13

H.—3la

5. Whether any further precautionary measures, whether usual or not, were desirable in such or will be desirable in similar cases in future. Notification and Precautions. As has been indicated in the preceding paragraph, further precautionary measures were desirable in the cases at Kelvin Hospital —viz., on the part of certain of the medical practitioners, notification, in terms of statutory requirements, " forthwith upon " reasonable suspicion " of puerperal, fever ; and, on. the part of the officers of the District Health Office, frequent inspection of this hospital, during the period of infection, by the Medical Officer of Health personally ; supervision by an officer of the Department of the disinfection, &c, after each case of infection became known ; and, upon the death of Mrs. Jones, and if not then certainly upon the death of Mrs. Dacre, such closure, evacuation of patients, and. disinfection of premises as were respectively found necessary upon the illness of Mrs. Delamore being notified. The Commission cannot refrain from here remarking that leaving so important an office of Public Health as that of Auckland with a Medical Officer in charge admittedly known to his superior officers to be both ill and overworked, and with his skilled staff of three reduced to one by the absence of the others on leave, is exceedingly difficult to justify. Closure of Hospitals. The objects of closure are twofold : (a) to avoid exposure of fresh patients to the danger of infection ; (b) when all patients have been evacuated, to enable, under expert supervision, a complete disinfection of the whole of the premises, such as would be impracticable while any of the rooms are occupied. It is recommended that all Medical Officers of Health and managers of private maternity hospitals have their attention drawn to Regulation 9 (3) of the regulations of 1907, and to the necessity of the issue of a certificate from the Medical Officer of Health before the hospital can lawfully receive patients after the occurrence of septic disease. Inspection and Investigation. Upon receipt of notification of so serious a disease as puerperal fever occurring in a maternity hospital it is imperative that a, Medical Officer of Health, and not an Assistant or Nurse Inspector, should personally proceed forthwith to the hospital concerned, make full investigation, and ensure the taking of adequate precautions to prevent the spread of infection. The Report (1921) of the Special Committee of the Board of Health upon Maternal Mortality in New Zealand contains (inter alia) the following recommendations : — " (].) That every case of maternal death shall be forthwith personally investigated by the Medical Officer of Health, who shall report to the DirectorGeneral of Health. (2.) That every case of notified puerperal sepsis shall be forthwith personally investigated by the Medical Officer of Health, who shall report to the Director-General of Health." With these recommendations the Commission entirely agrees, and it would appear that the Department of Health is also in accord, Dr. Makgill's evidence being, " We have no right to expect of a trained nurse the scientific knowledge necessary to question the diagnosis of a doctor, for this is what adequate supervision may entail." It should be explained that in accordance with the practice of the Department Nurse Inspectors perform the duties of inspection and report to the Medical Officer of Health, who is himself not called upon, by statute or regulation personally to inspect, however grave the position may be. It is understood that all Medical Officers of Health have been officially acquainted with the terms of this report, but it is evident the recommendations thereof have only to a partial extent been made operative, and no regulations have yet been issued giving them statutory effect.