The Malacca Hospital mass deaths

I MOVE to cut the salary of the Minister of Health by $100.

On August 22, 1973, 1 called a press conference in my Malacca office making public the unusually high number of deaths in the Malacca Hospital during July and August last year, because of the breakdown of the hospital’s autoclave, i.e. sterilisation plant, leading to blood and saline poisoning of the patients.

I called for a public inquiry into the deaths, and into the negligence and maladministration of the Malacca Hospital which made such mass deaths possible.

In response to my call and disclosures, the Minister of Health on August 24 ordered an investigation by his Ministry of Health.
Straits Times of August 25, 1973, reported:

“Health Minister Tan Sri Lee Siok Yew ordered today a full investigation into 12 deaths at the Malacca General Hospital earlier this month.

“In a statement, Tan Sri Lee said there had been allegations linking the deaths with an autoclave (sterillisation plant) breakdown at the hospital.

“Tan Sri Lee said it was unfortunate that some people had associated the 12 deaths with the breakdown of the autoclave.

“He stressed that the deaths could be due to many factors and in fact the nature of the illness could lead to death.

“I would like to clarify that one autoclave was condemned on July 21. Immediate action was taken by the hospital authorities to use the second autoclave available in the hospital.

“However, since August 13, the second autoclave also started to break down and was immediately stopped from being used.

“At the same time, action was taken to install two new autoclaves which were already available in Malacca General Hospital.

“While waiting for the two autoclaves to be commissioned steps were taken to obtain the necessary sterilised supplies from Seremban General Hospital and the Central Medical Stores in Kuala Lumpur “

The Minister’s statement of August 24 was a tissue of lies, made deliberately to mislead me, the press, the people, the country, and to mislead his Cabinet colleagues.

107 Deaths

THUS, FIRSTLY, there were not 12 deaths during the period in question, but 107 deaths.

The Minister kept insisting there were only 12 deaths until December 10 when he was confronted with incontrovertible figures which I produced in this House. The average monthly mortality rate for the Malacca General Hospital for the first six months of this year was 70, but for the one month period from July 21 to August 20 when the autoclave broke down, there were 107 deaths – or an excess of 37 deaths.

SECONDLY, at the relevant time in question, the Malacca Hospital did not have two operational autoclaves. There was only one autoclave for sterilising bottles and drums of dressings and cottons and one disinfecting unit for matresses and beddings. It is true that the Malacca Hospital had received two new autoclaves and they could have been installed for operation in May. Unfortunately, owing to the mal-administration of the hospital authorities, no steps were taken to install them until innocent persons had died enmasse.

THIRDLY, the Minister said that the so-called ‘first autoclave’ was condemned on July 21. In actual fact this autoclave was to be condemned two months earlier in May. In other words, a condemned autoclave was used for two more months when it should have been taken out of operations.

Disinfecting Unit

FOURTHLY, when the autoclave that was to be condemned in May was finally condemned on July 21, the hospital authorities substituted it with the disinfecting unit meant for cleaning mattresses and bedding to sterilise bottles ad drums.

This disinfecting unit had no means to ascertain whether the correct pressures, times and sterilisation had been made.

No wonder that the Head of the Surgical Department in the Malacca Hospital refused to have his drums sterilised in this manner, and on his own inititive, made arrangements for his medical materials to be sterilised by the Muar General Hospital – and he was still doing so well into September.

The use of the disinfecting unit to sterilised bottles and drums and medical materials was the cause of the contamination of bottles, saline and blood.

FIFTHLY, the Minister said that since August 13 the second autoclave also started to break down and was immediately stopped from being used.

As I have explained, there was no second autoclave, but only a disinfecting unit. (Anyway, I am sure autoclaves are not made to last for only three weeks).

There was no question of “started to break down”. On August 13, a gynaecologist accidentally discovered moulds and particles in a saline bottle, sent to the laboratory for analysis and foreign bodies were discovered.

42 bottles of blood destroyed

This was why on August around August 15, the hospital authorities ordered the destruction of 42 pint-bottles of blood and over 2,000 bottles of saline.

It can thus be seen from the above that the Minister’s statement on August 24 was studded with lies and falsehoods, What I want to know is whether he deliberately told those lies and falsehoods, or he allowed himself to be completely misled by his underlings to tell lies and falsehoods.

In either case, he does not show his competence of qualifications as a Minister of Health.

The month from July 21 to August 20 was indeed a nightmarish month in the Malacca General Hospital, not only for the patients and their relatives, but also for the doctors, nurses and the hospital staff -those who are dedicated, those whose conscience are still alive.

Maternity, surgical and medical cases which required blood transfusion or transfusion of saline, or salt solution in drops, reacted adversely. Especially beginning in August, the majority, of them reacted with rigeurs or. convulsions. Others collapsed, lapsed into a coma and died. There had even been cases of deaths on the operation theatre, with the doctors and nurses at a loss as to what was happening- all running here and there, trying to contact each other, seeking mutual consolation and comfort which they could not find.

Routine cases of Caesarian operations, where deaths should not occur, ended up fatally. Surgical cases expired, and died. It was really a chamber of horrors and deaths.

On August 9 alone, there were 7 deaths. The mortuary was so crammed that corpses had to be put outside. In order to illustrate to this House the enormity and the iniquity of what had transpired during the episode, I will give some instances of the unusual deaths, and they have all one common feature, i.e. either blood transfusion had been given or saline drips administered.

Case histories

1. Zaiton bt. Mohamed, 33, house wife, admitted on July 19 and was in hospital for 26 days for pre-natal care before labour pains came on August 12. It was to be her eleventh delivery, and that was why she was in for twenty-six days, so that she could be given full medical care, and nothing amiss could take place. She had a Caesarian operation. She was given drips after the operation on August 12, sometime after midnight. When her husband, Rahim bin Mohamed Jan, saw her on the morning of August 13, she was tired but conscious and asked for food, but she was not given. She was given drips again; her hands became bloated. At about 6 p.m. she had rigeurs, her whole body was heated up as if “it was on fire”, and she died with her whole face and body turning blue at 9 p.m. She is survived by eleven children.

2. Vaithilingam s/o Kuppusamy, 35, rubber tapper. He went on his own, walked to the hospital, on August 10 for a stone in the bladder operation. He was given drips and blood transfusion. After his operation on the morning of August 10, complications developed. A second surgery took place the same afternoon. He died on August 11 at 7.00 p.m. I have been told that it is unusual for a fairly young man on a common complaint of stone in the bladder to die and he was assured, and his family was assured, that it was ordinary routine operation before he went in. The death certificate gave as cause of death: Acute Renal Failure. Was there a previous check on the renal condition before the operation?

3. Choo Khing Bui, 27, admitted on 16.8.73 at 2 a.m. for her sixth birth. In all five previous pregnancies she had normal deliveries. The husband went on the 17th August at 5 p.m. to the hospital to see her and was told that his wife was in a serious condition. He could not find out why or how. He had to wait until 10.00 p.m., when he was informed by a doctor that his wife was dangerously ill. When he was taken to see her, her hands and arms were bloated, and he saw her receiving drips. She was in semi-consciousness until she died on the 18th of August at 12.50 a.m. The death certificate gave as cause of death “Endotoxin shock”, which I have been told means blood poisoning. The deceased was in a fit condition as late as 16th August, when she could wash her own clothes in the hospital. She leaves behind 6 children and her latest child survived her.

4. Salpiah binti Hassan 46, admitted on 7th August for growth in stomach, for what hospital authorities said was an ordinary operation. Operated on 14th August, the patient coming out of operation in great pain, shouting and shivering. Given blood transfusion and drips. Died on 17th August. After her death, the family was told she underwent cancer operation. Before the operation, the family was not aware that the patient had cancer nor was the family aware that she was going to undergo cancer operation.

5. How Joo Choon, housewife, she was admitted on 29th June for a simple repair of a hernia. Operated on 2nd July, 1973 followed by complications. On August 2nd she developed rigeurs when she was given drips, which was repeated on 11th August, 1973. Lapsed into coma after 11th August and died on 19th August. Died because of a simple hernia repair operation. The family was assured before her operation on July that hers was a very, very simple and routine operation.

6. Theresa Das, 40, female. She was alive and well up to June, 1973 when she developed an ulcer on her left leg, and received outpatient treatment. Admitted to the General Hospital on 3rd August because of fever. She was later transferred to the gynaecology ward because of a lump in her lower…. Blood tests revealed that she was suffering from anaemia as well. Accordingly she was given a blood transfusion on 9th August 1973. Her mother visited her on the same evening after the blood transfusion, and found that her daughter was having fever and rigeurs. The ward nurse was informed but the mother was assured that there was nothing to worry, everything was all right, She went home at about 6 p.m.
The next morning at about 6.30 a.m. a policeman came and knocked at her house and informed her that her daughter was very seriously ill and advised her to go to the hospital immediately. She was too late, and found her daughter cold and very dead. Theresa had no operation, but only a blood transfusion to boost her up for an operation. Cause of death given in the death certificate was “Myocardial Infarction”. She has no history of chest pain to suggest that she had a heart complaint or disease.

7. Jamuldin Anan, 1 year 2months. Admitted on August 9th at 4,30 p.m. for breathing difficulties. Given injections. Operated on the 10th August and died the same morning.

8. Tan Kim Chat, 20. She was admitted on July 19th on first case of pregnancy. She was given drips on 26th July. Gave premature birth on July 27th at 12.30 a.m. Baby was still-born, but mother alive and well. The husband saw the wife at 8 a.m., and was told by the doctor that she was all right. Later in the morning, she had rigeurs and died at 2.30.p.m., turning blue the whole body. The cause of death given in her death certificate was ‘pulmonary embolism’. Tan Kim Chat was a strongly built person, who had no previous complaints about her health.

9. Lee Yong Wai, 2 years: Admitted on 14th August for intestinal obstruction. Operated on 14th midnight. The boy was well on 15th August. Given drips and complications developed, was given a second operation, lapsed into unconsciousness and died on 17th August. The parents were told on 15th August that the child had fully recovered from the operation by the medical staff. This must be the last unfortunate case, for before the boy lapsed into unconsciousness, the hospital authorities rushed in to remove all the saline bottles. They must have discovered about the autoclave contamination but for Lee Yong Wai it was too late.

10. Sukanthiranagy d/o Sithamparam 23: Sent from Segamat Hospital to Malacca Hospital on 10th August 1973 at 7.30 p.m., underwent Caesarian operation. Died on 11th August 1973. Cause of death given: “Septicaemic shock.”

I need not go further. It is not a very pleasant thing to narrate these deaths, the circumstances of their deaths, but if the Minister wants, if he does not have them, there is a full list of all those who died from 21st July to 20th August here, exceeding the average monthly mortality in the Malacca Hospital by some 37 persons.

If on August 13th, a gynaecologist had not accidentally discovered about the contamination in the saline bottles, more would have died. It is criminal negligence on the part of the hospital administrators to allow the whole situation to go on for one month, although unprecendented mortality rates were piling up every day.

I am not saying that autoclaves cannot break down. I know in other parts of the world autoclaves as machines now and then do break down, but there should, in any responsible hospital administration a monitoring mechanism and system whereby if there is unusual mortality rates for investigations to be made, enquiries to be held to find the cause. I am no doctor but I believe that is what would be done by hospitals where there is a minimum amount of patient care and responsibility.

I know that during this period, the doctors and staff were in panic, for they knew something was wrong but yet could not pin down the cause of the mass deaths. In fact, there was a high level attempt to hush up this entire black chapter in the history of the Malacca Hospital, and if it were not for my public disclosure on 22nd August, probably they would have succeeded.

In this connection, it is worth nothing that on 18th or 19th August, the Health Minister was in Malacca and met the Malacca Hospital authorities. Was the Minister of Health privy to an attempt to hush up the entire episode?

Hollow Reasonableness

I had right from the beginning sought to co-operate with the Minister of Health in order to get to the bottom of this ghastly episode. Unfortunately, the Minister of Health, apart from presenting an exterior of sweet reasonableness, of concern, of affability, seemed more interested in hushing up the matter.

On my initiative, I met the Minister of Health in his office in Kuala Lumpur on 30th August 1973 to tell him of the seriousness, the magnitude of the whole affair, and for which later some irresponsible cheap MCA officials tried to capitalise and say the D.A.P. chaps are running after MCA Ministers. I met the Minister of Health in his office in Kuala Lumpur on 30th August, 1973 to tell him of the seriousness of the whole affair. He tell me that he had no axe to grind and that the Committee of Investigations which he had established under the Secretary-General of his Ministry together with some representatives from the universities, would be given complete freedom to probe into the matter.

At my request, he promised that the relatives and next-of-kin of the deceased would be given opportunities to appear before the investigation committee to relate the circumstances of their dear one’s death.

Broken promise

This Ministerial promise was repeated by the Minister himself to the Malacca State Chief Medical and Health Officer, the Medical Superintendent of the Malacca Hospital, Heads of Departments of the Malacca Hospital and the then Acting Malacca State Chief Minister, Datuk Tan Cheng Swee, at a closed door meeting when the Minister visited the Malacca Hospital on 4th September and Heads of Departments of the Malacca Hospital. I was also invited to this meeting, together with my collegue Bernard St. Maria, the Malacca State Assemblyman for Kota Timur.

Unfortunately, when in public, the Minister refused to make the commitment, and to this date, with the completion of the work of the Committee of Investigations into the Malacca Hospital deaths, the Ministerial promise has been broken.

I want the Minister to tell this House why he broke this promise to allow the relatives of deceased to appear before the Committee. Is it because of pressures from his subordinates which he could not overrule?

The Minister set up a six-man Inquiry Committee, described subsequently as a ‘departmental inquiry’ by its Chairman, the Secretary- General of the Ministry of Health, Encik Abdul Majid Yusof, into the so-called 12 deaths mentioned by the Minister on August’24.

The other members were Prof. Lau Kam Seng of the University of Malaya, Prof. Francis Morasingh of the Universiti Sains Penang: Dr. Lim Teong Wah of the Institute of Medical Research, Dr. C.C. Lopes, Director of the National Blood Bank and Dr. Ezaddin bin Mohamed of the Ministry of Health.

To members of the public, all the six members of the committee are directly or indirectly associated with the Ministry of Health or the government.

Inquiry defects

The six-man inquiry committee suffers from four basic defects:

1. Its proceedings were not conducted in public;

2. It did not include an Opposition member, a foreign medical expert or a representative of the deceased families so that its findings would be the last word on the matter and accepted without reservations by the public;

3. It did not investigate into all 107 cases of deaths between July 21 and August 20 last year, when the autoclave broke down;

4. It did not hear representations and testimony from the relatives and next-of kin of the deceased.

The Minister is no stranger to these views of mine, for I had in August and September written to him several letters conveying my views, thoughts and informațion in my command so as to try to get him to take firm disciplinary action and corrective measures.

The Minister’s objection to the inclusion of an Opposition member on the investigation committee is that the investigation is a medical problem which should be handled by medical or professionally-qualified people. This is not a strong enough reason, for the chairman of the committee, Encik Abdul Majid Yusof, is himself a non-medical person.

Another highly unsatisfactory aspect about committee’s work is its inordinate delays and long postponements. The Minister had personally assured me that he wanted to have the Committee complete its work as early as possible. The press secretary of the Ministry of Health is on record as saying that the investigation committee would complete its findings at the end of September.

About five months have passed, we still have no news about the results of the committee’s investigations. I understand the investigation committee had submitted its report to the Minister a few days ago, and if so, I call on the Minister to immediately make public the findings and make available to every Member of Parliament a copy of the report.

I want to say in advance that I cannot but approach the investigation committee’s findings with grave reservations and qualifications, because of the reasons which I have given and other reasons which I shall touch on a short while later.

Commission of Inquiry

Here, I would like to know why the Minister of Health was so opposed to the holding of a Public Commission of Inquiry into the Malacca Hospital deaths so that a proper accounting, either way, can be made. There had been public inquiries for lesser tragedies, like the Raja Laut four-storey building collapse and the Pasir Mas derailments. Compared to them there is no doubt that the Malacca Hospital deaths put them in the shade, both in terms of lives involved, and the gross inefficiency concerned.

Another unsatisfactory feature about the investigations is that the Minister failed to take all necessary action to ensure that subordinate hospital staff would feel free and unrestrained to give full, frank and truthful testimony without fear of alienating or antagonising superiors to their future detriment.

As I wrote in my letter to the Minister on 21 September 1973, and I quote:

“Recently, the Malacca Hospital authorities have launched a witch-hunt to blacklist and mark for punishment personnel whom the top administrators suspect are responsible one way or another for furnishing information leading to my call and campaign for a public inquiry into the Malacca Hospital deaths.

“You assured me at our meeting on August 30 that you are personally anxious to get to the truth of the entire tragic affair and that there would be no witch-hunt either by the Ministry of Health or the Malacca Hospital authorities to victimise or penalise any officer or staff merely on suspicion that that person had given information to me.

“The most crucial and pressing task at hand is to find out how many innocent people died in the Malacca Hospital in July and August, and how to restore public confidence in the Malacca Hospital, and not to embark on a witch-hunt which can only end up as a wild goose chase just to satisfy some personal pride or venom.

“I urge you therefore to look into this matter personally, to ensure that the Malacca Hospital authorities will not be permitted to victimise or penalise any person for speaking truthfully, or for some unfounded suspicion, or to settle some personal score.”

In this connection, I cannot understand why the Minister did not take immediate disciplinary action against the Medical Superintendent of the Malacca Hospital, Dr. Wong Mae Yee, whose continued presence in the administration could only have a deterent effect on the staff from speaking freely. Why wasn’t the Medical Superintendent suspended immediately, as the officer in overall charge of the hospital during the mass hospital deaths, to clear the way for a thorough inquiry?

I have nothing personal against Dr. Wong Mae Yee. In fact, it is a very unpleasant task for me. However, I have my duty to my constituents, the people of Malacca and Malaysia, and I shall perform my unpleasant task with the greatest reluctance.

It is my considered conclusion that Dr. Wong Mae Yee must bear the brunt of the responsibility for the maladministration in the Malacca Hospital. In fact, if the doctors, nurses and staff are allowed to give their views freely without inhibition or fear, I have no doubt a similar verdict would be rendered by them.

On 14th September last year, when opening a conference of State Health Directors and Heads of Divisions in Kuantan, the Minister of Health ordered hospital authorities to take action against the few who are blemishing the good name of the hospital service and assured them of his full support.
Unfortunately, the Minister the Health has himself proved that he lacked the resolution or authority to exercise impartially disciplinary powers against heads of divisions.

Kua Tai Hock’s death

In fact, on the eve of the Minister’s special visit to Malacca on the 4th September, a two-year old boy, Kua Tai Hock, died unnecessarily. The facts of Kua Tai Hock’s case is as follows:

Kua Tai Hock was having fever for one week, and had been receiving outpatient treatment from the Malacca General Hospital. Kua Tai Hoc had difficulty in breathing, was sweating and had cold hands and feet.

On 2nd September night, his mother, Madam Tan Leong, took him to the Malacca General Hospital as he was very ill. Kua Tai Hock was seen by a doctor at about 10.15 p.m., after which he was given outpatient treatment again, without being admitted.

While waiting to collect the medicines, Tai Hock’s condition worsened, breathing became more difficult and his finger tips were turning blue. Madam Tan Leong pleaded with the nurses on duty for help. This time, the doctor came back, accompanied by another doctor, who both examined the boy and had him admitted into hospital. When Tai Hock reached the ward, he was seriously ill. He was put under the oxygen tent, but he had to share it with another baby. Later in the night, this other baby died but Tai Hock continued to be under the same oxygen tent. There was no change of bed or bedsheet or the tent canopy even though one patient had just died.

Since Tai Hock’s admission into the ward, no other doctor saw or reviewed his condition. He was very ill, restless and breathless. Madam Tan asked the staff nurse to help and she gave him an injection. His condition did not improve. It was only until about 9.30 a.m. the next morning, on 3.9.73 – 12 hours after his admission the previous night – that Kua Tai Hock was seen by a doctor, by which time the boy’s condition was already very bad. The boy died at about 1.30 p.m.., despite attempts to save his life. The cause of death was given as Bronchopneumonia with G.I. bleeding. This case of Kua Tain Hock happened after the autoclave affair.

Unanswered Questions

Many questions cry out for answer here:

(1) Was Tai Hock’s death unavoidable and necessary, especially one week previously- which means that all along, the hospital doctors did not when he had been receiving outpatient treatment for from the hospital think his case serious enough to warrant admission.

(2) Wasn’t there a doctor on call at the Malacca General Hospital at night to see or review serious cases hour by hour?

(3) Why didn’t a single doctor attend to Tai Hock for 12 hours despite his serious condition on admission?

(4) Was it hygenic and compatible with standard hygienic practice to continue to use any oxygen tent for a patient although another person has died under it, without any change of bedsheet?

(5) Was there adequate, early and timely medical supervision and nursing care?

The mother of the boy, Madam Tan Leong, wrote to both the Medical Superintendent of the Malacca Hospital and the Minister of Health on the boy’s death. I also wrote to the Minister of Health on the matter but I did not receive even an acknowledgement.

On 29th November, 1973, the Medical Superindent, Dr. Wong Mae Yee, in reply to the mother, which apart from “merasa sedih di atas kehilangan anak puan dan dukacita di atas segala kesusahan yang berlaku” failed completely to answer the five questions which was posed. I will quote only one relevant paragraph from Dr. Wong Mae Yee’s letter to the mother:

“Sentiasa ada seorang Doctor Pelatih di dalam panggilan pertama untuk Wad, beliau boleh memanggil Pegawai Perubatan di dalam panggilan kedua apabila perlu dan Pegawai Perubatan boleh juga memanggil Pendaftar ataupun Doktor Pakar Perubatan apabila perlu. Oleh kerana anak puan sakit teruk beliau sepatutnya memberi tahu Pegawai Perubatan dalam tugas panggilan dan juga melihat anak puan semula. Oleh yang demikian, doktor yang berkenaan telah diberitahu supaya jangan mengulang perkara ini lagi.”

Guinea pig

This has prompted the mother, in her letter to the Ketua Setiausaha of the Ministry of Health on 4th December, to make the following very heart-breaking comments and I quote:

“Pada ertinya saya terpaksa come to the conclusion that:

(a) Seorang Doktor Pelatih sahaja telah memeriksa dan member rawatan kepada anak saya;

(b) Tidak ada Pegawai Perubatan yang reviewkan, assess keadaan anak saya pada malam 2.9.73. Anak saya bukan sakit ringan, dia sakit teruk.

“Seorang Doktor Pelatih is just learning and under supervision. How can he decide on my son’s fate? He is not qualified yet. My son died because at the crucial and critical period after admission he was not attended to by a qualified doctor. My son need not have died. My son is not a guinea pig for the houseman to learn from his mistakes so that all the Hospital authorities can say is “oleh yang demikian, doktor yang berkenaan telah diberitahu supaya jangan mengulang perkara ini lagi.”

And what has the Minister of Health done concerning this case, although I personally wrote to him? As far as I know he seemed to have ignored it.
The reason why I am moving the present motion is because I am tired of the Minister’s exterior of reasonableness and concern, his promise of action, which all comes finally to nothing.

Last Tuesday, in the wake of great publicity, the Minister of Health made a surprise visit to the Seremban General Hospital and ticked off the authorities for the shabby state of the general hospital there. He also found that only three of the seven ambulances were in working order. This is all good, but the question is whether these visits accompanied by such great publicity will do any good.

Maternity ward lift

On 4th September, the Minister made a highly-publicised visit to the Malacca Hospital. He was good enough to ask me to come along. I told him again of the breakdown of the lift in the maternity ward of the Malacca Hospital, which I had raised in Parliament previously (on 24.1.73) and which had been out of order for two years.

Apart from the inconvenience to the expectant mothers, in the three-storeyed maternity ward, the unrepaired lift poses a threat to the health and lives of maternity cases which underwent operation. As I told the Minister and the State Medical and Health Officer during the visit, after an operation, the blood pressure will be low and it is essential that the brain should not lack blood or death can ensue. If patients after operation are carried up the stairs on an incline, with the head at a higher level than the legs, then the head will not receive blood. This is highly dangerous to post-surgical cases.

The Minister of Health promised to take immediate action and today, five months have passed and the lift is still out of order. If the Minister of Health cannot do a small thing like getting a lift fixed for two years, what other things can he do?

I have in this House raised cases of unnecessary deaths before due to negligence of the hospital staff, but I have never been able to get satisfactory action taken by the Minister of Health.

In January, 1972, I raised in this House the death of one Puan Chong Lan Jin 27, a housewife on 16.9.71. On 14th Sept. 1972, she was rushed down from Batang Melaka to the Malacca Hospital with a Salvation Army clinic, recommendation for hospitalisation. But when she came to the Hospital, the Hospital refused to admit her. Her husband had to take her back to Batang Melaka, about 15 miles away to find the Salvation Army nurse and bring her down to the Hospital. Only then she was admitted, i.e. after getting the poor woman to travel 45 miles. She died on 16th September, 1971.
The Minister took a lighthearted attitude to this and other similar cases.

So to conclude, Tuan Pengerusi, the Malacca Hospital has acquired such notoriety that for many years now, the well-to-do and the big shots in the MCA, for instance, do not go there but only the poor go there. But for the poor they have no other place to go but the Malacca Hospital and there is a need for a shake-up at the Malacca Hospital, which has not been done.

If the Ministry of Health is to start on a new page to regain public confidence and credibility, then there must be a Public Commission of Inquiry into the mass deaths. This is also necessary because we owe it doctors and nurses, because it is a slur on the reputation of the conscientious doctors and nurses who serve in the public service. I have come across doctor and nurses who have left Government Service because they find that they are associated with such incompetence and inefficiency to which they see no change, no possibility of reform.

(Speech by Member of Parliament for Bandar Melaka, Lim Kit Siang, in the Dewan Rakyat on 14th and 15th January 1974 during the 1974 Supply Committee Stage debate on the Ministry of Health)