Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts.

  • Great Britain. Committee on Coroners.
Date:
1909
Catalogue details

Licence: Public Domain Mark

Credit: Second report of the Departmental Committee appointed to inquire into the law relating to coroners and coroners' inquests, and into the practice in coroners' courts. Source: Wellcome Collection.

    128/232 (page 98)
    20 July 1909.) 9102. Have you had any cases of adults ?—Yes. I had a case of a nurse a short time ago, in one of the hospitals ; she was wearing a flannelette nightdress. 9103. A. dressing gown P—Something of that sort. 9104. There are many cases in which severe burns result from the use of flannelette from which death does not occur. Have you made inquiry about those ? —No, I have not. 9105. Coming now to the question of anzsthetics, if a death takes place under an anesthetic (I do not say necessarily from the anzsthetic) do you consider that on the true construction of the Coroners Act, you are bound to hold an inquest when it is brought to your knowledge P—Yes, I do. 9106. There is no option P—I think not. 9107. Some coroners think they are bound to make an inquiry but not to hold an inquest ?—I think we are bound to hold an inquest, because it is death by accident presumably, and you have to find out whether the death has arisen from pure accident or by reason of criminal neglect. 9108. Do you find any difficulty in trying those cases with a Coroner’s Jury P—None. 9109. You think they really appreciate the scientific evidence; or do they take your ruling P—My juries appreciate the scientific evidence. I have had questions of a highly scientific character asked of the doctor in the box by jurors. But I must add to that, that I get my jurors from a very good class of men. 9110. You rather specially choose a good class in those cases P—Not always; I do not know that I do always; I do sometimes. If I know beforehand ; for instance, if I get a report to-day of a death from that cause, I would say to my beadle, “ You had better, as “ there is a question of a scientific character in this * case, tell the officer to summon a better jury.” 9111. Who is your beadle ?—He is the inspector of police. 9112. Will you give us the number of deaths from anesthetics that you have had to investigate P—I have taken them for the same period of time as I have the death from burns. In 1904 there were 8; in 1905—6; in 1906—4 ; in 1907—7 ; and in 1908—10; and for this half year, 2. In all those cases the jury I should say found that the anesthetic had been properly and skilfully administered, and when an operation had taken place that it had been properly and skilfully performed. 9113. Do you refer to cases in which the anesthetic had been given with a view to an operation P—Just before the operation commenced. 9114. Death occurred before the operative pro- cedure began ?—Yes. weak hearts ?—Yes, that is why I always ask the question ; and it is known now in Liverpool that the patient should be examined with the greatest care before administration—unless it is a case of absolute life and death. 9116. But every skilled anesthetist makes an ex- amination of his patient to choose the anesthetic, does he not?—He should do so, but I always make the enquiry. 9117. Have the doctors in Liverpool raised any question about the necessity for an inquest where death has occurred under an anesthetic P—No, never so far as the cases have been reported to me. 9118. And in your opinion the Act gives you no option ?—I certainly think not. 9119. In all the cases you have dealt with the anesthetic has been administered skilfully by a qualified medical man ?—Yes. 9120. Have you had cases of dentists ?—One only, I think. 9121. Was it nitrous oxidé that was used P—No, chloroform I think it was in that case. In that case of the dentist—I am speaking from recollection of some years ago—a brother dentist administered it. 9122. There were two dentists P—Yes, I commented upon it; I am speaking now, it must be of 12 or 15 years ago; and whether in consequence of that, [ Continued. or not, dentists generally get in a qualified man to administer whenever the anesthetic is to be chloroform. 9123. That would not apply to nitrous oxide, I suppose P—I should say not. 9124. But when one of the longer anesthetics like ether or chloroform is used, you think it should be administered in the presence of a qualified medical man P—Yes. -9125. Who has experience to know what to do in case of an emergency P—Yes, that is the great thing. 9126. We have had some complaint before this Committee of comments made by coroners in cases of deaths in hospitals. It has been suggested that there is unnecessary public anxiety. Have you any opinion on that P—I think it is a pity to lay too great stress upon deaths arising under such circumstances. It not only causes or may cause the medical gentlemen them- selves to be a little anxious and so not to bring that coolness that is required when they are performing operations, but I think it has tended to alarm patients - or others who may have to undergo operations. 9127. And if patients are unnecessarily alarmed it increases the danger as regards the anesthetic. If aman is put under an anesthetic in a state of grave apprehension there is greater risk P—Yes. Ihave often made the observation in court when these cases have been investigated, that, having regard to the very large number of cases in which relief has been given to patients by reason of the operation and the adminis- tration of anesthetics, it would be well not to place too much emphasis upon the few deaths that take place now and again as likely to deter persons from undergoing operations. 9128. That is not the fault of the coroner or the jury; it is the fault of the press. It makes good copy ? —Yes; but there again I think our press in Liverpool are very judicious. They do not always report these cases. 9129. You think they have been public spirited, and do not go in for sensational paragraphs in these cases where everything has been done that could have been done for the patients ?—Yes; of course, if there has been neglect, that is another matter; but in these cases they seldom report them. I think that is very desirable also; it-tends to allay any unreasonable apprehension. 9130. Do you think, if the law was altered, it would be sufficient if every case of death under anesthetics was reported to the coroner? If he satisfied himself that everything has been done properly and in order, and the death was an inevitable accident, he should have power to dispense with an inquest ?—Yes, that is very desirable. 9131. That is the law in Scotland. Everything is done by the Procurator Fiscal in private P—Yes. My observation is subject to this: that in large cities there is always a public opinion, which is a good thing. In small districts, I am not quite sure my experience would lead me to say whether an inquest ought to be dispensed with or not; but it certainly should be in the discretion of the coroner. In large cities there are always a number of medical gentlemen who know the facts, and if anything was wrong the coroner would be sure to hear of it. And then again the coroner in a large city is, I take it, of course, above all considerations of personal matters. What would be the effect in small country districts with a widely dispersed popula- tion I would not like to say. 9132. Now as regards death certification, you have one or two points to bring out. That, of course, touches the coroners’ jurisdiction ?—Yes. I am of opinion that all still births should be registered upon the certificate of a registered medical practitioner, and in the absence of such a certificate those cases should be reported to the coroner. 9133. Who would report them?—That is the question ;- either the midwife, if there is one in attendance, or some person in the house; or the police, who generally know of these cases; at any rate, anyone who knows the fact. Whether you could enforce it or not is a question for consideration. But I think they should be reported to the coroner in a case where there is no medical certificate. i