| 词条 | Draft:Bundaberg tragedy |
| 释义 |
The Bundaberg tragedy (or Bundaberg disaster) was a medical disaster that resulting in the deaths of 12 children in Bundaberg, Queensland, Australia. Six other children were seriously ill. A royal commission concluded that the deaths were caused by the contamination of a diphtheria vaccine with the bacterium Staphylococcus aureus. DisasterOn Friday 27 January 1928, 21 children between the ages of one and nine were inoculated against diphtheria by the local medical officer of health, Ewing Thomson. By that evening, 18 of the children were seriously ill, initially with vomiting and diarrhoea, then with fever, cyanosis, delirium, and coma. [fuller list of symptoms in Hooker] The other three children experienced few symptoms. Between 15 and 34 hours after the inoculation, twelve of the children had died. Three were from a single family, the Robinsons, while two other families lost two children. The mass fatality overwhelmed the town's two hospitals, Bundaberg General Hospital and St Vincent's Hospital, which did not have the staff or capacity to handle multiple paediatric emergencies. Most of the fatalities occurred within the first six hours of admission. The hospitals' mortuary facilities were also inadequate to deal with multiple victims. Dr Hains, the general hospital's superintendent, was unwilling to sign the children's death certificates and requested that a pathologist be sent. Initial post-mortem examinations were performed by the government medical officer of Maryborough, Dr E. G. Schmidt. On 30 January, pathologist Dr Richards arrived from Rockhampton, but only performed one autopsy.{{sfn|Akers|Porter|2008|p=267}} Thomson's procedures listed in Hooker. Need bios for William James PenfoldAnnie HensleyMavis FreemanReactionTermination of immunisation programsThe inoculation program in Bundaberg was suspended immediately after the children's deaths, following shortly by those in the major cities of Brisbane and Melbourne. As news spread, programs were also suspended in New Zealand and Cape Town, South Africa. Royal commissionThe federal government called a royal commission into the deaths on 31 January.{{sfn|Akers|Porter|2008|p=268}} Hearings began on 13 February.{{sfn|Akers|Porter|2008|p=270}} The manufacturer of the toxin–antitoxin was Commonwealth Serum Laboratories (CSL), owned by the federal government. As a result, responsibility for the deaths was seen to lie with the federal government rather than the Queensland state government (the administrators of the immunisation program), and inquiries were conducted by the federal government. The three commissioners were Charles Kellaway, director of the Walter and Eliza Hall Institute; Peter MacCallum, professor of pathology at the University of Melbourne; and Arthur Tebbutt, bacteriologist at Sydney's Royal Prince Alfred Hospital. Kellaway was appointed as the commission's chairman. There was some criticism of the appointment of three medical professionals, The commissioners heard evidence in Bundaberg, Stanthorpe, Toowoomba, Brisbane, Sydney, and Melbourne. The sessions were open to the press and were extensively reported. Kellaway delegated much of the commission's work to Macfarlane Burnet, his assistant director at the Hall Institute and a future Nobel Prize laureate. Burnet was able to isolate Staphylococcus aureus in both the toxin-antitoxin mixture and in pus taken from the surviving children.{{sfn|Akers|Porter|2008|p=275}} The commission's report was presented to the House of Representatives by Neville Howse on 13 June 1928. four-month investigation{{sfn|Hobbins|2010|p=435}} The Medical Journal of Australia and British Medical Journal concurred with the findings of the commission.{{sfn|Hobbins|2010|p=435}} The commission concluded that the children's deaths were the result of the serum being contaminated with the bacterium Staphylococcus aureus. The commission concluded that the manufacturer, CSL< had contributed to the deaths by distributing bottles of serum that did not contain antiseptic.{{sfn|Hobbins|2010|p=436}} The report made five main recommendations. It was immediately forwarded to the state departments of health. The day after the report was issued, Prime Minister Stanley Bruce announced that the federal government would issued compensation payments to the families of the deceased and would cover the medical expenses of the surviving children.{{sfn|Hobbins|2010|p=438}} ReferencesSources
5 : Health disasters in Australia|1928 in Australia|1928 in science|Medical scandals|1920s health disasters |
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