[2] At that time, it was common practice[3] to store such anaesthetic in glass ampoules immersed in a phenol solution to reduce the risk of infection.
Unknown to the staff, the glass had a number of micro-cracks which were invisible to the eye but which allowed the phenol to penetrate.
A later analysis suggests that the most probable cause of the paralyses was an acidic descaler which, by an oversight, had been allowed to remain in the sterilizing water boiler.
The standard of care required of defendants was judged by applying an objective test, considering what a "reasonable man" would or would not have done in the same situation.
Thus, since no reasonable anaesthetist would have stored the anaesthetic differently, it was inappropriate to hold the hospital management liable for failing to take precautions.
The attention of the profession was first drawn to this risk in this country by the publication of Professor Macintosh's book on Lumbar Puncture and Spinal Anaesthesia in 1951.