A tribute to Michael Christian Daly & Eileen Gertrude Green,
to their descendents and to their ancestors and to the many cousins


I contacted the South Australian Coroner about whether there was a report into the death of my sister Kathryn Margaret Daly. The office was able to provide a copy of original documents held in their archives. Below is a transcription of these papers relating to Kathryn's death which occurred during a fairly routine tonsillectomy on 1 February 1949. At the time a coronial inquest was deemed to be unnecessary however there were police reports and other reports into her death.

There are some minor errors in the reports regarding spelling and names. For example Kathryn's second given name has incorrectly been recorded in different documents as "Mary". Any errors have been transcribed as they were originally written. I have not commented on the content of the reports or their findings. According to her death certificate the cause of death is "tonsillectomy and adenoidectomy".

However I do wish to explain that in one police report, a witness says that the drug Coramine was administered to Kathryn following her "collapse" during the operation. Coramine is a stimulant which mainly affects the respiratory cycle. It was used in the mid-twentieth century as a medical countermeasure against tranquilizer overdoses (source:

At the end of the original police statement are some hand written notes concerning the necessity for a post mortem and an inquest; this text is also included in my transcription.

Readers may be distressed by these reports and may decide not to read any further.

Michael Daly

(updated October 2016)

Copyright material is acknowledged and is used for research and study purposes to the extent permitted by law and may not distributed nor commercially exploited without written permission

Links to Reports covered in this document

Reports to North Adelaide Police by family and doctors

North Adelaide Police Station Report to Superintendent Homes

Death Under Anaesthesia Report by Hospital

Post Mortem Notes by Dr von der Borch

Dept of Chemistry Report on Anesthetic

Warrant to Bury

Downloadable PDF copy of the reports

Link to Kathryn's Memorial Page


Reports 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.

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 1949.

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

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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.

Reference: -
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 Terrace Adelaide.

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 Road, 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 Smith

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Death Under Anaesthesia Report by Hospital


Name of patient: Kathryn Margaret DALY age: 2 yrs 5 mths sex: Female
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 …… 15 minutes
10) Did the deceased die during the administration, if not how long after its administration …………………………. During
11) State shortly the exact course of events ………………. 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.
Twenty-five minutes.
13) To what cause or causes did you attribute death … Cardiac collapse.

Signature and Qualifications signature of Geof Cheeseman MB BS
1ST February, 1949

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NAME OF CHILD DALY, Kathryn Margaret.
AGE 2 years, 9 months.
SEX Female.
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.
Rectum normal.
Stomach Contains some dark chocolate coloured fluid.
Mucosa, pylorus and duodenum - normal
A little congestion small intestine. Remainder of intestine normal.
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 of adenoidectomy.

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 lymphatic hyperplasia.

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Report on Anesthetic

Kintore Avenue, Adelaide
11th February, 1949.

D.C. 43/49

(the document is ink stamped as follows)
REC'D 12 FEB 1949

On the 3rd February, 1949, I received from P.C.C. F. B. Cocks:-

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 1949.

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:-

1. Peroxides,
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.

by Mr. R. J. Cowan, Deputy Government Analyst.


. . . . . . . . . . . . . . . . .
(signature of S D Shield)

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Warrant to Bury


to wit
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 February 1949

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 1949.

(signature of C Twedale Smith) J. P., Coroner.

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