nd, and he was not examined-by any other doctor. Deceased was sent in for a special purposes, hnd not as an ordinary patient. That was why lie was not fullv examined. About 2 o’clock witness went to the ward, and saw Sister Tomlinson, who was in charge ot the ward. She m l .is to no off duty at 2 P-m----*‘f asked her.” continued the doctor, “to hold up the giving of the actual meal in the meantime. I may have said something to Dr Rich about altering the chart, hut I do not remember it. I knew then that Sister Jmulinson would be going off duty at 2 o’clock. I did not know thn a barium meal bad been noted on the chart at the time. The first 1 knew- ot it was. T think, after he died, when the book came to the office. If f bad known it was on bis chart, it would have been advisable to b-ive crossed it out: till at is. if it bad been definitely suspended, but I bad merely put it riff IV.r a while. I am administrative head, as well as medical officer m charge of the hospital. Nurse .Barrett was not there as head of the dispensary, hut as a pupil, as lar as dispensine- was concerned. Sister Prior had Hone off a little early with the matron s permission, find Sister Taylor was to supervise in the disoensnry. As it happened. I had no knowledge ot the change of dispensing sister I rum Sister Prior to Sister Taylor. At that time it was customary for another sister to come to the dispensary when Sister Prior was not available, find the matron was following the ordinary custom in sending Sister Taylor to relieve Sister Prior. Evidence was given by Dr I* i asei and Sister Taylor. CORONER’S COMMENT. This concluded the evidence, and in commenting upon it the Coroner said that so far as he could learn, the duetors usually referred to barium without reference to the existence ol two bariums. All men at all times, in all professions, found themselves Miser af\er the event. Tt was human to make mistakes, bid what they must aim ot was the reduction ol errors to a minimum. This enquiry Mould be of considerable ethical ion value, and would he useful to medical men, belli in public and private practice. No doubt this case would lie referred to by medioi! journals and in books mi medical jurisprudence. He had b n eu told that already, as a result of the ease, medical men had learned a stood deal more about the two bariums than they had known before. The accidental poisoning ol the late Mr Patrick Aleennn cast a stigma on the hospital administration, and it,was their duty tr> do what was .possible to guard against the possibility of a repetition nf such a happening. Ho knew that the Aledieal Superintendent at Hie 'I imam Hospital. Dr T. L. Parr, was a man of high personal integrity., and one who did not. lmulk anv awkward question, hut he was liable to make an error the same as anyone "Ise. He (Hie Coroner) was satisfied that Dr PlU’r laid nar done all that he migH; have done with a view to avoiding the mistake by his staff, (liven as Ibis ha iu.-ii had been, given, it was an irritant poison, I’nd shou’d have been label!;-.1 “poison.” AVliy it- was not was hard to understand. Doing in the disnetisnry. it was liable to be. dispensed bv nn inexperienced person. ft, would have been better bad this barium carbonate been destroyed, tt did notseem to have been used far Hi" oust four years. There was a mistake for which lie one hut Dr Parr could tie blamed. Then there was ;.he fact that there was u-:: qualified dispenser at the hospital, line! Hurt was a great weakness. To rely upon an unqualified dispenser was not safe. The pub ie should demand an alteration, and he was satisfied that, I.hev would do «" DR ERASER’S RESPONSIBILITY. The C'roller revirwed the evidence in some detni l .ami said that the neglect c-f duty on the part, of Dr Fraser was mol’" sir, '' l , than !"'■ had at first thought. The Coroner suggested to th" Hospital Board that there should hr a qunliMc' l dispenser ni the hes|)i:id. and said it "’as not tail' to put. medical men in the position in f which these men bad boon placed. The doctors worked very hard, and bad ) long hours, and it was unfair that j they should also he responsible for s the dispensary. He was sure tlf.it the Hospital Board would do this. Ihe ? conclusion that lie had come to was » that while Dr Fraser could not be rei Roved of all responsibility, bis respon--5 sibilitv was more of a teebnieal riiture, } and was not so grave as the sneaker 5 bad at first thought. The greater rcs sponsibility feP on Dr Parr. wlio bail , i great many duties to perform, and ' held an exceedingly responsible posi- » tion. The Hospital Board was also at 5 fault in having put too much upon ) the shoulders of the Aledieal SupcrinJ tondent and on his young and inex- > perienced house surgeon. If trie Hos- . pita I Board Mould remedy defects, , good would result to this and other hospitals.