National Women's Hospital - The institution whose reputation took such a battering during the Cartwright inquiry - was back in the dock for the chest physiotherapy inquiry, whose report is due out this week. Did it deserve to be there this time? 

Donna Chisholm reports

THE images were chilling. The baby having chest physiotherapy bounced around like a ragdoll on a trampoline. It seemed blindingly obvious this was a treatment that could turn fragile brains to mush.

News reports catalogued shocking brain damage to 13 tiny, premature babies and the deaths of five of them between 1992 and 1994. It was, Paul Holmes thundered, "another cover up" at National Women's.

But like so much about the chest physiotherapy inquiry, things were not quite what they seemed. None of the videos seen by the public or the inquiry panel during its hearings in February and March showed the treatment performed on any of the affected children - or even babies the same size as the injured infants.

One screened repeatedly on television showed an outdated technique not used since the 1980s; three others at the inquiry showed babies weeks or months older than the babies concerned. For National Women's, the video images are part of the reason the inquiry took place at all.

The Accident Compensation Corporation's medical misadventure advisory committee, whose investigation prompted the inquiry, watched a video of vigorous physiotherapy performed on a large, fullterm child before deciding the health workers who gave the treatment to very premature twins - one of whom died were negligent.

A neonatal paediatrician advised the ACC, on the basis of the video, the pressure used in National Women's physiotherapy was at least three times greater than any other centre treating very premature babies. The hospital, trying to rebut the findings, found tapes of physiotherapy being performed on two smaller infants - one born eight weeks prematurely, another 11 weeks early.

The doctor later told the inquiry it was difficult to identify one baby from another - yet the full-term child was at least three times larger than the other two babies on the tape and five times bigger than any of the affected infants.

The videos are, with hindsight and to the lay eye, shocking - the more so because of the startling incongruity of the soundtrack. The cracking thud of each rap on the chest provides brutal punctuation to the loving monologue of nurses and physiotherapists. "See, you like that after all, don't you?" "What a good little man."

In one, though less vigorous, the technique is still clearly flawed - the baby is being rapped using arm action when the movement should come only from the wrist. All the tapes show physiotherapy performed on an open table. 

But the babies the inquiry involved were children who, at 13 to 16 weeks early, had their physiotherapy performed through the portholes of their incubators making it difficult for anything other than wrist action to be used.

The parents of the 13 children probably didn't remember that when they gathered in a room at the start of the inquiry to watch the video before giving evidence it was just the same as the "cruel and barbaric treatment on their own babies five years earlier. And who can blame them when what they saw must have taken them back, emotionally, to the worst time of their lives. Critics raised the spectre of the Cartwright cervical cancer inquiry. Here again, they said, was a new treatment introduced without consent which had devastating results.

Ten of the 13 cases occurred after the hospital had increased the availability of the treatment in April 1993 - from 18 to 24 hours a day, giving the babies an extra one or two treatments daily - and had trained senior nurses to use the technique which previously had been given only by physiotherapists. National Women's had failed to learn the lessons of the past, they said. Where was the ethical approval for the change in frequency? Where was the evidence the treatment even worked?

But this time, the accusations stemmed from evidence gleaned not by a pair of campaigning journalists, but initially, the hospital itself.

Five years ago, neonatal paediatrician Jane Harding's study linking chest physiotherapy to brain damage and death in the premature babies was hailed by some colleagues as a fine piece of medical detective work.

The hospital stopped the treatment immediately on the smallest babies, visited the parents of every child involved to break the news; alerted every neonatal unit in New Zealand and Australia, and even issued a press release to make the findings public.

"If you like to think of it in court case terms," says Harding, "We were the only witnesses for the prosecution. We did the study which forms the basis of the prosecution evidence - and we have been given a hard time about that ever since, which I think in some ways is the supreme irony. "We hung ourselves in trying to be open and honest. I think the inquiry has been an unduly harsh process."

If the Cartwright Inquiry hammered home the importance of openess and honesty in dealings with patients, the message from the chest tapping inquiry has been precisely the opposite, says National Women's manager Gary Henry. "We are being pilloried for honesty but we would do the same thing again. Is anyone else going to rush forward now and admit to anything? "National Women's has been fair game because of Cartwright," he said. "In reality, this time it could not have been more different." One of the mysteries of this medical disaster which the inquiry hopes to resolve is why a treatment, widely used internationally but with little clinical evidence to support it, should create such mayhem at just one institution. What was National Women's doing with its chest physiotherapy that no one else did?

National Women's had introduced the technique in 1985 after sending a senior physiotherapist to train at the Brisbane hospital which pioneered it. Over seven years it was given to hundreds of babies without incident.

The treatment continues to be widely used here and overseas. Chest physiotherapy is offered around the clock at Waikato and Wellington Women's Hospital and Dunedin Hospital, although only Dunedin still uses a form of the cupping technique implicated in the National Women's cases, where the chest is percussed 160-200 times a minute with a small, soft, latex cup instead of the "vibration" technique using the fingers.

Of 23 Australasian neonatal units surveyed in 1996, 10 continue to use cupping, 20 use some form of chest physiotherapy, 17 have it available around the clock and 18 use nursing staff to give it. Most have made no change to their physiotherapy policy since National Women's made public their deaths and injuries.

They say they have not seen the injuries National Women's has. Evidence was given to the inquiry that the physiotherapy in Auckland was more vigorous, more frequent and lasted longer. Yet the inquiry was also told it was within the protocols widely used at the time.

Prior to 1995, no guidelines existed for what pressure should be used. Physiotherapists and nurses were required to use their own judgement in deciding what pressure and handling the babies could stand so different vigour was applied to different babies.

When National Women's in 1995 urged other neonatal nurseries to look for evidence of similar cases, the response was a resounding silence. Now the hospital believes it has been hung out to dry by a medical community reluctant to go hunting for similar cases for fear it might find them.

"Back in 1995 there was widespread scepticism and denial by other units that they had ever seen this injury," says Harding. "We went to considerable lengths to encourage them to look for it because we knew it was easy to miss. It has become apparent over the past few months that many units who have subsequently said: 'No, we haven't seen it', in fact have never looked. It is understandable but inappropriate. I know some units have looked but I suspect the vast majority have not."

But how could they miss deaths like that - and injuries so severe they appeared to rend great holes in the brain matter?

"National Women's is a very big nursery - one of the three biggest in Australasia," says Harding. "A smaller unit may have one or two of these cases in a year and may well not recognise them. We detected them only late in the course and when the babies had no symptoms. If we hadn't done the ultrasound scans [at four to six weeks] we would have missed it and we do know that 25% of units in 1995 didn't scan their babies at that stage."

David Knight, the clinical director of the newborn unit at National Women's believes neonatal units were running scared during the inquiry. "Some overseas units which gave evidence at the inquiry consulted lawyers first and one was represented. And the physiotherapist from the Australian unit which pioneered the treatment was terribly defensive. They were running for cover."

National Women's would have remained internationally isolated were it not for the experience of one other unit. A hospital in Birmingham, England had, two years before Auckland, reported similar devastating brain injuries in premature babies.

In Birmingham, 14 babies of 24-32 weeks' gestation and weighing between 600g and 1270g died between September 1988 and April 1990.

The Birmingham doctors, who suspected chest physiotherapy might be linked to the deaths, never told the babies' parents. Not only never told them, but never even considered telling them.

The Birmingham consultant in an audio link to the inquiry said: "Clearly we don't go back to parents whose babies have died months before ... and say 'By the way, your baby who died six months ago might have had something that we hadn't recognised'."

When the Birmingham team reported the brain injuries in a medical journal in 1992, it did not mention its suspicions of the link with chest physiotherapy. It believed a combination of other factors including low birth weight, low blood pressure and breech presentation of the babies were as important if not more important than chest physiotherapy.

Had the link been reported then, says Harding, National Women's may have thought twice before increasing the availability of chest physiotherapy in April 1993 to 24 hours a day.

As it was, National Women's did not become aware of the Birmingham experience for more than two years. After Harding discussed National Women's then unexplained cluster of cases at a meeting in Dunedin in December 1994, a paediatrician mentioned the Birmingham paper and thought the experiences may be similar. She phoned the Birmingham consultant, and made notes of the call: "Resonating head movement on plastic mattress, started steadying baby's head." Then, the note says, the cases mostly disappeared. At the inquiry, however, the consultant said the babies' heads were always held during physiotherapy - but after the cases appeared, the policy was reinforced and there was "even more strenuous effort to steady the head".

So why didn't it report its suspicions of the link?

"We didn't believe we had enough evidence to set the hare running," the consultant told the inquiry.

Media reports seized on a description of the brain damage as a "shaking injury", but, says Knight: "We are talking about a completely different degree of shaking to the sort you hear about in the nannies' court cases". It was a treatment that seemed to work and clinical trials showed short term benefits. Anecdotally, doctors and nurses were in no doubt babies' conditions improved after physiotherapy cleared the secretions in their lungs and improved their oxygen supply - and deteriorated without it. 

National Women's has tried without success to get other units to stop using it.

"It is ironic we have gone from being one of the greatest proponents of the technique to its greatest critic," says Harding.

But there is a final irony which completes the devastation for staff who thought they were doing the best they knew how for the babies in their care. 

When the treatment was halted overnight in December 1994, Knight and Harding watched for signs the babies might sharply deteriorate as a result. There were none - it seems that whatever the benefits of chest physiotherapy, they were at best transient. At worst, it was deadly.