H-—3lb

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(4.) That Dr. Tracy Inglis, in his capacity of Medical Officer to such institution, declined to allow the said Mrs. Chamberlain to be examined or her condition ascertained by another registered medical practitioner when a request for such examination was made by the husband of the said Mrs. Chamberlain at a time when her life was in grave danger; and (5.) That during the confinement of the said Mrs. Chamberlain the Matron of the said Hospital failed to provide her with the necessary and ordinary care, comforts, and requirements of such cases, and that in consequence thereof the said Mrs Chamberlain sustained unnecessary pain and suffering. The circumstances surrounding Mrs. Chamberlain's death were gone into very fully during the inquiry, but owing to the destruction of nurses' dailyreport books and the neglect to keep and preserve proper records at the Hospital I have not been able to obtain an entirely satisfactory and reliable history of the case, Or the particulars in detail of the patients' condition and treatment de die in diem. Dr. Inglis, the Medical Officer, did not keep a satisfactory record of his visits to the patient, the examinations which he made, and the course of treatment and diet ordered. The Matron during her evidence said (see page 84), " It is not possible for me or the doctor or submatron to give a detailed account of Mrs. Chamberlain's case from her admission till her death, except from memory." According to the case-book (Case No. 1325, written up some considerable time after Mrs. Chamberlain's death), and the temperature-chart (Exhibit 3), Mrs. Chamberlain was admitted to St. Helens Hospital on the 10th August, 1912, and on the following day gave birth to a male child. During the delivery the perinaeum was ruptured, and the Matron (Miss Ludwig) sutured it. According to the evidence of the Matron and Medical Officer the union was complete and the tear healed quickly. The patient's temperature and pulse rose on the day after delivery and continued to rise (see chart). Dr. Inglis stated that he examined the patient on the 12th August, and came to the conclusion that she was suffering from broncho-pneumonia. On the 13th August the patient was removed to Ward or Room No. 3, shown on plan Exhibit 2, and as her temperature' continued to rise (see chart) she was removed on the 24th August to the isolation ward outside the main building. Dr. Inglis continued to treat the case up to the 28th August as one of broncho-pneumonia. On that date he took ill and was confined to his bed. He asked Dr. Goldstein to attend the patient. Dr. Goldstein accordingly attended her from the 28th August to the Ist September. After examining her on the 28th August Dr. Goldstein discussed the case with Dr. Inglis, and on the same day Dr. Inglis wrote out a notice (Exhibit 58) to the District Health Officer at Auckland to the effect that he suspected that Mrs. Chamberlain was suffering from puerperal septicaemia. This notice was not, however, received by the District Health Officer till the 9th September. On the Ist September Dr. Goldstein called in Dr. Lindsay to consult with him as to Mrs. Chamberlain's condition. They examined the patient together, and apparently came to the conclusion that she was probably suffering from puerperal septicaemia. On the same day—viz., the Ist September —Dr. Inglis resumed duty and again saw the patient. He instructed Dr. Frost to make a blood test. This was done on the 3rd September, and Dr. Frost reported that it did not disclose the presence of streptococci. Dr. Frost then took a swab from the uterus and, having examined it, reported the presence of streptococci. Vaccine treatment was immediately adopted (see chart), but without success, and on the 9th September the patient died. On the 10th September Dr. Inglis certified in the usual form " that the cause of death was (a) puerperal septicaemia, and (b) heart-failure, and (c) that the time from attack till death was twenty days." (See Exhibit 59.) With regard to complaint No. 4, Dr. Inglis admitted that he refused to hold a formal professional consultation with Dr. Brockway, Mr. Chamberlain's family medical adviser, as to Mrs. Chamberlain's condition and treatment (see Dr. Inglis's evidence, page 44 et seq. and 50).