CORONER'S INQTUEST.

Nelson Evening Mail, Volume XV, Issue XV, 22 November 1880, Page 2

CORONER'S INQTUEST.

An inquest was held on the body of Edward Fearon at the Lunatic Asylum on Saturday afternoon before L. Broad, Esq., and a jury composed of the following:— Rev J. C. Andrew (foreman), Captain Webb, MessrßMacdonald.T. Scott, J. Hounsell.A.E. Moore, Burnett, J. Percy, Buckeridge, Builick, Drake, T. Mackay, and Muncaster. Mr Atkinson watched the proceedings on behalf of the relatives of the deceased. Evidence was taken as follows: — William Henry Mills, tbe Superintendent of the Asylum, deposed: The deceased was admitted to the Asylum on the 7th instant, upon the order and certificates produced. Until the 16th he was in fair health and -quiet. On the forenoon of that day he began throwing himself about the floor in such a '. way that I had a lot of mattresses put down ; to prevent him injuring himself, and had a oamasole put on him. When the medical ; ofljeer visited him on that day he ordered tbe (jaojasole to be taken off, and, on tbe tol-

, lowing morning he ordered him a shower bath, which he had at six a.m. At night hn bad a dose of chloral bj the medical otHcers 1 instructions. During the 18th he knocked himself about considerably again. He bad another dose of chloral that night. He would take no food all that day except a little beef tea. On the 19th I tried to induce him to take breakfast He took a little beef tea for dinner. At 330 p.m. an attendaut carried him on to the verandah, and he took a cup of cocoa and some bread and butter. During the foreuoon he had been roaming about his room a great deal, but was quiet in the afternoon. I gave him a glass of wine at his own request. At 530 I visited him again and found him seated at the table with the other patients, and I learned that he took a hearty meal. At 630 I saw him reclining on the grass, when I spoke to him and he asked me who I was. I told him, and he said " Oh, I know." I was returning to the ward when one of the other patients came running after me, , saying there was something the matter with Fearon. I went back as quickly as I could, and found one of the attendants holding him on the grass. His right eye was completely out of his head, and blood was streaming down his face. I ex-, amined bis hands, and found them covered with blood. I immediately , sent for the; medical officer, who came shortly after and dressed the wound. At B'3o I visited the patient after the doctor went away, and again at 9 30. I instructed the night attendant that if anything occurred during the night he was to call me. He called me at r3otnis morning, when I went to the patient's room and found him turning over and over. He was in a jacket, which I fastened as well as I could to prevent his throwing himself about, and told the attendant not to leave 1 him. At six o'clock I visited him again, and saw nothing to lead me to think he was in a dangerous state. He was lying perfectly quiet. At 7*lo the attendant came running to me, and said he thought the patient was either dead or dying. I 'went and examined him, and found him dead. I then sent for Dr Boor. By the Coroner : The doctor saw him last at 12 30 a.m. I did not see the doctor then. I bad no reason whatever for believing that the patient was in a critical state of health. Dr. Boor had told me he thought he would get all right again. When I went to him after the accident I asked him how he did it, but be gave me no reply. Mr Atkinson : You say that on the 16th he was under restraint, and that on the' 18th he knocked himself about considerably. Was he then under restraint ? Ans. : No, the doctor had ordered the camasole to be taken off on the 16th, and it was not put on again until after he had injured himself. Was there any protection against the wall in his 100 m ? Ans. : No, there is no padded room in the Asylum. The Coroner 1 How is that ? Is it not, under modern scientific treatment, considered necessary ? Ans. : I think myself it is necessary to have one. Dr. Boor : I am the medical officer of the Lunatic Asylum. Edward Fearon was admitted on Sunday afternoon, the 7th inst. I visited him the same evening, and found him standing in his room dressed, but weak and despondent. He recognised me, and appeared pleased to see me. He had religious delusions. I have seen him every day since with the exception of the 10th and 15tb. For the first few days he was doing fairly. I left directions if ever he became very restless and noisy that he should have a compos ing draught. He mixed with the other patients and conversed with them, and has given generally very little trouble. On the 16th he refused to get up, and on my visit ing him he pretended to be insensible. I remained with him a short time. On the 17th I found him in his room with a camasole on, and was informed he had been struggling very much. I bad the camasole re moved, as he was very hot, and found abrasions on his shoulders, hips and elbows I got him to the lavatory, when he began throwing himself about violently, when I had the canvas dress again put on, and sent him to his room, and had mattresses placed on the floor* In the evening he had quieted down, and I left directions that he should have a composing draught again. On the 18th he was less violent, and seemed a little better though persistently silent to me. Yesterday I did not see him until, about 7 p.m., I got a message that he had injured himself. On my arrival I found him on the dining-room floor held by the attendants and two patients. He was struggling very violently 1 His right eye was protruding from the socket beyond the eyelid. I replaced the eye and bandaged it with cold water pad. There was not much bleeding. I was informed by attendant Chant that Fearon had gouged the eye out with his own finger. I administered. a third of a grain of morphia, and he was carried to bis room. I visited him at. 12 30, and found him sleeping quietly and breathing freely. At 8 o'clock this morning I learned to my surprise that he was dead. I have made a post mortem examination, and found all the organs healthy except the membranes of the brain, which showed evidence of old inflammation, but not enough to cause death. The heart was firmly contracted but healthy. In my opinion the cause of death was due to spasm of the heart while in a state of acute mania. Ido not think the injury to the eye bad anything to do with death. Had I been shown the brain deprived of the membrane I should have said it was perfectly healthy. I do not think the optic nerve was divided, and possibly the eye might have been restored. In answer to a question from a juror whether it was not usual to have another medical practitioner besides the one in charge of the institution at a post mortem- examination of a patient dying in an Asylum, the , Coroner read the 23rd section of the Coroners Act, 1867, and pointed out that by this section a majority of the jury had tbe remedy in their own hands, as if they were dissatisfitd with the medical evidence they could require hitn to summon any other nieuioal man they pleased. The section even went so far as to authorise the jury to pick any special doctor they thought proper to have. By a juror : Indirectly the injury to the eye might have caused the shock, but I am of opinion that death is not to be attributed to it. Mr Atkinson: Looking back upon the case can you recognise anything more that might have been done ? Answer: No. Theattendantß.have been particularly careful in watching the patient and carrying out my directions. If a patient were brought in today under similar circumstauces I do not know that he could in any possible way be treated more carefully. By the Coroner : The attempt by the deceased to jump o*erboard from the steamer, taken together with this last injury to himself shows that he was a suicidal ! maniac. The Coroner: Mr Mills tells us that there is no padded roam in the Asylum although he considers it necessary. What is your opinion ? Witness: I look upon it as a useful addition to un Asylum but not necessary. All latest authorities say that the attendants should do the work. The Coroner: Have you enough attendant to do the work that might be required of them? Witness : No. This Asylum is very ill provided for dangerouß, violent, and noißy cases. By a juror : The superintendent ia authorised to employ any assistants from outside the Asylum when he may consider it necessary. Manson Chant : I am an attendant at the Asylum. I saw tbe deceased yesterday afternoon lying on the grass with five or six other patients. I walked round the building and when I got back I saw blood on his hand. I went to him and saw that he had a finger inside the socket. I pulled hia hand away and sent for Mr Mills. Deceased did not speak a word. I wan not away from him two minutes. By Mr Atkinson : I had seen no signs of violence in him during the day. The attendant whom I succeeded had told me that he had tried to escrpe. I had been in charge i about ten minutes. T-tomas Bullock, an attendant': I was on duty last night. I visited deceased's room : every quarter of an hour until 1 30, after ; which I remained in his room. He was very restless at that time, and Mr Mills and I held him for a few minutes. He was pretty quiet after that. He died at 7*lo, He never spolse all night. He breathed very softly.

He appeared to sink gradually from 6.30. He showed no signs of pain in dying. I sent Porter for Mr Mills a little after 7, but when he came Fearon was dead. A verdict was returned to the effect that death resulted from natural causes. At the close of the inquest the Rev J. C. Andrew, foreman, expressed an opiniou that the doctor making a post mortem should not be the regular medical attendant, but some outside practititioner. The Coroner, whilst concurring in these remarks as a general principle, pointed out that the Legislature apparently thought otherwise, as from the 2 1st and 22nd sections of the Act it eeemed that the regular medical attendant was usually the proper person to make such examination. The proviso to section 22 was as follows : — " Provided that if in any case it appears to the Coroner that the death of any such deceased' person was probably caused partly or entirely by the improper or negligent treatment ot any medical practitioner or other person, then such practitioner or other person shall not be allowed to perform or assist at any such examination." He bad no doubt of hia power to authorise any legally qualified medical man to make & postmortem examination, but it seemed to him from the general tenor of the sections quoted that except for special reasons the usual medical attendant ought to be selected for the purpose; By the' 2Uh section .it .seemed to be contemplated that in deaths in Lunatic Asylums and Hospitals the post mortem examinations should be made by the doctor in charge, as it was specially, provided that the usual fees were not to be paid in such cases, evidently, because the doctor was supposed to receive a fixed salary.