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Evidence showed the early symptoms of her fatal diabetic complications were similar to thoseof the acute mental an- xiety from which she also suf- fered. At the time August 18 doctors at the liOspital were working to save her life. a pregâ€" nancy test was positive and her family physician Dr. Socol be- lieved from her physical con- dition and information received that she was two months preg- nant. But the subsequent au- topsy showed she wasn't preg- nant. Evidence also showed Mrs. Mallory‘s relationship with her family physician Dr. Harvey Socol was a poor one. She had gone to another doctor when ad- mitted to the Clarke Institute for her mental illness and hadn‘t informed Dr. Socol of this until she became ill and felt in need of renewed psychiatric medica- tion. PREVENTED DIAGNOSIS jig”? Both a University of Toronto“gem medical expert and Dr. Socol Mrs told the jury her mental anxiety wau symptoms prevented immediate exar recognition of her diabetic aciâ€"luna, dosis complications in the earlyv ] stages at Dr. Soeol's office four M days before her death and inl the York Central Hospital enter-Ii if” gency department the night be-l0 j fore her death. A throat infec-‘qug‘ tion and her anxiety could have and made her diabetic condition de-[an 1 velop much faster than normal,’§ant It was said. I 0?. 30 WITNESSES Altogether 30 witnCSSes were heard. including doctors, nurses. relatives and friends of the de- ceased. Expert evidence showed thc‘ injury to Mrs. Mallory's head might have been received dur- ing one of her habitual bouts of fainting and falling. In any: event. the physical injury was‘ considered so slight it wouldn'tl have affected her fatal illnessi Evidence showed Mrs. Mal- lory, the separated mother of two children. had a recent his- tory of treatment at the Clarke Institute of Psychiatry for a mental illness, paranoid schizo- phrenia (with depressive fea- tures that might have led to suicide). For about the last half year she had residing with her a male companion she met while confined to the Clarke Institute Hospital. Mrs. Mallory was admitted to hospital for observation. But overnight no tests were made that revealed her true condition. A series of doctors and nurses failed to note any acetone smell on her breath. the symptom which the (court was told should have been present and an indi~ cator of her condition. A urine test was ordered upon her admittance to hospital be- fore midnight and this test would also have provided a warning of her diabetic condi- tion. But she was unco-opera- Live. probably because of her illness and approaching state of coma. and gave no urine sample when asked to do so by a nurse. Nursing staff hadn't any orders to force the urine test issue be- fore the routine time for hospi- tal patient testing in the morn- ing. Hula cunuuu I months of Before the results of routine Institute. 1, tests were available the next‘December I morning. Mrs. Mallory had gone panic" fmn into a diabetic coma the medi-‘tute also to. cal expert said was about 75%lafier she ha. fatal. Earlier diagnosis of herithat time 5 condition and earlier insulin Toronto Ger treatment would have increased'docmr. The; her chances of survival. the exâ€"iand kept in pert said. In his opinion it wouldi partl‘nent 5 take a minimum of two days foribeing releas Mrs. Mallory‘s diabetic condi-’information tion to develop, but usually much ' didn't have longer. [was told. Dr. Socol told the court Mrs.| Mallory’s incipients diabetes condition was known because of 10 the history of diabetes in hex"0 family. He told the court he did; 1013, a blood test for diabetes for Mrs.‘ tral Mallory three weeks before haan death and diabetes Wasn't indi-jdom cated at that time. T 12" f( ifs: But Dr. Socol said he doesn‘t note such tests on patients? cards in his office unless the; results show a positive indica-g tion of an illness. 0n the night“ Mrs. Mallory was stricken Dru Socol was away and his young! associate Dr. Paul Woo had no’ knowledge of the danger of dia-‘ betes when he sent her to hos- pital and saw her there. DOCTOR‘S RECORD Dr. Woo consulted Mrs. Mal- lory's card in the doctors‘ office and saw only two recent nota- tions by Dr. Socol about anxiety problems. There were no nota- tions there about her propensity to be diabetic and there was no record there of Dr. Socol's last test for diabetes. There was also no record in the office files of the numerous and extensive diabetes tests done the pre- vious year at the Clarke Insti- tute during the period of close to a year when Mrs. Mallory didn't go to Dr. Socol. But Dr. Woo did consult with Dr. Socol's long time partner Dr. Marvin Abrams on the m'g‘n she was stricken. Dr. Abrams was also familiar with Mrs. 10 THE LIBERAL, Richmond Hill, Ontario, Thursday, Dec. 16', 1971 Poor communications delayed a diagnosis and contributed to the death main-{iii {h‘é‘aiy'giie‘ai‘e‘a_ of a woman in Richmond Hill’s York Central Hospital in August, an inquest jury has found. “We are of the opinion that a contributing factor to her death was poor communications between patient, doctors, institutions and hospitals which de- layed the diagnosis of diabetic acidosis,” said a five-man jury on Thursday after- noon of last week. The jury was delivering its verdict at the end of a three-day inquest at the Metro coroner's office into the August 19 death at York Central Hospital in Richmond Hill of Mrs. Joan Mallory. 39, of 64 Bridgeport Street, Richmond Hill. The inqueSt was ordered by the Ontario coroner. A post mortem showed Mrs. Mallory had a recent brain injury probably due to a blow to the side of the head. 1 Evidence showad Mrs. Mal-[Mallory's history and knew she ory, the separated mother oflmight become diabetic, But this we children, had a recent his-ididn’t come to his mind when my of treatment at the Clarke she was admitted to hospital. ‘nstitute of Psychiatry for a After admitting Mrs. Mallory. nental illness, paranoid schiZO-lDr. Abrams said he expected to )hrenia (with depressive fea'lbe called if there were any pro- ures that might have led tOfblems overnight. but didn‘t get‘ .uicide). For about the last halflany can year she had residing with herl ‘MONEY CONSIDERATION imale companion she met “jhl‘el Dr. Abrams said it used to be :onfined to the Clarke Institute usual routine to do blood tests iospital- and a urine test when patients 30 WITNESSES were admitted to York Central Altogetheiao ‘f’ltt‘esses were:I-lospital. “But with financial irreversible by the time treat- ment was started. CORONER'S OPINIONS Coroner Bennett said he had prepared a list of his recom- mendations for the jury. but he added that after preparing them he wasn't strong in his feeling they were the right ones. He said it was probable there should be better communication between hospitals and medical personnel. such as in the case of the general practitioners and the Clarke Institute in the fraudcman‘ nl‘ “Kna- TUIalhu‘u Ian i FAMILY AND FRIENDS 1 Other witnesses called icluded: Robert Mallory of 64 iBridgeport Street. estranged husband of the deceased: Mrs. Doreen Herrington of 105 La- Rose Avenue, Apartment 1014. Weston. sister of the deceased: Helen and George Weston of 18 Sellmar Avenue. Weston. the parents of the deceased: Joan Sleep of 145 Byng Avenue. Wilâ€" lowdale. a long time close friend of the deceased Mrs. Mallory: Mrs. Joan Smart of 110 Inverlochy Boulevard. Thornhill. who worked with the deceased at a Metro school; Adolf Vanderstar of 11 Audley Avenue. Toronto. companion of Mrs. Mallory during the months preceding her death. Mrs. Mal- lory's 11-year-old daughter Su- san was on the court's list of witnesses. but didn't, appear or get called. The same was true ‘for William Tice. principal of Sir Stanford Fleming School. 50 Ameer Avenue. employer of Mrs. Mallory. mistakeâ€"EN“ He knocked on the door and guy-.. -...... -u. before anyone came to the door. .It was locked and he couldn't get in. Mrs. Mallory was pale.‘ having difficulty breathing. She1 collapsed and fainted. He; caught her. It took 112 min! utes to get to the hospital, ar- rriving at 8:19 pm. Oxygen was. .given during the trip. Kirkpatrick said the ambu- Llance was ordered by Dr. Soc-.‘ {ol's office. He wasn't sure wvhat happened to a nasal spray bottle she had in her hand when she came to the door and col-‘ lapsed. ‘ Ambulance attendant Wood-' :cock said he cared for Mrs. Mal- ‘lory during the trip to the hos- rpital and she appeared to be a little better when they arrived. She could speak after being given the oxygen. EMERGENCY ARRIVAL Four-year Registered Nurse 'Blunt said Mrs. Mallory arrived iat emergency pale. restless. an- ‘regislcred nurse. xious. in a nightgown and house-. rmm um km: same, “1911-115 ul- \.-u. usual] uuulu cause impaired and altered be- havior. Blood sugar levels at in- it was three or four minutesitime of autopsy weren‘t impor- tant. since these were clearly established to be markedly ele- vated prior to death. he said. Registered Nursing Assistant McCabe from YCH night shift said she was looking after about 30 patients along with Mrs. Mallory, With her was a duty At midnight Mrs. Mallory was very restless. Her eye pupils were dilated. She wet the bed and yelled for help. but seemed to settle right down by 12:30 am. Then at about 1 am her light went on and she was extremely restless again. ' BAG OVER MOUTH A procedure to stop hyper- ventilating. a paper bag over the nose and mouth. was applied and seemed to work. Mrs. Mal- lory seemed fully conscious and was offered a bed pan. She de- clined and again no urine sain- ple was obtained. No effort was made to wring a urine sample chm snip! lame Poor Communécatians YCH Diabetes Fatality “We are of the opinion that a contributing factor to her death was poor communications between patient, doctors, institutions and hospitals which de- layed the diagnosis of diabetic acidosis,” said a five-man jury on Thursday after- noon of last week. The’ inquest was ordered by the Ontario corofier. A post ymortem showed Mrs. Mallory had a recent brain injury probably due to a blow to the side of the head. Excessive thirst was also said to be a symptom of Mrs. Mal- lory's diabetic condition. Emer- Igency Department nurses gave Evidence at the inquest show- ed Mrs. Mallory‘s diabetic sister informed an emergency depart- ment nurse of the danger and history of diabetes. but this wasn‘t communicated to a doc- tor. The nurse did write “not known" on the hospital’s patient-admittance questionnaire where it asked if the patient had diabetes. The inquest jury apparently felt information about Mrs. Mal- lory‘s history should have been more readily available to the doctors examining her in the emergency, since it made the fol 10 w i n g recommendation: “Doctors to keep more accurate records. Times and results of tests, whether positive or nega- tive. should be recorded. This record should include a readily accessible summary of imporâ€" tant information." Mrs. Mallory large amounts of wateg' to drink but the doctors examining her that night were unaware of this. The inquest‘s expert witness said in his experience such tests wouldn’t have been done in the circumstances at a hospital un- less a doctor saw a need for them and ordered the tests be done. DIDN’T TELL DOCTOR Mrs. Mallory had exhibited to her family and friends evidence of an unusual thirst and fre- quent hunger for sweet items, and was probably aware this was and was aware this was signifi- cant. But she hadn’t told her doctor. As it happened. the psychia- tric drugs she was taking had as a side-effect a condition of dryness of mouth. something which Mrs. Mallory would pro- bably have identified as a con- tinuous thirsty condition. Dr. Abrams said it used to be usual routine to do blood tests and a urine test when patients were admitted to York Central Hospital. “But with financial worries. we have discussed de- creasing the frequency of such tests." he said. The inquest jury recommends in this regard as follows: "Bet- ter communications between doctors, hospitals, and staff . . . and (they) in no way (to) rely on (the) patient to pass on infor- mation." In its third recommendation the jury said, "‘When the pat- ient has a family doctor, a comâ€" plete report should immediately be forwarded to him by any specialist or institution follow- ing treatment of (the) patient.” After admitting Mrs. Mallory. Dr. Abrams said he expected L0 be called if there were any pro- blems overnight. but didn‘t get any call. Mrs. Mallory was frequently examined for her fainting spells over the years by Dr. Socol. She was also closely examined for this condition during the latter months of 1970 at the Clarke Institute. In the last week of December last year her com- panion from the Clarke Insti: tute also took her to his doctor after she had a fainting spell. At that time she was sent to the Toronto General Hospital by the doctor. There she was examined and kept in the emergency de~ partment several hours. then being released. This was further information her family doctor Mallory's history and knew she might become diabetic. But this didn’t come to his mind when she was admitted to hospital. “As the father of a son only re cently found to be diabetic. I can understand the feelings of the parents.“ He added that he could see how it would be easy to criticise the actions of the YCH emer2~ ency department. Dr. David El- combe and Dr. Paul Woo in their failure to recognize dia- betes that night Mrs. Mallory was brought in. “But we weren‘t present Aug- ust 18. The information they ob- tained. the attitude and reac- tions of the patient and the res- By HAL BLAINE the inquest court ‘ The inquest started at 10 am Tuesday morning in the old Tor- }onto City Morgue building courtroom on Lombard Street and continued late into the ev- ening. It resumed Wednesday ‘morning and continued all day. All the evidence had been heard by 5pm Wednesday. The inâ€" 1quest court convened again at .2 pm Thursday. After the coron- er summed up the evidence and directed the jury, the five Ijurymen went out at 2:23pm and took close to 1% hours to prepare their verdict. LIST OF DOCTORS Witnesses called to testify at the inquest included the follow- ing physicians: Dr. Donald Gurthrie, York Central Hospit- al pathologist of RR 1, Klein- burg, who did the post mortem; Dr. Bernard Granton of 117 Yonge Street South and 64. Denham Drive, Thornhill, the coroner called to York Central Hospital at the time of death; Dr. Harvey Socol of 294 Bay- view Plaza, Richmond Hill and 24 Forest Court. Thornhill, the family doctor who attended at York Central Hospital: Dr. Paul Woo of 294 Bayview Plaza, ,Richmond Hill and resident of ‘6040 Bathurst Street, Apartment 1802, Toronto, an associate with Dr. Socol and partner: Dr. Win- ston Chow of 59 Yonge Street North. Richmond Hill and resi- dent at 164 Norman Drive, King 1City. a specialist in internal medicine who assisted Dr. Socol at YCH: Dr. David Elcombe of RR 1. Maple, YCH staff mem- ber on duty at emergency dur- ing admission of the deceased; Dr. Marvin Abrams of 294 Bay- view Plaza, Richmond Hill and resident at 20 Cedar Court, Thornhill. partner of Dr. Socol and associate with Dr. Woo: Dr. ‘Vivien Smith of 155 Balliol Street Apartment 1105. Toronto, intern psychiatrist at the Clarke Institute of Psychiatry Hospital who attended the deceased; and iDr. Donald Killinger. staff member at Wellesley Hospital. specialist in body hormones and assistant medical professor at _the University of Toronto. who -was called before the inquest ;c0urt as an expert witness. The coroner also felt it might be a good idea if there was bet- ter communication of informa- tion between the doctors and emergency services personnel. He also felt it would be advis- able for doctors to seek reasses- sment or consultation with an~ other medical practitioner if a patient doesn‘t respond to treat- ment in a reasonable time. Coronor Bennett said he felt it was unrealistic to depend solely on the patient to inform her doctor of her treatment at Clarke. should be better communication between hospitals and medical personnel. such as in the case of the general practitioners and the Clarke Institute in the treatment of Mrs. Mallory. (She informed Socol and partner Ab- rams of her stay at Clarke In- stitute shortly before her fatal illness). Witnesses called from Scott‘s Ambulance Service were driver Murray Kirkpatrick of 286 Deâ€" maine Crescent. Richmond Hill and Leonard Woodcock of RR 3. King City. They took the dec- eased Mrs. Mallory from her home to the hospital emergency department. NURSING STAFâ€"F York Regional Police Detecâ€" tive Clifford Cox was the in- vestigating officer. The Crown Attorney was Paul Roche. LAWYER‘S AND JURORS Attorneys appearing includ- ed William Cornwall of To- ronto, representing Doctors Socol, Abrams and Woo; Hugh Kelly of Toronto representing the Clarke Institute of Psychi- atry; Donald Mills of Toronto. representing the family of the deceased: and Stuart Parker representing York Central Hos- pital. The five jurors picked for' the inquest were all men and from Toronto. including: Broker John Ebach of 294 Deloraine Avenue: Clerk James Elson ‘of 92 Edith Drive; Purchasing Manager Francis Edmonstone of 80 Tretheway Drive, Apart- ment 3 (the jury foreman): Sec- retary Victor Easton of 707 Eglinton Avenue West, Apart-1 ment B-1; and Clerk Thomas‘ Endacott of 184 Bain Avenuel Presenting the subject of the inquest to the jury. Coroner Bennett said the deceased Mrs. Mallory, the separated mother of two children. was twice at York Central Hospital for surg- ery in the years before her fatal illness. She was also at the Clarke Institute of Psychi- atry in 1962 and 1970. In his opinion her symptoms when she was stricken would be the smell of acetone on her breath. plus labored breathing called hyper-ventilation There would be impaired brain func- tion with the patient sooner or later developing clouded con- sciousness or coma. which might 'ibe followed by death. Nurse Supervisor Mrs. Finch was the first witness, saying she was acquainted with Mrs. Mal- lory and was on duty at the time of death. Local Coroner Dr. Granton told how he was called to the hospital where Mrs. Finch ident- ified the body of Mrs. Mallory to him. He took custody of the body and called in a path- ologist to do the August 20 post mortem. provide constant care for Mrs Mallory during the early after- noon of the day she died. Granton also said he checked the official hospital records in the case. He presented these records to the inquest court as an exhibit. Pathologist Guthrie said he found the body dehydrated. with the brain swollen due to fluid content -â€" a symptom of diabetes complication. Dr. Guthrie said there was a small recent hemorrhage on the left side of Mrs. Mallory’s head. It was three to four inches in diameter, he said, and very recent. It could have been caused by a fall or trivial in- jury to the head. INJURY BEFORE DEATH "It wa sn ’t important in death. but indicated an injury a few days before death," he said Mrs. Mallory at the time of death was also in “1" early stages of acute bronchial pneu- monia. stages of acute bronchial pneu- N0 BREATH SMELL monia. H “Wth I first saw her. I put The pathologist said his find- it down to a mental problem. ings were consistent with the When reassurance didn't work diabetes complication called di~I called in her physician. 1 abetes acidosis, except for the never thought of diabetes. I small head injury. She weighed didn't know she had excessive 125 pounds. He couldn't tcll‘thirst and four glasses of from his examination how long‘water." he said, while such she had the Small head inJUFY-‘knowledge might have changed In his opinion her symptoms‘his diagnosis. He was certain when she was stricken would be‘there wasn‘t any smell of ace- the smell of acetone on her,tone on her breath; In Mrs. Mallory‘s blood there were traces of a drug used to treat anxious tense persons or nausea. There was no way to tell from the autopsy how long she had diabetes. There was nothing about the head injury in the hospital records. He said the injury wouldn't have been evident to a nurse. since there was no external mark. Also there wasn‘t anything in the hospital record about any fall or bump. DIABETES INHERITED Dr. Guthrie said Mrs. Mallory could have had diabetes for a long period of time. or it could have developed fairly recently. Diabetes could be inherited. Mental depression and anxiety could be symptoms of the dis- ‘ease. “My findings didn't prove she out of bed and she stayed with had diabetic acidosis. The her for that reason. said Miss symptoms could have been as- Douglas- sociated as well with serious * V * * brain injury. In my opinion the‘ At this point in the inquest swelling of the brain wasn‘t due Pathologist Guthrie was recalled. to the small injury she had,"‘.He said swelling of the brain he said. would be a very important factor Next witness. 10-year-ambu-.C0Dtributing toward death. lance driver Kirkpatrick saileidges found on the brain from he received a top priority code.P1‘essing on bone was an indi- 4 can at 3:06 pm August 13 to‘cation of pressure. The brain 64 Brideeport Road for a wo- swelling could be an immediate man with an asthmatic condi- cause of death. but there were tion â€" difficult breathing. He other chcmicals abnormalities \arrived at 8:12 pm, the delaylthat could have contributed to Eleven-year Registered Nurse‘ Milne said: she first saw Mrs, Mallory on an ambulance stretcher. She was hyper-vent-1 ilating and anxious. She ob- tained the admittance informa- tion. Oxygen was given at a very slow rate but Mrs. Mallory became restless and took off the mask, so the giving of oxygen was stopped. DRY AND THIRSTY Mrs. Mallory’s sister and son ‘came in. They were very anx- ‘ious. Valium was given at ‘10237 in the amount of 10 milli- grams. She was very dry and ‘thirsty and was given two glasses of water in addition to those given by Nurse Blunt. Mrs. Finch came and recognized ‘Mrs. Mallory as someone who ‘previously worked at the hos- pital. having been due to his going;death. to Bridgeford Street first. by;' Swelling of mistake. Ycause impairm ‘ Dr. Elcombe said the patient lappeared very anxious. but re- ‘sponded well to reassurance. Having been told of her ree- ent treatment at the Clarke 1n- lstitute, he decided she was suf- fering from anxiety and with .Valium treatment could go jhome. He telephoned Dr. Woo to .tell him she could go home. what happened to a nasal spray Ambulance attendant Wood- cock said he cared for Mrs. Mal- lory during the trip to the hos- pital and she appeared to be a little better when they arrived. She could speak after being given the oxvven. .c~ 7dr.“- me’f‘ed by Dr. Elcombe- RNA McCabe said she checked Mrs. Mallory aSked for water Mrs. Mallory at about 7:30 am. and was given a drink twice. It she appeared drowsy then, but was a particularly busy evening was breathing fine" at emergency. Mrs. Mallory was * * a: la breathing heavily. was dis- Night shift Nurse McLean said tressed, but there was no smell Mm Mallory was awfully rest- of acetone on her breath. said less and would scream out. She Nurse Blunt. Mrs. Mallory “'35 seemed just to want reassurance. in emergency from 8:20 10 11210 The night nursing supervisor pm- came up. put the oxygen mask EMERGENCY ARRIVAL Four-year Registered Nurse Blunt said Mrs. Mallory arrived at emergency pale. restless. an- xious, in a nightgown and house- coat. Oxygen was given, along with eight milligrams of Val- Mrs. Mallory was put down as hyper-ventilating. a case in which tests aren’t usually done. There was only the second in- jection of the tranquilizer Val- ium, There was no odor notice- able on Mrs. Mallory‘s breath, said Nurse Milne. Emergency Dr. Elcombe, a 1967 McGill University grad- uate, said Mrs. Mallory looked distraught and agitated when she arrived. Dr. Woo called him before she arrived, saying Dr. Socol saw the patient some days earlier and gave medicine to a breathing problem and a cough. She had the problem approximately one week. His final diagnosis was hyper- ventilation and anxiety. She seemed fine, calmed down. her breathing normal, But half an hour later when it came time for her to be discharged. she was right back the way she was before. So he called Woo again to say she couldn't go home after all. “A severe emotional shock or severe anxiety can cause a sud- den change in a diabetic condiâ€" tion. I didn‘t note anything that might indicate the brain injury. Evening shift fourth floor Nurse Sheila Partridge of Thornhill said siderails had to be used when Mrs. Mallory was put to bed. She. was very rest- less. yelled she wanted some thing. She had the oxygen mask but didn't use it much. She checked the patient a couple of times before going off duty be- fore midnight. She was still restless. yelling out and hadn't settled down much when the shifts changed. The orders of ‘Dr. Woo were followed and the tests he wanted were requis- itioned. he said Registered Nursing Assistant Douglas said she was with Mrs. Mallory from 11:15 pm to 11:30 Pm. but was unable to obtain a urine sample. Blood pressure and temperature were recorded. Mrs. Mallory was trying to get out of bed and she stayed with her for that reason. said Miss Douglas. out of bed and she stayed Wi‘fll Registered Nurse Webb told her for that reason. said Miss of coming on duty for the ev. Douglas. ening shift shortly before Mrs. * v * * _ 'Mallory was pronounced dead. At this point in the Inquest, CARDIAC ARREST Pathologist Guthrie was recalled.i Part time Nurse Bull told how He said SWelling of the brain’She was doing constant care that could be a very important factorlday and was with Mrs. Mallory contributing t o w a rd death. from about 12:30 until her car- Ridges found on the brain fromadiact arrest at 12:45 pm, when pressing on bone was an indi-‘she called a Code 99 emergency cation of pressure. The brainlaud doctors took over with a swelling could be an. immediatevspecial cardiac team. '. was dis- Night shift Nurse McLean said was 110 Smell Mrs. Mallory was awfully rest- ' breath. Said less and would scream out. She . Mallory “'35 seemed just to want reassurance. 8120 to 11110‘The night nursing supervisor came. up, put the oxygen mask istered NUI‘Seion Mrs. Mallory for l/zâ€"hour. I‘St 53W Mrs» Mrs. Mallory seemed to settle> f1 amblflance down and go to sleep. She ap- S hYPer-Vent' peared to be sleeping between 115- She 0b" 6 and 7 am before the nursing "Ice informa' shift change. Medication had S giV€n at 3 been given to quiet the patient MI‘S- M81101? dmm. “As far as I was concern-j and 100k Off ed she was sleeping." said Mrs.‘ 19 giVing 0f McLean. BAG OVER MOUTH A procedure to stop hyper- ventilating. a paper bag over the nose and mouth. was applied and seemed to work. Mrs. Mal- lory seemed fully conscious and was offered a bed pan. She de- clined and again no urine sam- ple was obtained. No effort was made to wring a urine sampie from the bed sheets, she said. in answer to a question from Coroner Bennett. ‘ Night Supervisor Dew said she visited Mrs. Mallory be- tween 1:30 am and 2. Having known her before, she called Mrs. Mallory by name. The pat- ient responded as if conscious. “As far as I could see there was nothing unusually wrong. She seemed the same at 7 am. I didn't smell any breath odor. A person in diabetic shock would not be so restless as she. ‘and they don't settle down like what,” said Mrs. Dew. “no”. But this was stroked out and then the words “don’t know” were written in. Mrs. Finch said the questionnaire could have been answered by the deceased. but it was more likely they were answered by her sister. Nurse Steadman said no urine sample was yet tested for Mrs. Mallory. but “blood would have been taken for testing at the laboratory. Blood tests and uri- nalysis were normally done in the morning at the hospital. She saw one insulin injection ad- ministered. At 12:50 pm a Code 99 cardiac arrest emergency was called when all the doctors came. she, said. Socol was called at 8:30 and ar- rived by 8:40 am. He ordered and administered an intraven- ous saline and dextr05e transâ€" fusion. Returning to work the next day she was told of Mrs. Mal- lory's cardiac arrest. Mrs. Fine-h recalled Mrs. Herrington telling the night before about there be- ing diabetes in Mrs. Mallory’s family, but Mrs. Finch didn’t tell the doctor this. Mrs. Finch told how the sister said Mrs. Mallory met a chap at the Clarke Institute, wanted to take him with her on a visit to their parents home the year before, but couldn't. and they were ex- communicated. FORM CHANGED Shown Mrs. Mallory‘s hospital admittance consent form, where it asked if the patient ever was diabetic, Mrs. Finch said it said Nine»year Registered Nurse Steadman, assistant day shift head nurse fourth floor, said at 10 minutes before 8 o'clock in the morning Mrs. Mallory was very pale, but breathing easily. Called by name she did arouse. After 8 o'clock she was called by a duty nurse who had found Mrs. Mallory breathing shallow- ly and “1th pulse weak. Dr. Recalled to the stand, Evening Supervisor Finch said at emer- gency Mrs. Mallory's sister Mrs. Herrin'gton felt the patient couldn’t be sent home because there was no one there to look after her. Mrs. Mallory worked at YCH about 1963 as a secre- tary to the purchasing agent, she said. Mrs. Steadman said Mrs. Mal- lory “as extremely hard tn rouse at 8:20 and wasn’t respon- ding at 8:30 am. Upon arrival Dr. Socol ordered blood sugar tests and insulin was given at 10:32 am Day Shift Head Nurse Shier said she helped with the blood and urine tests and that Mrs. Mallory started to respond at about 11 am. The extra people attending her went to lunch and she was left in the hands of a special duty nurse. The insulin was given at 10:35. Recalled to the stand. emerg- ency admitting Nurse Blunt told how she started to fill out the SUPERVISOR VISITS the brain could Iadmittance form with the pat- ient Mrs. Mallory. But Mrs. Mal- lory became incoherent and she ‘finished the questionnaire with ers. Mallory‘s sister Mrs. Her- rington. She remembered be- ing told Dr. Socol had given Mrs. Mallory tests for diabetes. Next to give testimony at the inquest was the young woman psychiatrist who was interning at the Clarke Institute in 1970 and who treated Mrs. Mallory. Dr. Vivicn Smith told how she first met Mrs. Mallory on October 30. 1970 after she was admitted to the Clarke Insti- tute as an in-patient October 29. Mrs. Mallory's history was tak- en, she was given a physical examination and routine tests. MENTAL ILLNESS Dr. Smith said Mrs Mallnrv of her condition. She was ir- regular in attendance for ap- pointments and in taking med- ication. She was referred to an outside psychiatrist," said Dr. Smith. Mrs. Mallory was doing rea- sonably well and wasn't actively psychotic during her out-pat- ient treatment. Referral to an outside psychiatrisct was dis- cussed at length. because it is difficult for a patient to switch therapists. said Psychiatrist Smith. Dr. Smith said Mrs. Mallory smith 30t- baCk after was suffering from a mental m, PSYCHIATRIC DRUGS wasn‘t any no r1955. paranoid schizophrenia Asked if the phychiatric drugs say Where she with depressive features. She could have had any effects on “0 knOWIEdSE described this as a severe form Mrs. MalIOI‘fs diabetes. Bit-they have cal of mental illness. a thought dis- Smith said. "Not as far as I‘m dlabenc." he i order. She said Mrs. Mallory aware." She said stressful sit- ' * was psychotic. not in touch with nations seemed to bring on Mrs. Dr. Socol, a was psychotic. not in touch with reality. at the time of her ad- mission. She was treated and dis- charged December 28. 1970. She had some fainting episodes and because of the family history of diabetes was someone who had to have her blood sugar checked regularly. She had a urine test. blood sugar test. and a glucose tolerance test. Her several blood sugar tests at the institute were within the normal range. as were her urine tests. ‘ On November 11 one blood sugar test was abnormal. but conditions made it invalid. Tests taken during a fainting spell were normal. so they felt the spells couldn't be due to diabet- es nations seemed to bring on Mrs. Mallory's fainting spells. “She felt the .people at her previous place of employment were involved in a plot to give her psychotherapy. I was con- cerned about her suicidal pot- ential. but she made no actual attempts.“ ‘ Asked how Mrs. Mallory came to be a patient at the Clarke Institute. Dr. Smith said her son had been taking drugs and had gone to the Alcoholism and Drug Research Foundation. There they thought Mrs. Mal- iory's condition was such that she could have treatment. “I couldn‘t say she had diabetes. On the other hand I couldn't defintely exclude the possibil- ity." said Dr. Smith. Dr. Socol, a physician in gen- eral practice 10 years in Rich- mond Hill. said he had Mrs. Mallory as a patient since 1964 and saw her two or three times a year. He once referred her to a gynecologist and she made several visits with respiratory problems and anxiety states. She had surgery in 1967 for pel- vic cysts. She then had the rout- ine tests and had blood sugar [tests for diabetes twice a year. She was always a very difficult: patient to assess. he said. Socol said she was usually depressed and» would often break down and cry, even just after laughing. He referred her for several times for psychiatric care. She went~back on at least one set of occasions to see her a glucose tolerance test. Her several blood sugar tests at the institute were within the normal range. as were her urine tests. On November 11 one blood sugar test was abnormal. but conditions made it invalid. Tests taken during a fainting spell were normal. so they felt the spells couldn‘t be due to diabet- es On November 4, 1970, Mrs, The deceased woman's est-l Mallory was made an involun- ranged husband Robert Mallory‘ tary patient for her own pro- was the next on the stand. He tection as a precaution against said they were married Septem- suicidei Her medication was in- her 18, 1955. had two children creased to the maximum and and were seperated 1% years. she had electric shock treat- He said Mrs. Mallory’s health ment seven times. an amount was generally good, and she had described by Dr. Smith as pret- a vast amount of energy. She SUICIDE PRECAUTION “I always try to give my children something educational. So, I give them Commerce Growth Savings Certificates. They help the children understand savings.They only cost $6.81 and can grow to $10.00 in six years.You can give as many as you want. And they're cashable anytime, and after SIX months you receive “Commerce Growth Savings Certificates. Besides a Christmas present it can be a youngsters first lesson in how money grows.” CHRISTMAS GIFT SPECIAL! Buy a Polaroid Colorpack 80 and we will give you 3 packs of film FREE. Here‘s a great Chnstmas glft ldeaâ€"Colorpack BOâ€"the $ 2 9 9 5 new camera from PolamId that gives you new low-priced square pictures. in black and whlte and color, moments after you take them. Buy one now during thls lumited nHar and ink: 3A Purth nn {Thnetmac nanâ€"FREE TAKE YOUR FIRST @ CHRISTMAS ' .1 PICTURES! Here's a great Christmas gift ideaâ€"Colorpack 80â€"the new camera from Polaroid that gives you new low-priced square pictures. in black and white and color‘ moments after you take them. Buy one now during this limited offer and take 24 pictures on Christmas Day-FREE. ON US! atlas photo supplies ty average. Then Mrs. Mallory's mental condition improved quite markedly. She went home. con- tinuing to see the family doc‘ tor who admitted her. .plus the psychiatrist. "Her condition varied a great deal from time to time. She didn't have a real appreciation of her condition. She was ir- regular in attendance for ap- pointments and in taking med- ication. She was referred to an interest too. So, when the children are old enough to know what they want, they've got a little money to get it With. Give Commerce Growth Savings Certificates this Christmas.They're called the gift that grows." CANAIAN IMPERIAL BANK OF COMMERCE 3 Free Type 87 Films Included would get disturbed about min- or problems and build them up out of all proportion. When he left the home the children stay- ed with Mrs. Mallory and he vis- ited them. While she was at the Clarke Institute he went home to live with the children. “She was gasping. I think she was crying. She said she wasn't feeling well. She never was like that before. I picked the chil- dren up Wednesday. My son said she was all right about 6:30 pm. We went swimming and got back after 9 o‘clock. There wasn‘t any note or anything to say where she had gone. I had no knowledge she was what they have called a borderline diabetic." he said. "When she returned it was necessary for me to leave again. We had very little communica- tion." he said. Mallory told of speaking to his estranged wife when he asked to take the children out two days before she died. Socol said she Was usually depressed and would often break down and cry. even just after laughing. He referred her for several times for psychiatric care. She went‘back on at least .one set of occasions to see her previous psychiatrist. In 1970 he saw her in the summer and fall at least three times. treating a severe finger infection. In .September she was in for a fainting spell. and he put that down to an anxiety problem. SON’S DRUG PROBLEM RICHMOND HEIGHTS CENTRE 884-3221 Then Dr. Socol didn't see her (Continued on Page 11) QI?