Bundaberg tragedy

[6] Thomson began the immunisation program on 17 January 1928, with each recipient intended to receive three inoculations spaced one week part.

With one exception, post-mortem examinations were performed by Egmont Schmidt, the government medical officer of Maryborough, who concluded that the children had died due to "acute toxaemia" of an unknown cause.

Schmidt had little experience in forensic analysis, also lacking access to expert advice and facing pressure from families to certify death so that interment could proceed.

[12] The inoculation program in Bundaberg was suspended immediately after the children's deaths, following shortly by those in the major cities of Brisbane and Melbourne.

An early consensus developed that the deaths had not been caused by a fault in manufacture, but rather by the treatment of the serum after it left the CSL facilities in Melbourne.

[13] According to Akers & Porter (2008), "the swift announcement of an imminent Royal Commission, its open terms of reference and Page's visit, engendered scientific and political confidence".

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 delegated much of the commission's work to Macfarlane Burnet, his assistant director at the Hall Institute and a future Nobel Prize laureate.

[16] Following a four-month investigation, the commission's report was presented to the House of Representatives by federal health minister Neville Howse on 13 June 1928.

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.