Tag Archives: death

Remembering the Devonport Incident – 50 years on

One bottle is a killer. The other is entirely safe. They’re identical in every other way – indeed from the same manufacturing batch. This new acquisition was donated by Professor Barry Cookson, former Director of the Laboratory of Healthcare Associated Infection, HPA. But what happened to make one so deadly and the other not?

These are the first bottles of dextrose solution to be published ( Science Museum, London )

These bottles of dextrose are sad reminders of the life and death hunt for 500 similar bottles in March 1972. Five patients died at the Devonport Hospital in Plymouth having received fluid from the same batch as these. The fluid was found to be heavily contaminated with bacteria.  A landmark inquiry was launched to discover what went wrong and to ensure it wouldn’t happen again.

Sterilisation is a key story in the advancement of modern medicine. It’s critical to everyday hospital practice. Largely a practical matter of engineering and systematic checks, sterilisation isn’t glamorous but it’s critical for patient safety – as the Devonport Incident illustrated.

An autoclave is a machine that sterilizes equipment by subjecting them to high pressure steam ( Science Museum, London )

In 1971, these two bottles were autoclaved at the same time. A fault on the machine resulted in only the bottles on the top two shelves being sterilised properly. Those on the lower shelf were not. There were quality control checks – but the assessed bottles were only taken from the top shelf so the failure wasn’t detected and the whole batch was issued for use.

Eleven months later the bottles from the lower shelf reached Devonport hospital. During that time, surviving bacteria multiplied in the solution and produced a toxic fluid with deadly consequences.  There are only slight differences between the bottles – the aluminium cap on the contaminated bottle was still shiny as it hadn’t been sufficiently heated to go dull like the bottle that was sterilised

Image credit: Barry Cookson

 What’s sad is that it often takes tragic incidents like this to identify what’s going wrong with a system, and then implement new standards and checks. The inquiry identified numerous ways safety could be improved from manufacturer to hospital – thankfully those measures are still implemented today and the lessons from this incident are still taught to hundreds of healthcare workers every year.

These are a few of my favourite skulls

November 2 is the Day of the Dead, a colourful Mexican festival where people remember friends and family members who have died. A perfect day to have a look at some of our objects which represent the dead …

First off there are death masks, used both to commemorate the famous and the criminal. This death mask of Benjamin Disraeli was taken six hours after he died in 1881.

Wax death mask of Benjamin Disraeli,

Wax death mask of Benjamin Disraeli

We’ve also got some slightly gruesome anatomical models

Wax model of a female human head

Wax model of a female human head

Such models would normally be made as educational tools, but were also part of the strong aesthetic tradition which linked art and anatomy

We also have a whole range of vanitas figures and memento mori – reminding the living of the transience of life and the inevitability of death. Snakes and frogs are  a common feature of such figures, and I’m told that the use of the frog reflects the dramatic changes of form it goes through during its life cycle, making it a potent symbol of change and renewal.   

Ivory model of a skull and a human head

Ivory model of a skull and a human head

Finally, some encourage a sense of fatalistic humour about the end of life:

Ivory model of a human skull with moving parts

Ivory model of a human skull with moving parts

Yes, the tongue pokes out and the eyes roll up.  What more could you ask for in a memento mori?