to North Adelaide Police by family and doctors
North Adelaide Police Station
1st February 1949
Report into the death of Kathryn Mary (sic) Daly aged
2 years and 9 months on the 17th April 1948 late of Herston
Road, Herston Queensland and staying at 19 Brandreth Street
Tusmore South Australia which occurred at the Adelaide
Children's Hospital, North Adelaide on the morning of
Tuesday the 1st of February 1949.
MARGARET PHILLIS GREEN, single, trained nurse of 19
Brandreth Street, Tusmore states:-
"At about 2.45pm on Tuesday 1st February 1949 in
company with Plain Clothes Constable Cocks of the North
Adelaide Police Station, I went to the mortuary of the
Adelaide Children's Hospital, North Adelaide. In the mortuary
I saw the body of a young girl child aged about 2 years
and 9 months and I identified the body as being of my
late Niece, Kathryn Mary (sic) Daly aged 2 years and 9
months. On the 17th of April 1949 she would have been
3 years. Prior to her death deceased had been staying
with her mother at my home at 19 Brandreth Street, Tusmore.
At the request of deceased's mother, I brought deceased
to the Out-patient Dept. at the Adelaide Children's Hospital
at North Adelaide at 8.30 am Tuesday the 1st of February
1949 where she was to undergo an operation for the removal
of her Tonsils and adenoids. She had previously been attended
by Doctor von der Boren who had ordered the removal of
the tonsils and adenoids. Upon arrival, deceased was taken
away from me for a short time whilst she was examined.
She then returned to me and we sat in the Out-patients
dept. for some time together. Whilst waiting, deceased
was given a hypodermic injection. Deceased was then with
me up until the time she was taken to the Operating Theatre
at about 9.30 am on the 1st February 1949. That was the
last time I saw the deceased alive. I have never hear
(sic) of the deceased having any illness, other than infantile
eczema, and one attack of asthma, and also influenza,
during which time she had a very sore throat. Deceased
appeared to me to be a healthy child.
Eileen Gertrude DALY, married, home duties, mother
of deceased, of Herston Road Herston, Queensland, at present
staying at 19 Brandreth Street, Tusmore, S.A.
"Deceased was my daughter. She was born on the 17th
of April, 1946. When very young deceased had infantile
eczema. Apart from that she was a very normal baby. With
deceased and my husband I resided at Herston Road, Herston
in Queensland. Prior to deceased's death we have been
staying with my sister Miss Margaret Phillis Green of
19 Brandreth Road (sic) Tusmore South Australia. In May
1948, deceased had an attack of Influenza and tonsillitis
during which time deceased found great difficulty in swallowing.
These were the only sicknesses that I can remember her
having and apart from this she was always healthy and
was of normal weight and height. On or about the 15th
of November, 1948 I took the deceased to Doctor von der
Borch at his rooms at 188 North Terrace, Adelaide, where
he made an examination of the deceased. He recommended
the removal of the deceased's tonsils and adenoids, and
the deceased was to have been operated on, on the 23rd
of November, 1948 but there was a fear of Whooping Cough
in the family. Deceased was given an injection and never
caught whooping cough. It was then decided to operate
on the deceased on the 1st of February 1949. On the morning
of the 1st of February 1949, I asked my sister, Miss Margaret
Phillis Green to take deceased to the Adelaide Childrens
Hospital. Deceased then left to go to the Hospital with
my sister, and that was the last time I saw her alive,
shortly before 8.00 am on Tuesday the 1st of February
Rudolf Herman von de Borch, Legally Qualified
Registered Medical Practitioner and Honorary surgeon at
the Adelaide Children's Hospital at North Adelaide, with
rooms at 188 North Tce., Adelaide, states:-
On the 15th of November 1948, I first saw the deceased,
when she was brought to my rooms at 188 North Terrace,
Adelaide, by her Mother. Deceased's Mother stated that
the child had never been very well and had suffered from
infantile eczema and also asthma. The last attack being
about 3 months previous to the visit. Deceased I was informed
had recently had influenza and inflamed tonsils, and had
had difficulty in swallowing. Upon examination of deceased
I found a rather under developed child with in my opinion,
grossly infected tonsils. I recommended Tonsillectomy
(removal of tonsils). This was conducted on the 1st of
February 1949 at the Adelaide Children's Hospital at North
Adelaide. She arrived there at about 8.30 am and as far
as I know she was given the usual injection of Atropine.
Anaesthesia was then injected at about 9.30 am on 1.2.49.
The Operation then commenced and I removed the adenoids.
I then noted that there was little or no haemorrhage.
I requested the pulse to be taken and it was found to
be present but weak. The breathing was regular, but shallow
and colour pale. Artificial respiration commenced at 9.45
am., and at the same time a small tube of oxygen was passed
into the wind pipe. A coramine injection was immediately
given and artificial respiration continued, but there
was no response. After about 5 minutes of this treatment,
and the pulse was no longer present, the abdomen was opened
and cardiac massage commenced. At the same time an Adrenaline
xxx was injected into the heart muscles. There was no
response, the heart being quite still and further efforts
were abandoned after a further 30 minutes, when death
was deamed (sic) established at about 10.30 am on 1.2.49.
I think the cause of death was cardiac failure, associated
with so called status lumphaticour.
Frank Barry Cocks, Plain Clothes Constable stationed
at North Adelaide, states:-
At about 2.45 pm on Tuesday the 1st of February, 1949,
I accompanied Miss Margaret Phillis Green, an auntie to
the deceased, to the mortuary at the Adelaide Children's
Hospital at North Adelaide. In the mortuary I saw the
body of a female child, aged about 3 years. Miss Green
then identified that body as being that of her late niece
Kathryn Mary Daly, aged 2 years and 9 months, late of
Herston Road Herston in Queensland and who prior to her
death has been residing at 19 Brandreth St., Tusmore,
South Australia. The father of the deceased is at present
in Queensland, and the mother Mrs Eileen Gertrude Daly
was too ill as the result of this sudden death of her
daughter to go into the Mortuary and identify the deceased.
Miss Green has know (sic) the deceased all her life having
attended her during the first three months of her life
and off and on during the past 2 and a half years. I obtained
the attached statements from the Mother and Auntie Miss
Green and also the statement by Doctor Rudolf Herman van
der Boren who was operating on the deceased when she collapsed
and died. There does not appear to be any suspicious circumstances
connected with the deceased's death. Every possible care
having apparently being taken during the operation. Dr
von def Boren attended the deceased prior to her death.
He recommended the operation for the removal of tonsils
and adenoids when he first examined the deceased 1948.
The operation was then postponed due to a case of whooping
cough in the family. Deceased did not catch the whooping
cough and was subsequently operated upon on the 1st of
February 1949, when she collapsed and died under the anaesthetic.
Attached is a statement from Doctor Cheeseman, Resident
Medical Officer at the Adelaide Children's Hospital North
Adelaide setting out the particulars regarding the death
of the deceased, whilst under the anaesthetic.
. .(signature) . . P.C.C.
No Inquest necessary
(signed Illegibly) xxx Smith
2/2/49 Deputy City Coroner
Post Mortem Ordered. 2/2/49
Inquest may be necessary 4/2/49
this is the end of the page for
this police report
AUSTRALIAN POLICE REPORT TO SUPERINTENDENT HOMES
North Adelaide Police Station
3rd February 1949
To: Metro Supt Homes
Subject: Report re 12 bottles of "Austan" ether,
supplied to the Adelaide Childrens Hospital, by Brown
and Pearce, Surgical Suppliers of 227 North Terrace Adelaide.
2. I beg to report that for your information, that on
the 2nd and 3rd February 1949, Dr Rischbieth, Medical
Superintendent at the Childrens Hospital, report the deaths
whilst under Anaesthetic, and undergoing operations at
the Childrens Hospital, of Kathryn Mary (sic) Daly, aged
2 years and 9 months, late of 19 Brandreth Street Tusmore,
and Gertrude Grace Ballantyne, aged 2 years, late of 77
Belair Rd West Mitcham.
3. On each occasion, "Austan" ether, supplied
to the Hospital by Brown and Pearce, was being used. Subsequently,
Dr Rischbieth made enquiries and he was informed by Mr
Shields, of the Government Analyst, that a sample of the
"Austan" ether had been submitted to his Department,
from Whyalla, and that on an analysis being made, it was
found that the ether was unfit for use. Further enquiries
have shown that this particular batch of ether was delivered
from the factory at Cowandilla, in 88 5 lb bottles, to
the following persons and Firms:-
12 bottles to Adelaide Childrens Hospital. North Adelaide.
12 " to Malcolm McNeil. 136 Grenfell St Adelaide.
12 " to Mount Gambier Hospital. Mt Gambier.
38 " to Royal Adelaide Hospital. Nth Terrace, Adelaide.
14 " to Brown Pearce. Surgical Suppliers. 227 Nth
4. Mr Brown of Brown and Pearce, called at the North
Adelaide Police Station, at 3 p.m. on this date and he
stated that 11 bottles of the "Austan" ether,
had been supplied to the following customers and that
the Firm still had 3 or the 14 bottles in stock. Mr Brown
stated that he Firm would get in touch with the following
persons, on this date, and advise them that no further
use was to be made of the "Austan" ether delivered
on or after the 26th January last, until further advised
by his Firm. Mr Brown also stated that the ether would
be collected and returned to the Firm as soon as possible.
List of persons supplied b y Brown and Pearce:-
1 bottle to W. Ramsey Prty Ltd, 11 Austin Street Adelaide.
1 " to Dr Thorold Grant. 219 North Terrace Adelaide.
1 " to Port Lincoln Hospital. (By air).
1 " Assay Dept. School of Mines. Nth Terrace Adelaide.
1 " to Dr O. B. Lower, 15 Angas St Kent Town.
1 " to Dr R. T. Steele. Campbelltown
1 " to Dr M. W. Hamilton. C/o Dr Hussey. 197 Payneham
1 " to Dr S. Hecker. 15 Old Beach Rd Brighton.
1 " to Dr G. de Crespigny. 260 Main Nth Rd. Prospect.
2 " to Dr G. A. Hodgins. 150 Goodwood Road, Goodwood.
(signature of S R Stewart)
A hand written note is at the bottom of this report
and it reads:
"23/2/49 No inquest necessary"
Below this notation appears the signature of C Twedale
Under Anaesthesia Report by Hospital
CASE OF DEATH REPORT TO HAVE ARISEN FROM OR DURING ANASETHESIA.
Name of patient: Kathryn Margaret DALY age: 2 yrs 5 mths
Date of Death: 1st Feb 1949 Place: Adelaide Children's
Hospital NORTH ADELAIDE
1) Abnormalities of patient ascertained previous
to administration of anaesthetic
|Grossly enlarged tonsils and adenoids.
History of asthma.
|2) Nature of operation, and
name of surgeon
|Tonsillectomy and Adenoidectomy.
Dr. R. H. von der Borch
|3) Preliminary Medication, if any
||1/150 grain of atropine at 9.15 a.m.
|4) Preparation of patient
||No special preparation.
|5) Type of anaesthetic, whether general,
local or combined
||General - Ether
|6) Method of induction of anaesthetic
and position of patient
|| Ethyl chloride.
|7) Method of continuance of anaesthetic
and positions of patient
||Ether insufflation via Davis Boyle gag.
Supine - vertex down.
|8) If local anaesthetic was used name
of drug, strength of solution and quantity used
|9) How long after induction did fatal
symptoms ensure, and at what stage in operation
|10) Did the deceased die during the administration,
if not how long after its administration
|11) State shortly the exact course of
||Respiration became weak just after removal
of adenoids. Anaesthetic stopped. Pulse weak and rapid.
Respiration ceased. No cyanosis
|12) What remedial measures were employed
and for how long were they carried out
||Arteficial (sic) respiration commenced
and oxygen given. Poor air interchange although vocal
cords were flaccid and open. Intra-tracheal oxygen and
intra-cardiac adrenalin followed by cardiac massage
through a left paramedian incision.
|13) To what cause or causes
did you attribute death
Signature and Qualifications signature of Geof Cheeseman
Official Appointment RESIDENT MEDICAL OFFICER
ADELAIDE CHILDREN'S HOSPITAL
1ST February, 1949
MORTEM NOTES by DR VON DER BORCH
NAME OF CHILD DALY, Kathryn Margaret.
AGE 2 years, 9 months.
HONORARY Dr von der Borch.
P.M. NOTES There are bruising in scalp corresponding
with markings on left side and moderate layer of subcutaneous
fat in opening abdomen. Some fluid in peritonail (sic)
cavity; appendix 4" long curled into a reverse &
behind coecum. Excess of pericardial yellow fluid - about
3 ½ oz. . Bags are collapsed on opening chest.
L lung being at level of 6th R/B posterior axillsar line;
front border reaches only as far forward at that line.
Heart R ventricle dilated; contains fluid blood. Valvular
orifices are dilated; mitral normal. All valves normal;
Coronary orifices clear. Heart muscle good colour and
texture; Thoracia and abd. (sic) aorta normal.
Gall Normal Basin; congestion of superficial vessels and
appreciable congestion of deeper vessels of white matter
of cerebral hemispheres.
Middle Ears and sphenoidal cell - normal.
R Adrenal - normal
L Adrenal - small haemorrhage just beneath capsule, but
not in substance of adrenal at lower surface.
R Kidney Weight 40 grms. Deeply congested and swollen
- capsule peels easily - cortex regular - no pathology.
L Kidney Weight 37 grms. Deeply congested and swollen,
similar to right. Both ureters normal.
Both ovaries normal; uterus congested; Liver mostly dark
blood on pressure
Bladder congested, otherwise normal.
Abdominal aorta normal.
Stomach Contains some dark chocolate coloured fluid.
Mucosa, pylorus and duodenum - normal
A little congestion small intestine. Remainder of intestine
Pancreas Congested particularly at head.
Spleen 75 grms. - larger than normal - pale with predominance
of lymphoid tissue.
There are numerous enlarged lymph glands in mesentery
of small intestine near appendix.
R Lung There is blood in the main bronchus and in its
branches with a plug of clot in air passage on upper side
on luman. There are dark areas of collapse in lowere (sic)
part of upper lobe and lower part of lower lobe.
L Lung Blood is also present in main bronchus, but no
clots are to be found. There are dark patches of collapse
in both lobes.
Tongue Normal: Pharynx congested: Oesophagus normal.
Trachea lined with blood stained mucous.
Tonsils still in position. Blood clot present at site
Summary Blood in air passages of lung with clot obstructing
a large branch anteriorly in upper lobe of right lung
: partial collapse of both lungs : enlarged thymus : large
spleen : large mesenteric lymph glands : congestion of
pharynx : kidneys : liver : pancreas : and brain.
CAUSE OF DEATH Consistent with respiratory obstruction
and consequent heart failure in a child with generalised
AUSTRALIA GOVERNMENT DEPARTMENT OF CHEMISTRY
Report on Anesthetic
Kintore Avenue, Adelaide
11th February, 1949.
(the document is ink stamped as
POLICE COMMR'S OFFICE ADELAIDE
REC'D 12 FEB 1949
TO THE DIRECTOR :-
On the 3rd February, 1949, I received from P.C.C. F. B.
One bottle containing a sample of ether. The bottle
was said to be representative of the ether administered
to Gertrude Grace Ballantyne, aged 2 years on the 15th
February, 1949, who died whilst under anaesthesia, at
the Adelaide Children's Hospital, on the 2nd February
From the results of analyses made I am of opinion that
the sample of ether passed the following tests for Anaesthetic
ether as described in the British Pharmacopoeia, 1932:-
2. Acetone and aldehyde
3. Methyl alcohol.
As the sample of ether was insufficient for further
tests, I went to the Adelaide Children's Hospital on the
9th February, 1949, and received from the Chief Pharmacist,
Mr S. A. Downie, an unopened 5 lb. Winchester of ether
said to be from the batch of ether received at the Adelaide
Children's Hospital, on Friday, 28th January, 1949.
From the results of analyses made I am of opinion that
the ether passed further tests for Anaesthetic ether as
described in the British Pharmacopoeia, 1932, viz:-
4. Weight per ml.
5. Foreign odour,
6. Sulphurous acid and other free acids,
7. Non-volatile matter.
. . . . . . . . . . . . . . . . . .
(signature of R J Cowan)
Deputy Government Analyst.
RETURNED TO THE COMMISSIONER OF POLICE, with report
by Mr. R. J. Cowan, Deputy Government Analyst.
. . . . . . . . . . . . . . . . .
(signature of S D Shield)
DIRECTOR OF CHEMISTRY.
WARRANT TO BURY
|To the constables of the
State of South Australia, and to all others whom it
may concern :
WHEREAS, I, with my inquest, the day and year hereunder
written, have made enquiry respecting the death of KATHRYN
MARY (sic) DALY, aged 2 years & 9 Months
Herston Road, Herston; Queensland, but late of 19 Brandreth
Street Tusmore, in the State of South Australia
Who died at Childrens Hospital North Adelaide on 1st
And I have proceeded therein according to law: There
are therefore to certify that you
may lawfully permit the body of the said deceased to
be buried, and for so doing this
shall be your warrant.
Given under my hand and seal the 3rd day of February
(signature of C Twedale Smith) J. P., Coroner.