H.—3la

10

Mrs. Jones's case was not notified as puerperal septicaemia until after her death at the public hospital, obviously for the reason that the medical practitioner in charge had not earlier recognized that the case was one of puerperal fever. Mrs. Dacre's case was notified, not in the form prescribed by law, but by a letter from the medical practitioner dated the Bth November, 1923, two days before her death at the private hospital to which she had been removed. There was good reason for suspecting puerperal septicaemia in this case on the sth November, and it was definitely ascertained on the 6th November. In Mrs. Delamore's case a reasonable suspicion should have arisen in the mind of the medical practitioner in charge on the Bth November, if not earlier, but notification was not made until noon of the 10th November. In Mrs. Carter's case a reasonable suspicion clearly arose on the 4th November, whereupon notification should have been made. There is, however, some excuse here, as the patient improved almost immediately, and the medical practitioner apparently abandoned whatever suspicion he had previously entertained in view of the discovery of signs of pyelitis. In Mrs. Muir's case notification was prompt. Isolation and Disinfection. As to isolation in each of these cases, all that was possible in such a building as the Kelvin Maternity Hospital was done, but no thoroughly satisfactory isolation was possible in that building, a disability common to most private maternity hospitals in the Dominion. Dr. Makgill, who has held and still holds high office in the Department of Health, stated, " We have never asked private hospitals to make special provision or convenience for isolation." With regard to the method of disinfection employed, the Commission cannot fairly take exception to the steps taken by the Matron of the hospital, as they in each case complied with all the requirements of the Department of Health. The Department has no standardized plan of disinfection, and has not officially laid down its requirements. The Commission is, however, of opinion that the use of sulphur, which was employed at Kelvin, should be discontinued, and the more generally approved and effective disinfection by formalin insisted upon. The requirement, under Regulation 9 (5) of the regulations of 1907, of written authority from a medical practitioner before a nurse who has been attending a septic patient be permitted to resume duty was not in any case fulfilled, but it seems abundantly clear that the fault here, if there be any fault, is with the Department of Health, which has deliberately omitted this requirement in its leaflet H. 628. The Department of Health (Precautions by). The Auckland District Health Office staff consisted, at the time of the happenings at Kelvin Maternity Hospital, of the following : Dr. Hughes, Medical Officer of Health ; Dr. Boyd, Assistant Medical Officer of Health ; Miss Bagley, Assistant Inspector of Hospitals, Superintendent of District Nurses, Inspector of Midwives ; Miss Mirams, Nurse Inspector, Assistant to Miss Bagley ; Chief Clerk, Accounts Clerk, three other clerks, cadet, and three typists. Dr. Hughes went to Rotorua on the 6th November, returning by train on the 9th November, arriving in Auckland at about 4.15 p.m. Dr. Boyd was absent on annual leave from the 29th October to the 12th November. Miss Mirams was on annual leave from the 29th October to the 20th November. As to the precautions taken, and the action generally of the officers of the Auckland Health Office in the direction of controlling and preventing the spread of the infection revealed to them at the Kelvin Hospital, it is obvious there was a complete, and, having regard to the exceptional circumstances, an amazing, absence of vigour. This hospital was subjected to the routine inspection by Assistant Inspector Miss Bagley on the 16th February, 1923. Although there had been a death in July, two in September, and one on the 10th October, of patients of this hospital, it was not again visited by any officer of the Department of Health until the 16th October, 1923.