The Mercury 20 April 1945 

CORONER'S FINDING ON SOLDIER'S DEATH

The Coroner (Col J. P. Clark) in returning a finding at the inquest at Hobart yesterday that Lt Colin Alexander Hughes (41) died from natural causes in an ambulance while being taken to the 111th AGH Campbell Town on Dec. 26, 1944, said Capt Leopold Winthrope, a medical officer was guilty of grave and serious neglect of duty in failing to examine the patient personally at the RAP, but that Capt Winthrope was not guiltv of negligence to a criminal degree.

Lt HUGHES had been refused admittance to two Hobart hospitals, and the inquiry was ordered by the Attorney-General (Mr McDonald).

"I am informed that there is a cardiogram at the General Hospital at Campbell Town, but not at Brighton, said the Coroner. Had there been such a mechanical device, either at Hobart or at the Brighton Camp Hospital, a correct diagnosis might have been made, and the life of the deceased might at least have  been prolonged.

The hall porter at the Royal Hobart Hospital took upon himself the responsibility of refusing admission to the military patient without even seeing him, and did not obtain the services of the night sister on duty or a medical officer to examine the patient. The practice at the hospital is generally not to admit, soldiers into the out-patients department, but where a case might appear desperate, the hall porter would have kept in touch with the night sister or medical Officér and either one or the other would have the right  to admit the patient immediately into a ward.

"Dr J. B. Muir's evidence is to the effect that the hall porter had no discrétion. He could not admit, but must call the proper authority, the resident medical officer on duty. This the hall porter did not do.

I feel satisfied that the patient was wrongfully refused admission to the Royal Hobart Hospital.

"When Capt Winthrope was informed by the orderly at the RAP that the patient was suffering from acute abdominal pain, to my mind this should have put him on the alert, and it was his duty to attend at the RAP and personally examine the patient. As I understand the position, the first duty of a medical officer in his examination of a patient is to obtain a detailed history of the case. This assists the medical man in his diagnosis. Had Capt Winthrope personally  attended at the RAP, and questioned  the patient, as it was his duty to do, I think he would have found out from the patient that he had had previous attention from Dr Ralph Whishaw, a heart specialist, in which case he might have made a diagnosis of coronary disease, and would have immediately given an order for the patient to be admitted in to the Royal Hobart Hospital.

I think that Capt Winthrope, as a medical officer, was guilty of a grave and serious neglect of duty In failing to attend at the RAP, and personally examine the patient, but I am not  satisfied that this officer showed such disregard for the life and safety of Hughes as to amount to a crime against the State. In other words, I do not think that he can be said to be guilty of negligence in a criminal degree.

"When examined at Brighton by Capt Stegmann the patient informed him that he had been subject to pains in the chest for some months, whenever he walked 200 or 300 yards, said the Coroner. When Capt Stegmann examined the patient, he came to the conclusion that Hughes was suffering from either biliary colic, ruptured peptic ulcer, or coronary occlusion. He gave the deceased two injections of morphia, and one of atropine. 1 should think this would obscure the condition of the patient, rather than be helpful to his condition. Capt Stegniann ordered the removal of the patient to the Military General Hospital at Campbell Town.

We are all satisfied now that the deceased was suffering from a coronary disease, which caused his death, said the Coroner. .Had a correct diagnosis of the patient's condition been made, either at the RAP at Hobart or at the Brighton Camp Hospital, there was only one treatment likely to benefit the patient, and that was absolute rest. His removal in an ambulance for a distance of over 60 miles would, I think, aggravate his condition.

One is at a loss to understand why there is not a Military General Hospital at or near where it would appear to be most required, said the Coroner. It does not appear to me to benefit patients by having to transport them from other portions of the State such, a long distancé."

Evidence was given yesterday by Dr Whishaw that he had been treating Lt Hughes from June to August 194 4 for a coronary disease of the heart. When he last saw the patient, he considered his condition hopeless. He was aided in his diagnosis by mechanical aids.

Dr Whishaw said it was his opinion that Dr Winthrope's action in sending the patient to Brighton was reasonable.

Replying to Mr Baker (representing the RSL), he said the RAP orderly's report of acute abdominal pain would indicate to him that thé patient should be admitted to the nearest hospital for observation. In the light of his present knowledge, this meant admittance to the Royal Hobart Hospital.

Dr Camp-bell Duncan, Government pathologist, said had the deceased informed the RAP corporal of his treatment by Dr Whishaw a diagnosis' would have been made easier. Even if the patient had been placed in bed at the Royal Hobart Hospital, his recovery would have been most unlikely, but there was a possibility. The patient could not have lived longer than five years.

Dr Siegmann, recalled, said a cardiograph at Brighton would have assisted him in his diagnosis.