South Yorkshire Times, November 18th 1944
Second P.M. Settles Cause of Thurnscoe Baby’s Death
No neglect at Montagu Hospital
Evidence of a pathologist called in to conduct a second post-mortem examination during an inquest on a six-month-old baby, which was found collapsed in its cot at the Montagu Hospital last Monday, excluded the possibility that asphyxia, by which death was caused, was due to strangulation by the tapes of a restrainer used to prevent the child, which was in a restless condition, from moving about in the cot.
The inquest, which was on Michael Eric Wood, son of Henry Wood, bricklayer, and Vera Wood, 1, Marlborough Avenue, Thurnscoe, was conducted on Friday by the Doncaster District Coroner (Mr. W. H. Carlile).
“Misadventure” Verdict
A nurse who, with a doctor, found the child collapsed, insisted in evidence that there was nothing tight round the child’s neck. In view of this, after evidence by the doctor who conducted the first post-mortem and expressed the opinion that death was due to asphyxia due to a constriction round the neck possibly caused by the tape, a request by the hospital authorities resulted in the second post-mortem being conducted. Following his examination the pathologist stated that a substance found in the lungs proved by inspection under the microscope to be the same as was in the stomach. His opinion was that asphyxia was caused by inhalation of regurgitated food upon which the unusual position in which the child was found would have no bearing.
At the end of the long hearing, which included an adjournment for the second examination, the coroner said I think it has been proved satisfactorily that there was no restriction to the child’s neck. I am very pleased indeed that this case has been cleared up in the way it has. One never likes to find there has been any neglect in a hospital. It has been proved beyond doubt that asphyxia was caused by regurgitation. On the evidence before me there will be a verdict that the child died from asphyxia due to regurgitation, which is one of “Misadventure”.
Mrs. Wood, mother, said the child was suffering from pink disease, and was removed to the Montagu Hospital on October 11th.
Sanchi Ruth Brown, staff nurse at the hospital, said she was on duty in the children’s ward that morning. She went into the ward about 7.45 a.m. During the morning she took the child’s temperature, he seemed just as she had left him the night before; he was normal, quite comfortable, and quite well.
The coroner: Was he restless?
Witness: He was very restless, extremely restless.
That was due to his condition? Yes.
Owing to his restlessness, said witness, the child was placed in a restrainer. Witness demonstrated to the coroner how the restrainer, which was produced, was fitted. The single tapes at either side being fastened to the cot headpiece. The tapes were tied very tightly without any undue play, and the child was held in a sitting position.
Witness said that she bathed the child about 8.45 and put the restrainer on him. On her way out of the ward at 9.30 she played with the child for a while. The restrainer appeared as she had fastened it. Returning to the ward 20 minutes later, she saw Dr. Ossip and Nurse Clifford, to whom witness handed over, when she left the ward, attending the child.
Replying to the coroner, witness, who said that she had experience of restrainers as a senior nurse, said she had never previously known a restrainer, or any part of it, get round a child’s neck. She could not understand how, with the restrainer properly applied, the child could turn over on its face.
Collapsed In Cot
Senior nurse Rosemary Clifford said she had nearly three years nursing experience. She was with nurse Brown when she was with a child just before leaving the ward, but did not stay with the child after nurse Brown had left. At 9:40 she again played with the child, who was sitting up, and seemed not particularly restless. With the restrainer properly adjusted the child would be able to turn on its side, but would not be able to turn right over or slip down its cot very far. Dr. Ossip came into the ward about five minutes after she had last been with the child. Witness automatically went towards him and they began to walk round. When they came to the child’s cot she saw Michael in a state of collapse. He was lying in the top corner of his cot, having fallen over onto his face on his left side. His face was in the bed up to a pillow, which was against the cot rail. The restrainer had twisted.
The coroner was there anything round his neck at that time?
Witness: No.
Are you sure of that? Yes, nothing apart from his gown.
Informing the witness that there appeared to be a possibility that the child had been strangled the coroner asked “do you still say that there was nothing round his neck?”
Witness: there was nothing round his neck.
What had he on? A nightdress. Do you think that was tight round his neck? No.
The child had not been moved when she and the doctor went to it. The Doctor had not touched it. Witness turned the child over and went for the oxygen cylinder. The child was slightly blue in the face and seemed in a state of collapse.
R.S.O.’S Evidence
Dr. Julius Ossip, Resident Surgical Officer, said that on entering the ward for his first visit that morning about 9:45, he turned and saw the child obviously not well. He asked nurse Clifford, who was standing a few yards away, what was the matter with him. She made some exclamation and ran for the oxygen. He went to the child. He could not remember whether the child had a restrainer on or not. I think I saw some tapes round its neck, though my mind was blank at the time, my whole object was to get the child to breathe. Whether she cut them or I cut them, I don’t know
Witness said he called for Dr. Russell, administered oxygen and continued with artificial respiration, which Dr. Russell continued for about half an hour after he had been called downstairs.
Later in the day he asked the nurse how the restrainer was round the child’s neck. She said it was not round his neck. When the post-mortem examination was conducted, and agreed that the child had died from asphyxiation. A mark round the child’s neck, in his opinion, was consistent with the tape of the restrainer having been tight round the neck.
The coroner recalled nurse Clifford at this stage. After asking her if she had heard the evidence the Doctor had just
given, he asked her once again if she was sure that there was nothing round the child’s neck.
Nurse Clifford: I was never more sure in my life than that there was nothing round his neck.
Coroner: no string, no tape? No, it’s been cut, I cut it.
When? After I fetched the oxygen.
The Doctor seems to think that the string was cut before you fetched it? No, it was not.
Do you think anything could have been removed before you cut this from the child’s neck? No.
Dr. Thomas Lindsay said he had made a post-mortem examination. He found multiple abrasions on right cheek, the right side of jaw, neck and on the tip of nose. There was a definite ligature mark round the neck just above the level of the thyroid gland. There were haemorrhages of both lungs. In his opinion death was due to asphyxia due to a constricting bend round the neck to the level of the thyroid.
Coroner: And this type of this restrainer jacket, was that the kind of mark you found?
Witness: Yes, quite consistent. That could have caused the mark on his neck.
The other marks, said Dr. Lindsay, were superficial and were consistent with a child suffering from pink disease, with which also they had a habit of burying their head in the pillow. The child had a large thymus gland which would make it more susceptible to death from asphyxiation. Witness questioned by the coroner; said he could not suggest any other means by which the child might have been asphyxiated other than by the tapes.
Asked by the coroner whether he wished to say anything on behalf of the hospital, Mr. A. W Young, (Secretary Superintendent) said he would like to suggest that with regard to the whole matter, which he was sure the hospital authorities very much regretted, there was the fact of the cause of death. The evidence seemed conclusive, but he would like to put forward the suggestion that the coroner consider a further post-mortem examination, to put the matter absolutely conclusively. Evidence had been given by the nurse that there was nothing round the child’s neck.
An Adjournment
The coroner agreed to Mr. Young’s suggestion that a pathologist should be called upon to conduct the second post-mortem examination, and the inquest was adjourned until the afternoon. The pathologist Dr. Louis Constant Daniel Hermitte of the Sheffield Royal Infirmary, at the resumed inquiry said his examination revealed contusions on the right cheek and nose due to the disease from which the child was suffering.
Coroner was there any mark on the neck?
Witness: I found no mark on the neck.
That’s a funny thing, I thought I saw one this morning. Yes, Sir, you may see all kinds of marks. The difference is, a mark that is of importance and one that is not important.
Witness said that there was no extravasation of blood such as must result from external pressure. “In my opinion said Dr. Hermitte an external cause of asphyxia can be definitely excluded.”
Coroner: that is in spite of two other doctors, including the resident surgeon?
Witness: That makes no difference. We have found the cause of asphyxia.
The only abnormality found on examination of the internal organs was fairly extensive collapse of both lungs with sub-pleural haemorrhages over both organs. These were taken as strong evidence of asphyxia. The stomach was full of recently taken food, and a substance taken from the bronchial trees of both lungs microscopically proved, said witness, to be exactly the same as the contents of the stomach. The cause of death was clear, and was due to inhalation into both lungs of food regurgitated from the stomach. As to how it came to be regurgitated, he could not say.
Coroner: You know he was found in a forward position bent over in the corner of the cot? Would the fact that he was bent in that position cause regurgitation?
Witness it could not get into the lungs. It might get into the trachea, but not into the lungs. To get into the bronchials there must be an active function of the lungs.
The coroner recorded a verdict as stated.