H.—3lb

7

I am inclined to the opinion that, as Mrs. Chamberlain's condition was very unsatisfactory immediately after the birth of her child, and as her condition apparently grew worse as time went on, Dr. Inglis should have had a consultation with Dr. Brockway or another experienced and reliable medical practitioner on or about the 16th or 17th August, if not earlier, as to her condition and treatment, and that blood and swab tests should have been made some time before the 24th August, when, as already mentioned, she was removed to\the isolation ward. The evidence does not entirely satisfy me that every step was taken and effort made during the earlier stages of the patient's illness —say, up to the 28th August —to ascertain as far as possible the true cause or causes of her very high and increasing temperature. With regard to complaint No. 5, the evidence does not establish to my satisfaction that the Matron failed to provide Mrs. Chamberlain during her confinement — i.e., during labour—with the necessary and ordinary comforts and requirements. With regard to complaints Nos. 1, 2, and 3, the Matron, as already mentioned, sutured the rupture of the perinaeum. lam inclined to the opinion that it is not advisable that Matrons of maternity hospitals or midwives in private practice should be permitted to suture ruptures of the perinaeum or other injury of the soft parts except in cases of absolute necessity, or when the services of a medical practitioner cannot be readily obtained. (See Rules Central Midwives Board, London, page 17—Exhibit No. 21.) 2. Administration. The St. Helens State Maternity Hospital at Auckland was established in the year 1906 under the Midwives Act, 1904, since consolidated by Act 1908, No. 118. I forward herewith (a) plan of the site on which the present hospital is built (Exhibit No. 1); (b) plan of the building showing the ground floor, basement, first floor, and isolation ward (Exhibit No. 2). The brick portion of the building was built for a Mr. Gorrie (the original Crown grantee of the land) in 1854. In November, 1880, Mrs. Purchas, wife of the Rev. Dr. Purchas, bought the property from Mr. Gorrie, and in 1885 added the wooden portion of the building as it now stands. In 1897 Mrs. Purchas sold the property to Dawson and others, who used the building as an institute for the treatment of habitual drunkards by the " Hagey process." In February, 1899, Dawson and others sold the property to one John Leydon, who used the building as a boardinghouse until April, 1906, when it was purchased by the Crown for the St. Helens State Maternity Hospital. The evidence given during the inquiry by many medical men of standing clearly establishes that the building is quite unsuitable for a maternity hospital, and that the site on which the building is erected is not an entirely satisfactory one. The opinion of the District Health Officer (Dr. Makgill) on this point is clear and emphatic. He says (see page 85) that the building is " both old and unsuitable. As time goes on the risk of injury to patients from the structural defects of the building will not diminish : it will rather increase." Section 5 of the Midwives Act provides that " There shall be established in New Zealand one or more State maternity hospitals where pupil nurses can, on payment of the prescribed fee, be carefully instructed in all the duties required for the welfare of mother and infant during and immediately after childbirth." Section 18 of the Act provides that " The Governor may from time to time appoint fit persons to be examiners of pupil nurses "; and section 7 provides that " Examinations of pupil nurses in the prescribed (i.e., prescribed by the Act or by regulations made thereunder —see section 2) subjects shall be held at the prescribed times and places." Section 19 provides that " The Governor may from time to time by Order in Council gazetted make regulations— " (a.) Prescribing the subjects of examinations under this Act; ■ " (b.) Providing for the regulation of maternity hospitals and the training therein of pupil nurses: