H.—l9b

XXXVI

11. The extent and causes of the mortality among the troops. These are shown in the medical review. 111. Whether due care and efficient measures have been at all times taken to prevent or minimize such sickness or mortality Having regard to our findings under No. I, we say that due care and efficient measures were not at all times taken for these purposes. IV. Whether an efficient system for the treatment of the sick has at all times existed in connection with the camp. We answer this in the negative. Under this head we specially refer to the non-provision in advance of hospital accommodation and equipment at a stage when the necessity for it was imminent, thus rendering sudden action necessary when the emergency arose, with consequent disorganization, confusion, and overcrowding to the prejudice of the sick. V. Whether an efficient system of medical examination has at all times existed in connection with the camp. We group under this question— (a.) Diagnosis : It is not established that the system adopted for the examination of the sick in camp was other than the usual system followed, and efficient. (b.) Sanitation : We think the medical examination with respect to sanitation failed—(l) In permitting overcrowding of the hutments; (2) in not recommending drying-apparatus; (3) in not recommending better accommodation at sick-parades. VI. Whether in any cases the sick have been neglected or improperly treated. Evidence was given in regard to certain individual cases of hospital treatment, in some of which the suggestions either expressly or impliedly was that the patient had been neglected or improperly treated by the Medical Officer and nurses in charge of him. We consider that the evidence before us does not warrant a finding that there was neglect or improper treatment in any of the cases referred to. Instances were given of inattention by orderlies, but as these men could not be identified by name it was impossible to inquire further. VII. Whether undue delay has in any cases taken place in the removal of the sick from the camp to a hospital. There is no instance brought before us of any undue delay in the removal of any patient from the camp to a hospital. VIII. Whether proper notification has at all times been made to the relatives of the sick, and sufficient facilities given to those relatives to afford assistance or comfort. We find that there was for a time no provision made for notifying relatives or next-of-kin of cases of sickness unless or until the Medical Officer in charge of the case reported it as serious. There was some delay at a certain stage of the epidemic in the transmission of the messages sent by the sick themselves to their friends, and in certain instances, under the circumstances mentioned in paragraph 137, delay in the case of serious illness. We find that in no serious cases have other than full facilities been given to the relatives to afford assistance and comfort. IX. Whether an efficient system of drainage, water-supply, and sanitation at all times existed in respect of the camp. As regards surface and sewage drainage, at the outset the system was efficient, but as the camp grew the necessity for a better system arose, and at the period of the overcrowding of the camp we find that the system became inadequate. To remedy this inadequacy the aid of the Public Works Department has been invoked.