Obituary
1
1452 HIV infection or hindering its control include migrant labour, regional destabilisation and population movements, the disruption of health services, and the lack of representation of affected groups in HIV and AIDS policy and planning in South Africa. The conference committed itself to promoting community-based initiatives for combatting HIV transmission, gave high priority to involving legitimate political leadership in stressing the importance of HIV disease, and agreed to set up a progressive National AIDS Taskforce. Anthony Zwi Medicine and the Law The price of poor communication The reluctance of clinicians to spend time with the patient or family, putting them in the picture and providing a full explanation of the proposed treatment, can, especially if followed by a disappointing result, sow the seeds of litigation or demands for an inquiry. Failure to produce medical and nursing notes will fuel suspicions that there is something to hide. These ingredients were present in a fatal accident inquiry into the death of a 67-year-old woman at the Royal Infirmary, Glasgow. The relatives were very discontented with the woman’s treatment, and a report was obtained from a consultant, Mr J. H. Saunders, who had not been involved in the patient’s care. This in turn highlighted the family’s sense of frustration when they tried to discuss the patient’s symptoms and treatment and when the hospital did not produce the nursing and intensive care unit records. The unexplained disappearance of the records immediately after the patient’s death (even though it was known that an inquiry would follow) was a significant impediment to the inquiry, the sheriff said. On Sept 5,1988, the patient had undergone sigmoid colectomy. After her discharge home she deteriorated, with pain from her wound, sleeplessness, diarrhoea, perspiration, vomiting, and loss of appetite. The abdominal wound became infected and on Sept 22 she was readmitted as an emergency. On Oct 3 cutaneous gangrene in the abdominal area was noted, necessitating emergency surgery to remove a large area of abdominal wall and transverse colostomy with closure of the rectum. When the abdominal wound was opened faecal fluid exuded and the sigmoid anastomosis had separated by about 10 cm. The patient died on Oct 7. Concern focused on the period between readmission on Sept 22 and Oct 3, when the gangrene became apparent. It was accepted that after bowel surgery anastomotic leaks will develop in 30% or so of cases, usually within 6 days; that the preferred management is conservative, by maintaining the patient in the best condition possible to give the fistula the opportunity to heal without a further operation; that the mortality risk for a laparotomy after colon surgery is very high where general sepsis is present; that generalised sepsis of the abdomen is heralded by a sudden clinical deterioration, a rapid pulse, fever, and hypotension; and that the final gangrenous infection in this case was unusual. Conservative management was opted for by the patient’s surgeon, Mr 1. G. Finlay. The case-history did not suggest generalised sepsis, and laparotomy would have been inappropriate up to the sudden deterioration on Oct 3. The timing suggested that the leak was caused by a failure of blood circulation in the bowel ends, and the absence of sutures at the anastomosis indicated that they had passed out via the fistula track, and the disappearance of intervening bowel indicated consumption by necrotising gangrene. The sheriff rejected criticisms by Mr Saunders that there must have been clinical signs that should have prompted laparotomy several days earlier and that once it was known that bowel organisms were escaping into the abdomen antibiotics should have been prescribed. It was Mr Saunders’ hypothesis that, besides the surface wound infection and abscess, other infectious material had leaked but had not been detected. The sheriff also concluded that gas in the left upper abdomen suggested by the X-ray films was not definitive in the light of an ultrasound scan done 2 days later. He concluded that the clinical condition of the patient did not reflect, until Oct 3, the major symptoms associated with generalised abdominal sepsis; and he was satisfied that conservative management was the correct decision. The loss of records was disturbing, especially since "the next of kin were concerned that there may have been some neglect in care... Had these records been available it is likely that a great deal of speculation could have been excluded and other fears allayed which might have foreclosed the need for this inquiry", the sheriff said. The patient’s children could see that their mother was very ill and expected something to be done. The decision to pursue conservative management was not explained and seemed to them like a failure to act. As the patient deteriorated they became more and more concerned, but doctors did not seem to be available with whom they could discuss things. When they were told that the bowel ends had separated they drew the worst possible conclusions about the care their mother had received. The patient’s family was a large one and there was some incoordination in the way advice was sought or given, which gave rise to friction. One daughter who had managed to talk to a junior doctor on Sept 30 had been told, in effect, to "tell your rather large and extended family to stop harassing this hospital". Another daughter had intercepted Mr Finlay on the ward on Sept 29 when he made time to explain what had been happening. There was no regularised procedure for a family to meet the medical staff other than by interfering with their other duties. This should be reconsidered, the sheriff said. Inquiry into the death of Mrs Mary Morrison: Detennination by Sheriff Andrew C. Henry (Glasgow, March 16, 1990). Diana Brahams Obituary Charles Thomas Andrews Charles Andrews, who died on March 31, aged 86, was without doubt the architect of the present hospital service in Cornwall. Appointed as medical member of the South Western Regional Hospital Board in 1947, he was involved in the integration of the numerous and fiercely insular voluntary hospitals that served the county before 1948 into a specialist hospital service based on the District General Hospital in Truro, to the planning of which he devoted fifteen years of his professional life. Most unusually for a general physician of that era, Charles took a deep interest in services for the elderly. This interest was aroused when in 1946 the Cornwall County Council invited him to do a survey of the seven Public Assistance Institutions in the county. This unique survey, the first of its kind in the country, involved the detailed examination of the patients in these institutions during the years 1946/47. In the report Charles recommended the appointment of a geriatrician with supporting staff. The report was accepted in its entirety by the County Council, and the first post of geriatrician to be established in the UK was filled in 1948. An article describing the Cornish service, the first of its kind in the country, was published in The Lancet in April, 1953. Throughout the subsequent years he continued his interest in and support for the development of services for the elderly, not only in Cornwall but also in the whole of the South West Region. He was a member of the British Geriatric Society from its earliest days, and a vice-president from 1950s. The psychogeriatric assessment unit, built in 1967 at Barncoose Hospital Redruth, was named the Charles Andrews Clinic in recognition of his services. T. S. Wilson
Transcript of Obituary
1452
HIV infection or hindering its control include migrantlabour, regional destabilisation and population movements,the disruption of health services, and the lack of
representation of affected groups in HIV and AIDS policyand planning in South Africa. The conference committeditself to promoting community-based initiatives for
combatting HIV transmission, gave high priority to
involving legitimate political leadership in stressing theimportance of HIV disease, and agreed to set up a
progressive National AIDS Taskforce.Anthony Zwi
Medicine and the Law
The price of poor communicationThe reluctance of clinicians to spend time with the patient orfamily, putting them in the picture and providing a fullexplanation of the proposed treatment, can, especially iffollowed by a disappointing result, sow the seeds of litigationor demands for an inquiry. Failure to produce medical andnursing notes will fuel suspicions that there is something tohide. These ingredients were present in a fatal accidentinquiry into the death of a 67-year-old woman at the RoyalInfirmary, Glasgow. The relatives were very discontentedwith the woman’s treatment, and a report was obtained froma consultant, Mr J. H. Saunders, who had not been involvedin the patient’s care. This in turn highlighted the family’ssense of frustration when they tried to discuss the patient’ssymptoms and treatment and when the hospital did notproduce the nursing and intensive care unit records. Theunexplained disappearance of the records immediately afterthe patient’s death (even though it was known that an
inquiry would follow) was a significant impediment to theinquiry, the sheriff said.On Sept 5,1988, the patient had undergone sigmoid colectomy.
After her discharge home she deteriorated, with pain from herwound, sleeplessness, diarrhoea, perspiration, vomiting, and loss ofappetite. The abdominal wound became infected and on Sept 22she was readmitted as an emergency. On Oct 3 cutaneous gangrenein the abdominal area was noted, necessitating emergency surgeryto remove a large area of abdominal wall and transverse colostomywith closure of the rectum. When the abdominal wound was openedfaecal fluid exuded and the sigmoid anastomosis had separated byabout 10 cm. The patient died on Oct 7.
Concern focused on the period between readmission on Sept 22and Oct 3, when the gangrene became apparent. It was accepted thatafter bowel surgery anastomotic leaks will develop in 30% or so ofcases, usually within 6 days; that the preferred management isconservative, by maintaining the patient in the best conditionpossible to give the fistula the opportunity to heal without a furtheroperation; that the mortality risk for a laparotomy after colonsurgery is very high where general sepsis is present; that generalisedsepsis of the abdomen is heralded by a sudden clinical deterioration,a rapid pulse, fever, and hypotension; and that the final gangrenousinfection in this case was unusual.
Conservative management was opted for by the patient’ssurgeon, Mr 1. G. Finlay. The case-history did not suggestgeneralised sepsis, and laparotomy would have been inappropriateup to the sudden deterioration on Oct 3. The timing suggested thatthe leak was caused by a failure of blood circulation in the bowelends, and the absence of sutures at the anastomosis indicated thatthey had passed out via the fistula track, and the disappearance ofintervening bowel indicated consumption by necrotising gangrene.The sheriff rejected criticisms by Mr Saunders that there must
have been clinical signs that should have prompted laparotomyseveral days earlier and that once it was known that bowel organismswere escaping into the abdomen antibiotics should have beenprescribed. It was Mr Saunders’ hypothesis that, besides thesurface wound infection and abscess, other infectious material had
leaked but had not been detected. The sheriff also concluded that
gas in the left upper abdomen suggested by the X-ray films was notdefinitive in the light of an ultrasound scan done 2 days later. Heconcluded that the clinical condition of the patient did not reflect,until Oct 3, the major symptoms associated with generalisedabdominal sepsis; and he was satisfied that conservative
management was the correct decision.
The loss of records was disturbing, especially since "thenext of kin were concerned that there may have been some
neglect in care... Had these records been available it is likelythat a great deal of speculation could have been excluded andother fears allayed which might have foreclosed the need forthis inquiry", the sheriff said. The patient’s children couldsee that their mother was very ill and expected something tobe done. The decision to pursue conservative managementwas not explained and seemed to them like a failure to act. Asthe patient deteriorated they became more and moreconcerned, but doctors did not seem to be available withwhom they could discuss things. When they were told thatthe bowel ends had separated they drew the worst possibleconclusions about the care their mother had received. The
patient’s family was a large one and there was someincoordination in the way advice was sought or given, whichgave rise to friction. One daughter who had managed to talkto a junior doctor on Sept 30 had been told, in effect, to "tellyour rather large and extended family to stop harassing thishospital". Another daughter had intercepted Mr Finlay onthe ward on Sept 29 when he made time to explain what hadbeen happening. There was no regularised procedure for afamily to meet the medical staff other than by interferingwith their other duties. This should be reconsidered, thesheriff said.
Inquiry into the death of Mrs Mary Morrison: Detennination by SheriffAndrew C. Henry (Glasgow, March 16, 1990).
Diana Brahams
ObituaryCharles Thomas Andrews
Charles Andrews, who died on March 31, aged 86, waswithout doubt the architect of the present hospital service inCornwall. Appointed as medical member of the SouthWestern Regional Hospital Board in 1947, he was involvedin the integration of the numerous and fiercely insularvoluntary hospitals that served the county before 1948 into aspecialist hospital service based on the District GeneralHospital in Truro, to the planning of which he devotedfifteen years of his professional life.Most unusually for a general physician of that era, Charles took a
deep interest in services for the elderly. This interest was arousedwhen in 1946 the Cornwall County Council invited him to do asurvey of the seven Public Assistance Institutions in the county.This unique survey, the first of its kind in the country, involved thedetailed examination of the patients in these institutions during theyears 1946/47. In the report Charles recommended the
appointment of a geriatrician with supporting staff. The report wasaccepted in its entirety by the County Council, and the first post ofgeriatrician to be established in the UK was filled in 1948. An articledescribing the Cornish service, the first of its kind in the country,was published in The Lancet in April, 1953. Throughout thesubsequent years he continued his interest in and support for thedevelopment of services for the elderly, not only in Cornwall butalso in the whole of the South West Region. He was a member of theBritish Geriatric Society from its earliest days, and a vice-presidentfrom 1950s. The psychogeriatric assessment unit, built in 1967 atBarncoose Hospital Redruth, was named the Charles AndrewsClinic in recognition of his services.
T. S. Wilson
