[The Daily News, 23. November 1869]

Eingeklebter Zeitungsausschnitt
Icon dass Zeitungsausschnitt symbolisiert
The Daily News. Nr. 7352, 23. November 1869. S. 3.
Icon dass Zitate symbolisiert



Yesterday morning, shortly after 10 o’clock, Dr. Lankester resumed, at the College Arms, Crowndale-road, St. Pancras, the inquiry into the causes of the death of several persons recently in the infirmary of St. Pancras Workhouse. The case of James Plant was, it may be remembered, partly heard on the 10th instant, when, in consequence of the remarkable evidence given by Mr. S. Solly, Surgeon and Lecturer of St. Thomas’s Hospital and Vice-President of the College of Surgeons, and of Mr. R. Brudenell Carter, F.R.C.S., an adjournment took place in order that the investigation might be made as complete as possible. At the first sitting verdicts were returned in the cases of two persons, viz., Jane Harrison and Julia Conder, who died in the infirmary, to the effect that death was accelerated by overcrowding and want of ventilation. The names of the deceased, whose cases had still to be investigated, were, besides James Plant, Jane Hayes, Mary Brown, Mary Smith, and John Fox.

Mr. Parker, jun., of 40, Bedford-row, appeared yesterday on behalf of the relatives of June Hayes and Mary Brown.

The Coroner, having reminded the jury of the nature of the evidence given at the previous sitting by Mr. Carter and Mr. Solly with regard to the impure atmosphere of the wards, referred to the charge made since the 10th inst. against Dr. Ellis, the surgeon of the infirmary, to the effect that he caused the ventilation to be stopped immediately before Mr. Solly’s visit, and observed that if that serious charge could be proved, Dr. Ellis must have been guilty of manslaughter, if not of murder. There had, it appeared, been some improvements in the wards since the deceased persons died, but of course that could not affect the verdict with regard to the cause of death. Since the last sitting, he had written to the President of the Poor Law Board, drawing his attention to the state of the infirmary, and asking him to allow the Poor Law inspectors who had visited it to give evidence. The reply was to the effect that the unsatisfactory state of the infirmary was well known to the board, whose best efforts had been directed to the removal of the evils complained of; and it was hoped that in a few weeks the new infirmary at Highgate would be ready for the reception of patients; and that as an official inquiry covering part of the question at issue was about to take place, the Board did not consider it desirable to comply with the request made. It was added that the inspectors might of course be summoned in the usual way.

Some of the jury having here expressed a wish to visit the infirmary they were conducted thither by the coroner’s officer. On their return, after the lapse of about twenty minutes, the case of Jane Hayes was, for special reasons connected with witnesses, first proceeded with.

Dr. Ellis deposed that deceased, who was 17 years of age, was admitted on the 24th of July into No. 24 ward, and died on the 2nd of November from phthisis. When she died there were, he said, 29 patients in the ward, and the quantity of cubic feet of air per patient was 600, or 250 feet below the minimum requirement of the Poor Law Board. On a post mortem examination, the brain was found to be congested, and he believed the cause of death was typhoid or gastric fever, connected with consumption, and that death was accelerated by the |48 poisonous air of the ward. On the previous day he saw some water, obtained by the dispenser from the bottom of the air shaft of the infirmary, and found that it contained sewage contamination. That water ought not to have been there. It was not his duty to look after the air shafts, and he did not know whose duty it was.

The Coroner said it seemed very remarkable that, in the case of that workhouse there was no one to look after such matters. He wished to know what the witness meant to do with regard to this water.

The witness said he should report to the Board on the subject, as he had already reported from time to time. He reported the existence of bad smells in No. 24 ward as far back as September 18. Two new ventilators had been put into No. 24 ward since Jane Hayes died, but he did not perceive any improvement. There had been no reduction in the number of patients, but rather an increase. On June 30, and at other times, he reported to the Board that patients had been sleeping on the floor. Reporters as to bad smells were made before he entered upon office, which was in June last, by Drs. Harley and Gibson. He agreed with Dr. Edward Smith that the minimum number of patients in the wards should be 144. On July 1st, there were 168 beds, and within the last ten days there had been 203. More beds had been put in the wards since Mr. Solly and Mr. Carter gave their evidence.

The Coroner—Then you think the tendency to overcrowding and the acceleration of deaths has rather increased since the revelations of the 10th of November?

Witness—Yes, sir.

Examination continued—On the 6th of November there were 169 patients in the infirmary, and yesterday (Sunday) there were 190. The witness then put in his half-yearly report to the Board of Guardians, and also a reply from that Board requesting him to couch his reports in language more becoming a medical man and a gentleman.

Mr. Corbett, Poor Law Inspector, was then examined. He deposed that he had been acquainted with the St. Pancras Infirmary since October, 1866, and that from that period the Infirmary wards had always been more or less overcrowded. He had reported this to the Poor Law Board, and the reason why the order that there should be 850 cubic feet for each patient was not enforced, was—

Dr. Edmunds, one of the guardians, here interposed, and begged the Coroner to afford them facilities for aiding in the elicitation of the truth, especially by letting him have a chair to take notes, and prepare for an examination of the witness. The guardians had, he said, to contend against a conspiracy. Several gentlemen in the room, evidently connected with the vestry, loudly protested against this expression, and quite a scene occurred in the court. In the course of the uproar—for such it was—the foreman protested against a statement which he had seen, that the Coroner’s officer could easily pack a jury; but the Coroner assured him that he need not trouble himself about the matter, as he could defend his court against any imputation of that kind. Dr. Edmunds was then with some difficulty—the room being crowded—accommodated with a seat at the Coroner’s table.

Mr. Corbett’s examination continued—The order that there should be 850 cubic feet per patient was not enforced by the Poor Law Board, because it was thought that many patients whose cases were urgent might thus be excluded, and because better provision was being made for patients. He visited No. 24 ward between half-past four and five that (Monday) morning. The air was still offensive, but he did not think it was quite as offensive as it was on the night of the 14th instant, when there were two more patients in the ward. He believed that after Dr. Markham’s report as to bad smells the guardians conscientiously endeavoured to remove the cause of the evil. He could not tell whether the Poor Law Board had power to do anything beyond calling the attention of the guardians to the matter. The witness then deposed to the removal of one serious sewage nuisance in consequence of a complaint on the part of the Poor Law Board.

By the Foreman—In consequence of the crowded state of the infirmary wards some persons who were ill had been placed in the infirm wards.

By the Coroner—On the night of the 14th of Nov. there [were] 32 patients in No. 24 ward, whereas on the 15th of Oct. there were only 27. The position of the water-closets was not satisfactory, but he had never had occasion to complain of their condition. He thought the ventilation of the wards might be improved with a limited number of beds and proper care. That morning he found the patients in No. 11 ward nearly all coughing in a distressing manner, and he thought that was owing to the circumstances that the ventilators, which were about 3 feet above the heads of the patients, were open.

Dr. Edmunds, who said he had been a guardian only since April last, then examined the witness upon points of discipline in workhouse management. Referring to a resolution of the guardians, passed, he said, last Friday week, requiring that no more patients should be admitted to the wards than the number prescribed by the Poor Law Board, he asked whether the medical officer was not responsible for any excess.

The witness replied that the person responsible was he who gave the order for additional beds, adding that the responsibility in such cases devolved, as he thought, on the master.

By the Coroner—As a lawyer, he did not think the Board of Guardians could expose themselves to a verdict of manslaughter by allowing an excessive number of patients.

The Coroner said he was afraid there was no law on the subject. The public had trusted to gospel, and it had failed them.

Dr. Edmunds continued his examination of the witness at considerable length, for the purpose of showing that the Board of Guardians had done everything in their power to improve the ventilation.

Dr. John Henry Brydges, Acting-Inspector of the Poor Law Board, was next examined. He said he had visited the infirmary but once, namely, on the 14th instant. The size and construction of some of the wards he considered pretty good, but there was a bad smell from one of the sinks. There were too many patients in all the wards; and he thought that persons suffering from phthisis and disease of the lungs would be likely to have their deaths accelerated by the state of the wards. He made a report to the Poor Law Board of what he observed, and that was all he could do.

The Coroner—Don’t you think, Dr. Brydges, that the people of England, when they read the report of this inquiry, will be astonished to learn that you, representing the Government, found this state of things and were powerless to remedy it?

The witness repeated that he had only power to report.

In reply to Dr. Edmunds, the witness said he believed the Poor Law Board had power to make an order limiting the number of patients in the infirmary. There were hospitals in London where a patient suffering from lung disease would be much better off as regarded pure air than at his own home. He thought that an opening at the top and at the bottom in the St. Pancras Infirmary would be better than the present system of ventilation. He did not know any workhouse infirmary in which there was better structural ventilation than there was in that one.

It was here stated, in reply to inquiries from the coroner, that the infirmary was built about 1849.

The Coroner—Ventilating apparatus was not as effective then as it is now.

The Court then adjourned for half an hour.

When the Court had again met,

Mr. B. Carter was re-examined. He deposed to having visited that morning Nos. 16 and 24 female wards, and No. 11 male ward. Having visited them on the 4th of November, he found little improvement; the air being close and offensive; and he thought that, with precautions to prevent cold, the ventilation might have been improved. The condition of No. 24 wards, as he found it that morning, would accelerate the death of a patient suffering from phthisis. Did not know any hospital in London where there was as much overcrowding, or as great a want of ventilation as he had found in St. Pancras Infirmary. Would be sorry to spend 24 hours in the wards, and considered them quite unfit for human habitation.

Mr. J. W. Barnes, surgeon, was, at his own urgent request, here examined with regard to the deceased James Plant, whom he attended just before his admission into the infirmary. The gist of his evidence was that he found Plant in such a state that in his opinion he could not possibly live; but, in reply to the coroner, he admitted that he did not discover any organic disease. Knew the wards, and when he visited them found no want of ventilation. Did not believe their state had accelerated the death of anyone.

The witness was pressed very closely by the coroner and the foreman with questions on this point, but he adhered substantially to his statement. In reply to a question suggested by Mr. Parker, he said that he is elected one of the parish surgeons annually by the board of guardians.

Dr. Ellis, medical officer of the infirmary, was then cross-examined, it being a cross-examination only in form, by Mr. Parker. His evidence related chiefly to reports which he and some of his predecessors had made at different times to the board of guardians, with respect to the objectionable state of the wards, and he expressed his belief that, if his own suggestions had been carried out, considerable improvement would have resulted.

Mr. George Blake, master of the workhouse, who was there in that capacity for two years and left on the 1st inst., said that when he entered upon office the number of beds was 203, which number was gradually reduced. On the 27th of May last he reported to the board about an increase. When he quitted the house there were 169 beds—a number which exceeded that prescribed by the Poor Law Board. During his term of office there were many complaints of smells, and though a good deal had been done to remedy the evil, there were smells when he left. Had the new ventilators been supplied earlier, he would have used them. To meet the evils complained of, the old guardians sent twelve patients to King’s College Hospital, and they would have sent more had there been room for them. The workhouse was drained very well, but the infirmary very badly. Saw the new Infirmary at Highgate in October, and believed it was then dry enough to be occupied by patients. The ventilators were not generally used while he was in the house, being too close to the patients’ heads.

James Peel, medical dispenser of the workhouse, was then examined with regard to the water just found by him, as stated by Dr. Ellis, in the air-shaft of the infirmary, and deposed in effect that, having analyzed it, he found that it contained organic matter connected with the sewage. The witness gave the quantity of such matter, and said it far exceeded the organic matter in the ordinary water of the workhouse.

John Ward, engineer of the workhouse, was thereupon examined, and said he thought the water in question must have percolated through a main which was broken six or seven weeks ago, adding that the air shaft was used, not to let in air, but to draw it off, and therefore the patients could not have been injured by that cause. He had found that morning a stench arising from a cesspool outside the infirmary walls, on the ground of the Midland Railway Company, and he believed that smells in the wards arose from that source, knew of the existence of that cesspool before.

The Coroner asked the witness why he did not report the fact of its existence to the Medical Officer of Health?

The witness replied that it was not his duty to do so, and went on to say that the cesspool was not used now, and he was surprised that it had not been removed.

Ellen Petts, night nurse in the infirmary, deposed that on the night of Mr. Solly’s visit to the infirmary it was in its ordinary state, and she had no orders to close the ventilators. Great efforts had been made to improve the state of the wards during the last two or three weeks.

The Coroner then asked the jury if they felt themselves in a position to come to a conclusion on the case of Jane Hayes.

The jury having intimated that they did,

The Coroner addressed them. He observed that although 80 cubic feet of air was the prescribed quantity per patient it had not been enforced, and no one appeared to be legally responsible for a deficiency. He did not think the jury could find any one criminally guilty, although some persons had, no doubt, been negligent. Before the guardians were blamed by the jury it should be considered whether the Poor-law Board should not have exercised the authority vested in it. Dr. Ellis had, the Coroner remarked, been cleared from the charge of having purposely over-crowded the wards.

The room was then cleared for the jury to consult. After the lapse of about an hour they declared that the death of Jane Hayes was accelerated by the overcrowded condition of the ward in which she died; adding to this verdict the following expression of opinion:—“That the wards of St. Pancras Infirmary have been overcrowded for the last three years, and the jury desire to express their regret that the Poor Law Board have not enforced the sanitary measures which they have from time to time recommended to be carried out; and they also feel that the Board of Guardians have failed in their duty towards the parishioners of St. Pancras in not carrying into effect the recommendations of the Poor Law Board.”

The court adjourned at a quarter-past six for the hearing of the other cases until Monday, the 29th instant, at four o’clock.


  • Social cases. 1869