H.—3la.

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REPOBT. To His Excellency the Right Honourable John Rush worth, Viscount Jellicoe, Admiral of the Fleet, Governor-General and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies. May it please Your Excellency,— We, Frederick Earl, Donald Johnstone McGavin, James Sands Elliott, and Jacobina Luke, the Commissioners appointed by Your Excellency on the 12th November, 1923, to be a Commission under the Commissions of Inquiry Act, 1908, to investigate and report upon the conditions under which the disease of puerperal septicaemia or like diseases arise or are spread, and particularly into the occurrence of maternal deaths at the Kelvin Maternity Hospital, Auckland, during the year 1923, for the purpose of ascertaining the cause or causes of such deaths or illnesses ; the circumstances thereof ; whether there was any, and, if so, what, connection in their causes or origins ; whether all necessary and desirable measures were taken to prevent their occurrence ; and what steps, if any, are necessary or desirable to guard against, deal with, or prevent the recurrence of similar illnesses or deaths under like circumstances ; and particularly to investigate and report upon the following matters —viz., the circumstances surrounding the illnesses of (a) Mrs. Heather Hill Barker, (b) Mrs. Hazel Montgomery Morison, (c) Mrs. Doris Elsie Jones, (d) Mrs. Evelyn Maude Dacre, (e) Mrs. Emma Caroline Ada Delamore, (/) Mrs. Muir, and certain other matters specifically set out in paragraphs numbered 2, 3, 4, 5, and 6 of the order of reference of the 12th February, 1924, have the honour to report as follows : — We have made a full and exhaustive investigation of all those the several matters committed to us for that purpose by Your Excellency as aforesaid, and in the course of our investigation we have taken the evidence upon oath of several officers of the Department of Health, of all the medical practitioners who were in anywise concerned in the several specific cases inquired into, and of the Matron of the said Kelvin Maternity Hospital, and of all other persons ascertained or believed to be able to afford information affecting the said specific cases, or other cases demanding inquiry occurring in the same hospital in the year 1923, and we have inquired into and examined the legislation, statutory regulations, and departmental instructions affecting licensed maternity hospitals and other matters pertaining to the subject of investigation. 1. (a.) The circumstances surrounding the illness of Mrs. Heather Hill Barker. The patient was admitted to the hospital on the 17th July, 1923, at about 9 p.m. She was confined on the morning of the 19th July, early. The other cases in the hospital were normal. The medical practitioner in charge of the case was Dr. Sydney Charles Allen, of Remuera, Auckland. Her illness developed on the 21st, and she became unconscious at 3 a.m. on the 22nd, and died at 2 p.m. the same day. This was not a case of puerperal septicaemia or any like disease. It was clearly one of those cases grouped as " toxaemias of pregnancy " -possibly ura;mic. No fault can be found with the medical attention or the nursing of this case. Mrs. Barker could not have been a source of infection to other patients. (b.) The circumstances surrounding the illness of Mrs. Hazel Montgomery Morison. The patient was admitted to the hospital on the 23rd August. She was confined on the following day. The medical practitioner in charge of the case was Dr. Ernest Williams, of Remuera, Auckland. This, in the opinion of the Commission, was a case of primary local septic infection, and death resulted from embolism, causing heart-failure. In all probability this embolism arose from septic thrombosis of the pelvic veins. No bacteriological examination was made, so that it is impossible to determine the