Throughout history, doctors have treated patients, and doctors have made mistakes. Casebook has delved deep into the past to see what doctors used to get away with

These cases are based on publications within the 19^th Century Poor Law Union and Workhouse Records and the Royal Navy Medical Officer’s Journals – previously released by the National Archives in the United Kingdom.

Acid attack – a case of vicarious liability?

Thomas S Fletcher was a surgeon at the Bromsgrove Workhouse, Worcestershire. One of his patients, young Henry Cartwright, died in 1842 after being immersed in potassium sulphate – in an attempt to cure “the itch”, or scabies. The postmortem result described how his skin was inflamed and scalded.

Dr Fletcher was found to have failed to supervise nurse Sarah Chambers, who placed the young boy in the acid. Was Dr Fletcher vicariously liable? Although the incident was investigated, Dr Fletcher was not struck off, owing to his “previous unblemished professional record, and kind attention to pauper patients”.

Letter from Ralph Docker, Coroner for Worcestershire to the Poor Law Commission, 17 February 1842. National Archives: Ref MH 12/13905/153.

Laudanum overdose – learning from adverse events

Mrs Elizabeth Galloway of Newcastle was suffering from inflammation of the bowels. To aid her recovery, she was given a tincture of rhubarb, which was collected from the druggist, Mr Tinn, by her young daughter. Unfortunately, the druggist mixed up the wrong remedy; the cup contained laudanum rather than rhubarb. Mrs Galloway immediately worsened and the doctor was called. Her stomach was pumped, first with a mixture of brandy and ammonia, followed by water and strong coffee, but she later died.

At the ensuing inquest, Mr Timms was found to have administered the drug in an act of human error: “One of those mistakes to which all men were liable, however much they were to be deplored.” In an early example of learning from adverse events, the inquest recommended that in future, druggists should store poison separately from other medicines.

BMJ archives: Death from Laudanum: Given by Mistake, Prov Med Surg J, 1-1:334-335 (1841)

Deadly nightshade

In a similar case, Mary Ramshaw, from Northallerton, was knocked down and severely fractured her thigh. Doctor Lumley was called, and prescribed both a mixture to take and an embrocation. Mrs Ramshaw’s daughter unfortunately administered the medicine from the wrong bottle and Mrs Ramshaw instantly began to convulse. Ten minutes later, she died. The embrocation she had accidentally been given contained belladonna (deadly nightshade). The inquest heard how Dr Lumley did not place any labels on the bottle to warn of its poisonous nature. The jury recorded in their verdict that “the medical attendant was not free of blame in the matter”, and stressed the importance of dispensing poisonous mixtures in roughened or fluted bottles, as well as ensuring appropriate labelling in future.

BMJ Archives: Fatal Mistakes in Taking Medicine, 2:1120-1132 (1885)

Under the influence

A woman died following childbirth in 1839. The postmortem revealed that the fatal injuries were caused by the unskilled use of “some instrument” during delivery. The surgeon was thought to have been intoxicated during the delivery and was charged with manslaughter – but was later acquitted.

The Times, 12 April 1839. Ferner RE, McDowell S, Doctors charged with manslaughter in the course of medical practice, 1795-2005, Journal of the Royal Society of Medicine, Vol.99 (2006).

Errors in time

Medical negligence has been described as “a space, more than a thing” – a shifting, malleable interaction between time and place and, to varying degrees, society, law, ethics, medical practice, health professionals, and patients.[1] What is perhaps most interesting about the extracts from the medical archives is that the definition of medical negligence hasn’t shifted all that much.

While the prescribed treatments and remedies mentioned may be different, the same high expectations of professional conduct, skill and integrity from doctors remain. Some of the issues are strikingly contemporary: vicarious liability, prescribing errors, significant event audits following adverse events, professional misconduct and, of course, human error.