“A MISTAKE.”

Hokitika Guardian, 13 July 1927, Page 1

“A MISTAKE.”

HOSPITAL PATIENT’S TREATMENT CORONER’S REMARKS AT INQUEST. CHRISTCHURCH, July 12. "It seems to me that there lias been a lack—l don’t want to say it lack of care—hut a lack of something which should not have been wanting.-, 1 shall leave it to the public and to the Hospital Board to say whether any remedy is possible.” Mr E. I). Mosley, Coroner, concluded an investigation yesterday into the death of .Mrs Elizabeth -McKnight, who died at the Hospital on June 20th, as the result of it fracture of the skull, which was not revealed until the post-

mortem examination was made. .Mr T. .Mii’liken appeared for the relatives of the deceased. Albert Charles Sandst’on, honorary surgeon tit the Christchurch Hospital, said that he saw Mrs McKnight, the second day after she was admitted. She was completely conscious on June 17th, and witness was told that she had been admitted on June loth as a result of ail injury received in failing off it tram while under the infliicy alcohol. The X-ray report wnsQßKy tive of a fracture. There was a r .se tit the hack of her- head. Witness', examined the patient, feeling the skull, hut could find no fracture. There was some tenderness and swelling in the muscle ol the neck at the hack ol the skui'i. flic patient was able to take her lood. the next day she appeared quite ordinary so far as witness could judge. Mit ness was asked if the patient might he allowed to go out. lie said she might go out in the next day or two il she appeared to ho all right. "What- seems extraordinary to me,” said the Coroner. ’’ is that such a fracture should have escaped detection.” NOT A NORMAL FRACTURE. “So far as the fracture is concerned. three incites at the base ol the skull is not it normal fracture,” said the witness. " and it would he very difficult to discover.” The Coroner: ft seems strange to mo that she should he sent from Hospital when the history of her case was known the fact that her head had been injured in a fall. Dr Fox. the superintendent of the hospital, said that if a fracture could not he felt in through an open wound, and the X-ray and patient's symptoms failed to reveal' it. then it was practically impossible to detect the fracture in life.

Witness explained that apparently the injury was so situated near the brain, that it would take some time before inflammation could he seen. The Coroner: That is all the more reason why she should have been watched. " That is so.” said the witness. " I’m quite sure.” continued the Coroner. *• that had the whole history of the ca.-e been made known to you. you wouldn’t have fallen in. I am going to call the evidence of the son. who called on her three times, and wii'l say she never recognised him." To Mr Millikott witness said lie would not he sure whether he questioned the patient on the Saturday. He saw her twice when she was at the Hospital, between June loth and June tilth. Janies McKnight, a son of the deceased. said that ho went to see ins mother at the Hospital on three occasions. She did not know him and justmumbled away talking all sorts of rubbish. On the last: occasion the nurse said to witness, “Your mother will he going home to-morrow.” Witness salt!. "Is she able to go home,” and the nurse said she was. While his mother was talking incoherently there wontwo nurses nearby, hut lie did not call their attention to his mother's babbling.

In witness’ opinion his mother was not fit to he taken home. On the Sunday ho enii'od with los sister and took Mrs McKnight home. She was still talking strangely. Witness did not see her till the following Friday, when Dr Crooke called. She was still talking nonsense, and next day they shifted her to a sister’s, and Inter hack to the Hospital on Dr C'rnokc’s recommendation. She died on June 30th. DIFFICULT TO DETECT.

The Coroner said tliat it was evident tliat when Mrs MeKnight met with the aeeident she had had some liquor. The post-morterm hy Dr Pearson did not reveal that she was habitually intemperate, and this was important, hut unfortunately on the evening of the accident she appeared to have been somewhat under the influence of liquor. The Tramway Board’s officials had behaved extremely well, and no blame could bo laid on them for anything that had happened. Mrs MeTxuight had been admitted to the Hospital on .Tune loth, discharged on Juno 19th. readmitted on .Tune 27th. and had died suddenly on June TOth.

“I am quite satisfied from the report of Dr Pearson,” said the Coroner, “from the remarks <>T Dr Box and I rum Dr Sandston's evidence, that the fracture was. under the circumstances, very difficult to detect. In fact, the amount of medical talent available and the fact that the fracture was not detected leads one to believe that it was a very difficult one. Moreover, the precaution, al X-rav producing a negative would strengthen the opinion that a fracture had not occurred. But the fracture, was. of course, rovoaVed at the postmortem, ns one would expect. DISCHARGE NOT JUSTIFIED. “ But there is something more than that.” he continued. The evidence of the son was sufficient to convince a Coroner that the woman should not have been discharged front 11ospital on June 19th. It may have been that, the demand for beds was so great. . Dr Fox: No! “Or that may not have been the ease,” said the Coroner. “ hut even if it had been so 7 cannot conceive an circumstance justifying the patient,' discharge from Hospital. Tam quit satisfied that had Dr Sandston bee made aware of all the circumstances lie would not have consented, even tacitly to the woman’s discharge.” ■ T leave it to the public and the Hospital Board to say whether any l emedy is possible,” said the Coroner, in suggesting that there seemed to ho something wanting. "I understand that the Superintendent has strict regulations regarding the admission and discharge of such eases, and if they bad been carried out T don’t think the woman would have been discharged. At the same time it is finite probable that she would have died in any event.” •• One does not like to think that a patient should he so discharged,’ eoneluded the Coroner. “ The public mind woni’d not he easy if that practice protailed. but T do not think it does, and the public- is under the impression that the Hospital is well conducted.” “ j suppose mistakes must happen, and this is one of the mistakes.” The-Coroner then returned a verdict that death was due to haemorrhage and laceration of the brain following a fracture of the skull,