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The Bendigo Advertiser Tuesday April 18, 1871
The unfortunate death by poison, in the Hospital, of Mrs Moran, on Friday night last, is an event that must be very deeply deplored. It is a matter of a most serious character as regards the public at large and therefore calls for some comments at our hands. Not wishing to awaken the smallest alarm, or to invest the sad circumstances with any unnecessary degree of sensational interest, we may state at the outset of our remarks our firm belief not only that the confidence of the community in that institution need not be shaken, but that it may, on the contrary, be more firmly established than ever. The occurrence of such a lamentable accident will prove such a sure preventive in future of such mistakes as that by which it was caused. We may appropriately call it an accident, since nothing can be more certain than that there was an utter absence of all intent even to injure the poor woman, far less to cause her death. But it was an accident which ought not to have occurred, for a strict adherence to the rules of the Hospital would have rendered it impossible. We would not harrow the feelings of the persons who are to blame. There can be no doubt they are undergoing a very severe punishment in their own minds for their fault. But it is absolutely necessary that so grave a matter should be submitted to public discussion, and for these reasons: - a human life has been unnecessarily sacrificed in a public institution, and the community will naturally, properly, and reasonably expect from the Press a full and decided opinion on the merits of the case.
At an inquest held before the Coroner for the district the facts of this shocking affair were fully and clearly elicited. They were simply these: - On the 28th of March last Mary Moran, the wife of a miner residing at Raywood, was admitted to the hospital suffering from cancer. She had undergone a surgical operation, from which, it appears, she was recovering satisfactorily. A composing draught had been ordered for her every night since the operation until that on which the fatal accident occurred. The phial which had contained her medicine, and had been labelled with her name and the number of her ward, had, of course, been returned to the dispensary. A wardsman in charge of another ward applied to the dispensers apprentice (Mr. Barker), as usual, for the daily physic for the patients in his ward. The resident surgeon had ordered the use of a disinfectant in that ward. The wardsman asked the dispensing official for the disinfectant, ad the latter being unfortunately in a hurry, and having the empty phial which had been used for Mrs Moran at hand, and knowing that it would not be wanted that evening, poured the necessary carbolic acid into it, placing it, so it would appear, last of all in the hands of the wardsman, Buckler, who, it is clear, could not have noticed the bottle and its label on which Mr. Barker had written the word "carbolic." Finding among his own lot a phial labelled for Mrs. Moran, he delivered it to Mrs. Frost, the nurse in charge of her ward, and subsequently distributed the medicines he had received among his own patients. Having done this, he appears to have bethought him of the carbolic acid, and finding that he had none, went to the dispensary and mentioned the circumstances to Mr. Barker the apprentice, who told him that he had put it into Mrs. Moran's bottle. In the meantime Nurse Frost, believing that the draught had been ordered by Dr. Macgillivray, gave it to the patient's daughter who administered it to her unfortunate mother. The potent drug had such an immediate effect that she declared as soon as she had swallowed it, that she had been poisoned. Such was, indeed, found to be the case, and the use of the stomach?pump, and the application of other remedies were to no avail. She died in little more than an hour after Dr. Macgillivray's attention had been called to her condition.
The whole circumstances must be bitterly distressing to all the parties concerned. There is not one of them, we feel satisfied, that does not feel very severely pained, and we can readily imagine that the three especially implicated, namely Mr.Barker, Wardsman Buckler, and Nurse Frost stand in need of consolation as much as any human beings possibly can do who have been subjected to such terrible misfortune. It is so obvious however, all three of them should have exercised greater care, that in the interests of the public, and of the institution, it is impossible to forebear from a review of the parts severally taken by them. It is certain in the first place, that no bottle, or parcel of medicine should, on any account, or for any reason whatever, be issued from the dispensary without being duly and clearly labelled. Such is one of the fixed rules of the hospital, and its transgression, it can not be denied, is an act of a very culpable nature indeed. Secondly, it must, we feel sure, be contrary to the rule and custom of the institution for persons in charge of certain wards, except perhaps under special and extraordinary circumstances, to take receipt, from the dispenser, of medicines labelled for any other wards. We think that Buckler in delivering the phial to Mrs. Frost, and she in receiving it from him, must have been acting contrary to the regulations by which they should be guided in all their acts. But the wardsman seemed to have forgotten altogether that Mr. Barker had told him he had given him the disinfectant. It was his duty, we conceive on finding that he had received medicine not intended for any of the patients under his charge, to have returned it to the dispensary. This is so clear, that it will be seen at once if he had done so, the sad result which took place would have been averted. He failed to do this, however, having evidently desired to avoid giving trouble. But the nurse, in pursuance of a rule which ought to admit of no deviation, should not have taken it from him, or, having done so, should have ascertained from the dispenser whether it was really intended for her patient. Mrs. Frost was all the more to blame in this instance, because Dr. Macgillivray had not given her instructions to administer any medicine to Mrs. Moran on that day, and he states in his evidence that it is practice to point out everyday, to the wardsman or nurse, what each patient is to get until his next visit.
We see then that this melancholy occurrence was a consequence of a departure by three officials from their strict line of duty. The rules and regulations of the hospital, which are of such a description that if properly and daily observed are sufficient to prevent any mishap of the sort taking place, were not obeyed by any one of the three persons concerned. Now, this truly lamentable result of their disobedience and neglect cannot fail to act as a powerful and lasting warning, not only to themselves, but to the whole staff of the hospital. It will be remembered that a departure from the rules and regulations, however slight and venial it may appear at the time of its omission, may lead to a fearful eventuation. It would be very wrong, and might even appear to be inhuman, to say that the death of Mrs. Moran is a fortunate circumstance. But it is very certain that its occurrence will tend to the increased safety of the patients. It may indeed, very probably, have a much wider effect, and be the cause of the observance of a more strict discipline in other similar institutions. At all events, as far as the Bendigo Hospital is concerned, the community may rest assured that precautions will be taken, from this time forward, of a nature that will render a recurrence of such a disaster as last Friday nights last perfectly impossible.
A special meeting of the hospital committee, convened at the instance of the Hospital surgeon, was held last evening to consider the circumstances connected with the accidental poisoning of the patient Mrs. Moran by carbolic acid. There was a full meeting, ten members being present. Mr. Thunder in the chair. Dr. Macgillivray explained the circumstances of the case as fully detailed in our report of the inquest. The apprentice dispenser Barker, was examined at considerable length, and also Buckler, the wardsman. The result of the enquiry was that both were severely reprimanded. It was resolved in order to prevent any similar occurrence for the future, that all bottles containing poison should be fluted and labelled with colored labels, and Dr. Penfold, the dispenser, was instructed that he should examine all prescriptions and see that they were properly dispensed. The meeting then adjourned.
(source: Family Research & Records of Bruce English.)

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