[The Daily News, 30. November 1869]

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The Daily News. Nr. 7358, 30. November 1869. S. 2.
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The adjourned inquest on the causes of certain deaths in the infirmary of St. Pancras Workhouse took place at four o’clock yesterday afternoon, at the College Arms, Crowndale-road.

The names of the deceased whose cases had still to be heard are Mary Brown, James Plant, Mary Smith, and John Fox.

Mr. Parker, jun., of No. 40. Bedford-row, appeared on behalf of the relatives of Mary Brown, whose case was taken first.

Dr. James Ellis, infirmary surgeon, said the deceased woman was suffered from ulceration of the nose, which was not necessarily a fatal disease, and she never seemed to improve. She complained that the ward (No. 16) was close, and her case was one in which an abundance of fresh air was especially desirable. She ought to have had more cubic space, and if he could have got it for her he would. On the night when she died there were 32 patients in the ward, each having 700 cubic feet of air, and the beds were all full. Deceased was found dead by the night nurse on the morning of the 6th. He afterwards found the brain and liver congested, and the cause of death was, he believed, congestive apoplexy.

Jane Mather, day nurse, deposed that on the evening of the 5th there were seven patients lying on the floor of the ward.

By Mr. Parker—Mr. Robertson, one of the guardians, once opened a ventilator on his own authority.

By the Coroner—Had been lately in the habit of opening and shutting windows at the request of guardians without consulting Dr. Ellis.

The Coroner remarked that under such a state of things patients might be almost blown in pieces one moment and almost suffocated the next.

Frances Blott, an assistant nurse, stated that one patient, a countryman, killed fourteen rats within five weeks.

Ellen Petts, general night nurse, who was examined at the last sitting, stated that on the following day she received a notice of dismissal. She commenced her duties last March, and no formal complaint had ever been made against her, though she had had words with Dr. Edmunds and Mr. Watkins. Could not tell why she was dismissed. Did not know that she was either stupid or negligent, as had been stated in a newspaper since she gave her evidence.|


The Foreman expressed a desire to ascertain the cause of dismissal from the guardians’ minute books, but the Coroner deprecated any more time being occupied with a matter not directly bearing on the question before the jury, especially as they could all draw their own inferences.

Dr. Ellis, having been recalled, stated, in reply to Mr. Parker, that he unhesitatingly attributed the death of the deceased to the state of the ward.

William Richard Freethy, a clerk in the guardians’ offices, produced the minute-books of the guardians and their visiting committee and, at the request of Mr. Parker, read entries respecting complaints of Dr. Gibson, Dr. Harley, and Dr. Ellis, about the state of the infirmary.

From a statement of Mr. Blake, the late master of the workhouse, who was again present, and here examined on this question, it appeared that the complaints of the two first-named gentlemen were attended to.

The witness Freethy was examined minutely and closely by Mr. Parker, evidently with the view of fixing legal responsibility on guardians present at various meetings, on the ground that they had not, in accordance with the requests of Dr. Ellis, done what was necessary for the improvement of the infirmary. One of Dr. Ellis’s reports, placed before the guardians on the 8th instant, was, it appeared, simply ordered, on the motion of Mr. Watkins, to lie on the table. This report related to the excessive number of beds in some of the wards.

Mr. Joseph Smith, a member of the Board of guardians, and also of the visiting committee, was examined with regard to a meeting of the latter in July, in which a resolution was passed in reference to a report of Dr. Ellis, to the effect that no action should be taken upon it. He himself disapproved of that course. The other members present were Mr. Robertson and Mr. Borsley. As regarded the capacity of the infirmary, the witness said that until lately he never heard that the number of patients should be limited to 144, and if he had known that he would not have consented to any addition. He was not now aware that there had ever been more than 168.

In reply to the Coroner, Dr. Ellis here stated that there are at present 190 patients, whereupon Dr. Lankester expressed his surprise at such a want of knowledge on the part of a guardian.

The witness went on to state that the day after Dr. Solly gave his evidence he himself went to the infirmary, and arranged for additional accommodation, in the form of an extra ward, which Dr. Ellis accepted.

Dr. Edmunds, a guardian and doctor of medicine, was recalled, and examined on the same point. In defense of the guardians, he stated that up to last week an order of the Poor-law Board, dated November, 1868, required that as many as 212 patients should be received into the infirmary. Dr. Edmunds afterwards alluded very warmly to charges recently made against himself as a guardian, saying that he had been “shamefully libelled.”

The Coroner protested against the use of such language in that court, where, he said, the witness had met with the greatest indulgence.

The Coroner having briefly addressed the jury on the case of Mary Brown, the cases of John Fox and Mary Smith, which were workhouse, and not infirmary cases, were then inquired into, in order that all the remaining verdicts might be returned together. In both these cases, which were of an ordinary character, the verdict was, that death arose from natural causes, with the addition, in the last, that death was accelerated by the want of proper nursing and medical attendance prior to deceased’s admission to the house. The verdict in the cases of James plant and Mary Brown was, that the deaths were accelerated by the unsanitary condition of the wards in St. Pancras Infirmary in which they died, with the following addition:—“The jury wish to express their undiminished conviction that the death of the said deceased was traceable to the neglect of the Poor-law Board and the Board of Guardians to provide proper sanitary arrangements for the inmates of the wards of St. Pancras Infirmary.”

The inquiry did not terminate till about 9 o’clock.


  • Social cases. 1869