H.—3la

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the time able to inquire : the logical consequence of all this being that she incurs the risk of entering an infected hospital, in precisely the same circumstances as those of Mrs. Delamore's case. Members of the Commission are not entirely unanimous upon this question, the Chairman and Lady Luke holding that under subsisting conditions it is part of the trust reposed in the medical adviser that he should satisfy himself in the circumstances stated, and the medical members of the Commission being of opinion that—(l) Inspection by the Department of Health should be thorough and efficient; (2) further sufficient safeguard is provided in terms of the recommendation of the Commission set out already in this report under the heading " (D.) Co-ordination." (I.) Annexed to this report are the recommendations extracted from the report of the Maternal Mortality Commission of the Board of Health of 1921, to which special reference has been made, also the substance of the report of the Committee of the Board of Health of 1923, dealing with private maternity hospitals so far as it is applicable to the subject-matter of this inquiry. (J.) Lest any statement or comment in the present report may cause undue alarm to expectant mothers, it may be desirable, for their reassurance, to say that the occurrence of septicaemia after childbirth is by no means frequent. Dr. Williams, whose name appears in connection with the cases investigated, stated that he had attended over three thousand confinements, and had met with only one such case previous to the outbreak at Kelvin Hospital. Dr. McCormick, with an extensive midwifery practice, had, previous to these cases, attended but one such case ; and the Matron of Kelvin Hospital had no previous case of septicaemia in her long experience. Childbirth is a normal physiological process, and to the healthy woman in healthy surroundings is attended with very small risk. (K.) With regard to the costs of the inquiry, the Commission is of opinion that the costs of Mrs. Rhodes and others represented by counsel (Mr. Johnston) at the hearing, to the extent of £100, and the costs of Matron Gibbons to the extent of £100, and the reasonable allowances and expenses of Sister Vazey, a witness, should be borne and paid by the Department of Health. The Commission desires to place upon record its indebtedness to Mr. C. J. Drake, Secretary of the Board of Health, who acted as secretary to the Commission, for the zealous and very valuable assistance rendered by him throughout the proceedings. In witness whereof we have hereunto set our hands, this 28th day of April, 1924. Fred. Earl, Chairman. D. McGavin, "] J. S. Elliott, Jacobina Luke, J