11

H.—3la

Assistant Inspector Miss Bagley's evidence is that the deaths of Mrs. Barker and Mrs. Morison were not known to her, and that when Mrs. Jones's death was notified from the Auckland Hospital it was not known for a day or two that this was a patient removed from Kelvin Hospital. In Mrs. Jones's case Miss Bagley telephoned Kelvin Hospital and apparently satisfied herself from the Matron's statement that the room used by the patient and its contents were properly disinfected, equipment sterilized, and nurses in attendance disinfected. She then minuted the notification for the information of the Medical Officer of Health that " all precautions seemed to have been taken against further infection." This comprised all that was done by the officers of the Department of Health regarding this case. In Mrs. Dacre's case the medical practitioner concerned had written informally notifying and describing the case (letter dated Bth October). To this letter Dr. Hughes replied next day: " From your history of the case it certainly is suggestive of trouble prior to confinement, and there does not appear to be any necessity for any action on the part of this Department as in an ordinary case of septicaemia." The letter of the practitioner was minuted " No action." Miss Bagley again telephoned the hospital regarding the precautions taken, and, notwithstanding the patient's death on the 10th October, nothing further was done until the 16th October, when Miss Bagley visited the hospital and made general inquiry, following this by minuting the papers as to the precautions taken, and expressing the opinion that there was " nothing to show that the infection of the second case had been carried from the first." This comprised all that was done in Mrs. Dacre's case. The provisions of Regulation 9 (3) of the regulations concerning private hospitals set out above, requiring the certificate of the District Health Officer that in his opinion there is no risk of further infection before a lying-in patient is admitted after the occurrence of puerperal or other forms of septic disease, and repeated in the leaflet H. 628, seems to have been entirely ignored. The same remark applies to the recommendations 2 and 3 of the 1921 report of the Special Committee of the Board of Health on Maternal Mortality in New Zealand, requiring every case of maternal death and every case of a notified puerperal sepsis to be forthwith personally investigated by the Medical Officer of Health. These recommendations were conveyed to all Medical Officers of Health, with instructions from the Department to act upon them. As illustrating the extraordinary languor characterizing the actions of the Auckland District Health Office, and the continuous failure to appreciate the gravity of the position at Kelvin Hospital, it is sufficient to take the case of Mrs. Delamore. The evidence discloses that on Friday, the 9th November, the medical practitioner concerned telephoned the office of the Medical Officer of Health. It is clear that the message expressly mentioned Kelvin Hospital, septicaemia, and a question as to notifying a case which the speaker desired to discuss with Dr. Hughes. The message was taken by the Chief Clerk, Dr. Hughes being on his way from Rotorua that day. Dr. Boyd was at the time absent on leave ; but, although Assistant Inspector Miss Bagley was available, she was not communicated with that day. Next morning (Saturday, 10th November) Dr. Hughes, having been telephoned at his house by the Chief Clerk, made an appointment to meet the medical practitioner, and duly met him some time about midday, and was apprised of the facts. At about the same time a message was received from the Sanitary Department of the Auckland City Council concerning a " mysterious disease among Maoris in Parnell." Dr. Hughes immediately set out to investigate this matter (which turned out to be trivial), but, instead of proceeding from Parnell to Kelvin Hospital (less than three miles away), he went home. On this day Miss Bagley, of her own motion, telephoned to the Matron of Kelvin, advising that no fresh admissions be made, and inquiring as to precautions, &c, and was informed that fresh cases had already been refused. Nothing beyond this was 'done on the 10th. On Sunday, the 11th, Dr. Hughes, being ill, remained at home and in bed. Nothing whatever was done on the 11th, and it was not until after 2 p.m. on the 12th that Dr. Hughes, in company with Miss Bagley, visited Kelvin Hospital for purposes of investigation, by which time another case —viz., Mrs. Muir —had been notified. This was Dr. Hughes's first and only visit during the whole series of events.