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23
To-day, July 1st, the Medical Superintendent reports :
" The acute symptoms which she had on admission have
abated; fortunately the infection appears to be fairly well
localized in the pelvis. She still runs a temperature varying
from 99 to 101. The prognosis is doubtful, and however
favourably she progresses, her recovery is likely to be very
protracted. Her general condition remains fairly good."
This patient's baby was sent into the Kingston and
District Hospital on June 8th, and died the following morning.
An inquest was held and the Coroner gave a verdict in
accordance with the medical evidence—syncope from general
peritonitis, the umbilical cord having become infected from
an outside source.
It will be noted that Cases 1, 2 and 4, were all delivered
at their homes by the same midwife, and that the babies of
Cases 2 and 4 both died from pyaemia originating from
umbilical sepsis.
The Surrey County Council are responsible for the
administration of the Midwives Acts, but on May 26th I
wrote a confidential letter to the County Medical Officer of
Health, calling his particular attention to the fact that the
two cases which had been notified up to that time were
attended by the same midwife. I also reminded him that a
case of hers occurred in the Nursing Home just prior to last
Christmas, and informed him that I had made personal
investigations at that time into her cases in the past, but
was unable to produce evidence that she was the cause of
infection.
Though Cases 1 and 2 had occurred on the District, and
circumstances did not point to the infection being at the
Nursing Home itself, it was thought advisable to issue instructions
that no further patients should be admitted, and
an inspection of the Home was made, when some temperature
cases were discovered.
It was then decided to clear the Home as soon as
practicable, and to carry out complete disinfection of the
building and contents, and close the Home for at least one
month after the departure of the last patient.
The inquiries into the temperature cases in the Home
revealed the following facts:—
Case A.
Confined on March 11th, attended by a midwife—
adherent placenta removed by a doctor. White leg on March