To the Editor: Lightning can strike in the same place twice, or at least untoward medical deaths can. Today, I was looking through the Medical Journal of Australia of 7 July 1928 and was amazed to find the report of a Royal Commission entitled “The fatalities at Bundaberg”.1

It is a tragic story. On 27 January 1928, 21 children received an injection from “an india-rubber capped bottle purporting to contain diphtheria toxin-antitoxin mixture”. Eighteen of these children became ill during the night of 27 January. Eleven died on 28 January, and another child died on 29 January. The Royal Commission found that the bottle had become “contaminated with a pathogenic staphylococcus” when it was being used the previous week. The bottle had been stored at room temperature during the intervening week.

The Royal Commissioners made a series of recommendations including “biological products must be distributed in bottles or ampoules of clear glass”, “antiseptics should be included in bottles that might be used on several occasions” and, if this was not possible, bottles “should be used immediately on opening and any remaining product discarded”.

One similarity with the current inquiries into Dr Patel’s activities is the complicated and confused lines of responsibility and accountability. The immunisations were administered under a Bundaberg City Council program. The Council was implementing immunisation policies of the Commissioner of Health for Queensland. The injections were given on the Council’s premises by a private doctor on contract to the council. The product was manufactured by the Commonwealth Serum Laboratories in Melbourne and supplied to the council by a private firm in Brisbane.