H.—3lb

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And with the like advice and consent, and in further pursuance of the said power and authority, I do hereby confirm the said Commission, except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Companion of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this twenty-eighth day of March, in the year of our Lord one thousand nine hundred and thirteen. A. L. Herdman, For Minister of Hospitals and Charitable Aid. Approved in Council. J. F. Andrews, Clerk of the Executive Council. EEPOET. To His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of St. Michael and St. George, Member of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies. I, Charles Cargill Kettle, the Commissioner appointed by Your Excellency's Commission issued under the Commissions of Inquiry Act, 1908, and dated the 16th day of December, 1912, have the honour to submit my report on— (1.) The circumstances surrounding the death at St. Helens State Maternity Hospital at Auckland of Mrs. Laura Elizabeth Chamberlain; and (2.) Generally as to the administration of the said St. Helens State Maternity Hospital. 1. Mrs. Chamberlain's Case. Mr. A. E. Skelton, who appeared as counsel for the Auckland Timberworkers' Union, lodged, on behalf of the union, the following complaints with regard to Mrs. Chamberlain's treatment while she was in the Hospital from the 10th August, 1912, to the date of her death on the 9th September, 1912, viz. :— (1.) That the said Mrs. Chamberlain having sustained a rupture of the perinseum and serious injury to the soft parts during her confinement, it was the duty of the Matron of the said Hospital to immediately send for and obtain the services of a registered medical practitioner, but that the said Matron failed to send for or obtain the services of such medical practitioner until the third day after such injuries were sustained; (2.) That the said Matron further failed in her duty to call in medical advice when she discovered that such patient was suffering from puerperal septicaemia; (3.) That the said Matron, without the assistance of a registered medical practitioner, sutured the torn part of the perinaeum in some three or four places;