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THE SINGULAR DEATH OF AN ASYLUM PATIENT. THE INQUEST. An inquest tvas held at the Asylum on Thursday morning, before Dr. J. R. Hughes, coroner for West Denbighshire, on the body of Thomas Day, of the Snowdon Ranger Hotel, Bettws Garmon, a pauper patient, who died in the institution on Tuesday last. The following gentlemen formed the jury Messrs. J, P. Jones, High Street; W. H. Hughes, High Street; William Parry Williams, grocer John Davies, Love Lane; E. B. Barron, draper; W. H. Evans, Chirk Shop; Fred. W Roberts, Britannia Build- ings W. Marsden Davies, High Street; D. H. Davies, High Street; Fred Williams, hairdresser; James Green, High Street; John Williams, Highgate Thomas Andrew Roberts, High Street; John Roberts, shoe- maker, and William Hughes, Britannia Inn. Mr. W. H. Evans was elected foreman of the jury. Mr. Webster, who was present at the en- quiry on behalf of the family of the deceased, was the first witness examined, and identi- fied the body now lying dead at the institu tion, as that of Thomas Day. Thomas Roberts, examined by the coro- ner, said he was an attendant at the Asylum, and remembered the afternoon of the 8th inst. The Coroner: What happened about 4 o'clock ? Witness Joseph Roberts came to me to number 6 ward, and informed me that there was something wrong with Thomas Day, and that I had better come down to see him. What did you see ? I saw a lump on the jaw of Thomas Day, and blood coming down from the mouth. About what time would it be ? A quarter or twenty minutes past four. What did you do next ? I took him from the other patients into another room, and then called the doctor, wbo came with me straight. Did the man say anything at the time you were removing him ? were removing him? No, nothing Was he conscious ? Yes, quite. Did'nt he tell you how it happened ? Not then, sir, but Dr. Herbert was asking him questions in the room after putting him in bed. And that is all you have to say in the matter ? Yes. Joseph Roberts, attendant, said he had beeu at the Asylum for the last 12 years, and that he bad nothing to add to the evi- dence given by Thomas Roberts, which was correct. Mr. Barron- Was the deceased standing up, or sitting down when you sAw him Thomas Roberts He was sitting down. Mr. Fred Roberts: I suppose neither of you two were there when it happened ? Joseph Roberts: No. Mr. John Davies: Were there any savage patients about ,at the time ? The Coroner: I think that will come on in evidence again Mr. Davies. Mr. D. H. Davies Was this the first time that it became known there was something zn wrong with Day ? The Coroner I think we will leave this now, as further particulars will be forth- coming on this point. John Elias Jones, examined by the coro ner, said he had been attendant at the Asylum for the last 5 years, and remem bered Sunday, the 8th of this month. Where were you about 3 o'clock on that day ? In number 4 ward, on duty. Was there another attendant in the room with you Ii No, not at the time. Now, give us as clearly and acurately as you possibly can what occurred. Remember you must be most careful in what you say, as you are practically on your trial. What happened about 3 o'clock ? Witness: Thomas Day was sitting on a form in his usual place, near the corner of the room. About what time was that ? As near as I can say it was about a quarter to 3. What happened after this He took up a spitoon, and threw it on the floor but I cannot say whether he was try- ing to strike another patient or not. I was at the time siting about 3 yards from him, in front. I rose, took hold of him, and put him back on the form He was in rather a bad temper at the time. He was a little noisy afterwards; but I did not take any particular notice of him. Before he got up, was he shouting and swearing ? Yes he was very noisy before and after throwing the spitoon. Did you find any difficulty in putting him down? No; I put him down on the form easily enough. What happened-again ? I sat down on a chair in the middle of the room, near a table and in about 5 minutes, William Jones, Penmaenmwr, a young patient, crossed the room, and went towards Thomas Day in a running attitude. Did he rush towards Day? Yes and Thomas Day had risen on his feet by then. I am not certain whether Jones struck him but he pushed him on to the bench. Was there any talk between theru then ? No, none. Did Thomas Day shout ? Yes he said something which I could not understand. He was in a bad temper all this time, and this William Jones gave him a push. I saw William Jones pushing him, and he fell. Did be strike him ? I cannot say whether he struck him before pushing him. How did Day fall He fell on his face sideways on the bench. He fell on the right side. I then jumped to him, and picked him up and this William Jones appeared as if he was going to strike him again, but I prevented him. In rising Day up, be stumbled again, and fell down nearly in the same spot on the arm of the bench. Did he fall heavily the second time ? No, not very heavily. I got him up again, and put him to sit on the form. Did you look at his face, or ask him a question at this time ? I looked at him, but I cannot say there was anything wrong with him. What did you do with him afterwards I put him to sit on the bench, but he would not do so. He was shouting and swearing. I took him through the passage, thinking he would be quiet; but he went towards the lavatory, and came back in about 5 minutes. Dr. Cox: May I put a question to wit- ness? The Coroner: You had better reserve it until his examination is over. (To witness) Did you notice anything different with him when he came back? No; he appeared in the same condition, and he sat exactly in the same place as before. I did not notice anything the mat- ter with him. Then the other attendants came, and the patients went to church about 3 o'clock. How many patients remained after the others had gone to church ? About 24 to 26; and after they went to church, I went up to change my clothes. Did some one come to you after this ? Yes, W. Edward Davies, an attendant, came there after they went to church. What time would that be. It was after 3. Did something take place between 3 and 4 o'clockâsomething in the nature of a scuffle or a row ? No; nothing more than I have stated. Mr. John Davies: I suppose we shall have W. E. Davies before us ? The Coroner: Yes. (To witness): Can you tell the jury anything more in reference to this matter? Did somebody strike him, or did you strike him, or saw anybody else do so 1 I am not certain whether William Jones struck him or not. The Foreman Were you the only attend- ant in the ward the first part of the time when this disturbance took place ? Yes there was no other attendant. The Foreman: How many patients were under your charge at this time ? About 32, I think. The Foreman Did this disturbance upset the other patients ? No. The Foreman: Did it excite you in any way? No. The Foreman: After this disturbance, didn't you think it was your duty to follow Thomas Day to the lavatory ? No. The Foreman Did you know that Day was hurt in any way on that occasion 1 No. No. The Foreman Did he complain to you at all? No. Mr. W. Parry Williams: You are positive that you did not strike him ? Yes, quite, positive. Day was not very firm on his feet. Mr. D. H. Davies: Is it the usual thing to have spitoons in these wards ? I have always found them there. Mr. John Davies: Did you see this patient in this bad temper and excited state often ? I have seen him sometimes; but he was not often in an excited state. Mr. James'Green: Is this William Jones going to give evidence 1 The Coroner: That depends upon circum- stances. Dr. Cox: I want to ask John Elias Jones why he did not give me these particulars as regards coming against the arm of the bench when I examined him after the occasion of the accident. The Coroner I hardly think this is re- levant. Witness has given his evidence. Dr. Cox: I am quite satisfied, sir, only I want- The Coroner: I don't think it was a ques- tion you should put. Dr. Cox: It does not concern us very much. The Coroner: But it concerns the man himself. Dr. Cox What I say is this, that he did not give me these details as given to your- self and jury. He simply stated that W. Jones rushed across the room, and threw Thomas Day on the bench. Probably he was not prepared to give me these particu- lars at the time but this was the statement he made to me-- The Coroner I do not go on your state ment. We go on the evidence before us; and you may discharge everything you have heard out of doors bearing on this enquiry. We are hear to deal with the evidence pre sented before us: but we are not here to cross-examine the witness to his own pre- judice. Of course, you can call other wit- nesses to contradict his evidence. Mr. J. P. Jones: I presume that the state- ment he previously made was not on oath. Dr. Cox: No. Mr. J. P. Jones But he is now on oath. Mr. Marsden Davies Did Thomas Day go to church? Witness: No. Was this attendant with him when the other patients were in church? The Coroner: Yes, than has been said in evidence. Mr. W. Parry Williams: Except, of course, the time he took to change. Mr. John Davies: Did lie find that the bone was broken? The Coroner You will get further evidence on that point from Dr. Herbert. (To Mr. A. O. Evans) Do you represent anybody, Mr. Evans? Mr. Barker He is a member of the Asylum Committee, sir. The Coroner How long it took you to change your clothes? Witness About twenty or twenty-five min- utes. Mr. Fred Roberts: Do I understand him to say that, as far as he could see, there was no injury at all ? Witness Yes. The Coroner: Did you see blood coming from the mouth? No. Nor did you observe a swelling on 'the side of the face? No, none. Really, you did not think that he was at all injured? No. sir; when I came back to the room William Edward Davies, another attendant, was there. The Foreman Did you remain in the room until the two attendants already examined came there? I sat there near the window until about four o'clock, when they came from church, and all was quiet. Mr. Fred Roberts Was this witness in the room when the two other attendants were sent for ? The Coroner: It was Joseph Roberts who saw this man, and he called Thomas Roberts, who sent for Dr. Herbert. We are now en. quiring how this state of things came to pass. Mr. John Davies The question is a very reasonable one whether this man was in the room when the other attendants came there ? Witness I was in the door of No. 4 ward when they came from church, and Thomas Roberts was coming with them. The Foreman: re we to understand that one attendant leaves the room before another takes his place ? Witness: No, we remain until relieved. Dr Cox Did Joseph Roberts relieve you at four o'clock before you left the ward? Yes. The Coroner What was your duty had you found out that the man was injured? Report to the Head Attendant. Were you of opinion that he was injured ? No, sir. William Edward Davies was the next wit- ness called, and said, in reply to the Coroner, that he was on duty in a portion of No. 4 ward, known as the billiard room, which would.be about six yards from the other portion and divided by a passage. He heard some noise in No. 4 about ten minutes or a quarter of an hour before four o'clock. After the patients had gone to church, he got together the re- mainder of the patients, and put them in the room under the charge of John Elias Jones. Th Coroner Did you take any notice of Thomas Day ? I noticed him sitting down as usual; but I did'nt speak to him ? Did you notice that his mouth was bleeding, and that his face was swollen? No, sir. The Foreman Are we to understand that Thomas Day didn't complain to this attendant of being in pain ? Witness He did not complain to me of any- thing I didn't speak to him. The Foreman: What time did John Elias Jones return!? I cannot say exactly, but it was a little to four o'clock. Mr. Barron Did you see any scuffle when you were In the passage ? No, sir. You didn't see deceased on the floor? No, nothing. Yoa didn't notice any mark on his face? No. No marks of blood on the floor ? No, none. Charles Herbert Edwards, attendant, who was present during the previous witness' ex- amination, said that the evidence of Davies was correct. Dr. Herbert said Edwards' evidence as given to Dr. Cox and himself differed materially from that given by Davies, and asked the Coroner to have him examined separately. The Coroner: We have nothing to do with the evidence he gave you. He is now giving his evidence on oath. Proceeding, witness said he heard some noise in the No. 4 room on the Sunday in question. It would then be about a quarter to three. It was a noise as if someone had fallen. He did not fhear any talking, but Thomas Day was shoutingr. He saw John Elias Jones taking hold of Day from behind, and putting him to sit on the form. There was a spitoon on the floor, with the sawdust scattered about. Did you see anything wrong with Thomas Day's face? Only a spot of blood anCt..saliva. I did not notice any swelling of the face. Mr. John Davies: Was there blood mnning down from the mouth ? No, it was not running down. It was on the lips. Mr. Barron Was Day put down in a rough manner by Elias Jones. No, sirâgently. Mr. John Davies Day did not speak a word to you? No, sir, not a word. Mr. D. H. Davies: Did you see this Thomas Day at all after coming from church? Did you notice his face at that time ? Yes, sir. The Coroner And you saw this blood? I saw that before I went to 'church, and in coming from church, I noticed that the side of his face was swollen. The Coroner: Had he spafc a great quantity of blood on the floor ? No, not very much. The Foreman Did you think at the time there was sufficient cause to call in another attendant ? We have it in evidence that Joseph Roberts called in the head attendant. Mr. Barker explained that Joseph Roberts was the senior attendant present, and that he .was the man to send for the head attendant. The Foreman But I want to know whether this witness thought there was sufficient cause for interference. ThelCoroner interposed, and no answer was given to the question. The Coroner, having here called Dr. Cox, said it was a somewhat unusual thing to ask an inmate of fa lunatic asylum to give evidence in cases of this kind, or, indeed, in any other case but he believed there were two patients there who had something to say about this matter, viz., William Pritchard and William Roberts, who was known as Will Bodfari.' Although it was unusual to take the evidence of such men, yet the law acknowledged that their evidence was admissible under certain conditions. If Dr. Cox were of opinion that cheir understanding and their recollection, and their whole; character, was such that he could recommend them to the court as witnesses, then their evidence became admissible. He (the Coroner) wished to know from Dr. Cox whether he considered these lunatics capable to give such evidence. Dr. Cox: My opinion is, with regard to these two patients, and having regard to the circumstance, and the effect of their being pre- sent in the room The Coroner That is not the point. You are to say whether their mental condition is such that they can tender their evidence here to-day. Dr. Cox: I think so, sir. William Pritchard was then called, and made a statement in the presence of John Elias Jones. He stated that he had been an inmate of the Asylum for 10 years, and had noc been home during that period. Being questioned by the Coroner, witness, who appeared to be a quiet inoffensive man, and seemed at the time in a somewhat dazed condition, gave an incoherent statement as re- gards what occurred on Sunday, the 8th of May. At first he said he did not remember that anything occurred during any Sunday in this month. Several questions were put to him, in order to elecit the fact whether any dis- turbance took place between Thomas Day and an attendant, or anybody else, to all of which he replied that he had no recollection. Mr. Fred Roberts 1 do not think we can go any further than that. Dr. Cox, replying to the Coroner, said he had nothing more to say, except that witness gave him the information which he had already re- ferred to. The Coroner But we must not take that. Dr. Cox Will you ask him, sir, whether he remembers talking with me? Having been asked the question by the Coroner, witness said he did not remember that; but he could not say exactly what Dr. Cox spoke about. Dr. Cox: Do you remember me asking you whether there was a disturbance? The Coroner I cannot put him that question. He has already said that he does not remember that there was a disturbance. You should not ask him any question in order to prejudice the case of the attendant. After further attempts to gain the information required, witness, at last, said he remembered Dr. Herbert interrogating him in the ward regarding th-, shaking man (Thomas Day). The Coroner Can you say what you told Dr. Herbert ? Mr. A. O. Evans Would what he told Dr. Herbert be evidence? The Coroner Hardly, I think. Dr. Herbert: What the disturbance on the Sunday was? Will you put him that question Mr Coroner? The coroner having done so. Witness said that the man had been strock. The Coroner: Do you remember some man striking him ? Witness: Yes, sir. Who was the man who gave the blow? Witness John Elias. Mr. Parry Williams Who did he strike? Witness That man. The Coroner What man ? Witness: I cannot say who he was. Mr. Fred Roberts: Was there anything pecu. liar on the man ? was he shaking ? Witness Yes. The Coroner I don't think we can attach much importance to his statement. He seems to be so confused about the whole thing. Dr. Herbert: But he knew the 'shaking man' all right. The Coroner But that would be hardly suffi- cient identification. To Witness: H..w did he strike him ? With his open hand in the face. Was he standing, or on the floor? On the floor I saw him. The Foreman How can we accept his evidence. He said at first that he did not recollect anything about this. The Coroner: Take it as a statement, and not evidence. You can either believe it or discard it, as you think fit. I really do not think myself that he would know the difference between a dog and a cat. Mr. D. H. Davies did not think the evidence could be relied upon. John Elias Jones, on being asked whether he had a question, denied that he struck the deceas- ed. The Coroner asked Dr. Cox whether the other witnessâWilliam Robert", Bodfary, was in a fit condition to give evidence, to which the Dr. re- plied in the affirmative. Proceeding, the Coroner asked whether those were the only two patients Dr. Cox had examined in reference to the accident. Dr. Cox No, I have examine I some half a dozen. The Coroner We have it that there were about twenty-six patients in the room at the time. How many of these did you examine? Dr. Cox About half a dozen. The Coroner With what result ? Dr. Cox Negative result. The Foreman Why were these two chosen to come before na then ? Dr. Cox: I chose these two because they were the only persons that gave me any information bearing on the disturbance. The others knew no- thin g about it. William Roberts, Bodfary, was then brought into the room, and accosted the Coroner with the question, I How are you, Will Bach ? The Coroner You know me, do you not ? Witness Yes, of course, are you not Mr. Roberts, the Geinas ? Being further questioned, he said he did not know anything about the oath or the Bible, and the jury unanimously decided that his statement could not be taken, and he was then removed from the room. Dr. Herbert, assistant medical officer, said he was called to see Thomas Day immediately on his return from chapel on Sunday, the 8th. It would then be about a quarter past four. He was seated in No. 4 ward; and the first thing that attracted his attention was a large tense swelling on the right side of the face. His lips were also swollen, and he was saliving freely from the mouth, and blood was dropping down to his knees. Further examination showed that the jaw had been fractured. The patient was sent to bed, and immediate inquiries were instituted as to the cause of the injury. He despatched a messenger to town to summons the attendants under whose charge the patient had been during the afternoon. In the meanwhile, he interrogated Charles H. Edwards, with the result that he tendered him the same informa- tion as he had given to the jury that day. Some of the patients in the ward gave a his- tory of a disturbance, but their statements were vajiue, with the exception of that of William Pritchard, who said that the shaking man had been struck by his I master.' who he afterwards learned was John Elias Jones. Afterwards he saw David Davies and John Elias Jones and on questioning them, he found that David Davies knew nothing whatever of the matter. Judging by the nature of the swelling, he thought it was very probable that the injury would have been caused some time betore he saw the patient. It was possible that a fracture might have taken place at an earlier hour, without displacement so as to cause the local symptoms to be afterwards evidenced. The deceased man was suffering from St. Vitus Dance and his body was in constant motion. John Elias Jones told him (witness) that the patient had been pushed down by auother man. Some questions having been put to the witness with reference to the time at which the accident might have taken place, he went on to say that they put John Elias Jones in company with two or three other men for the purpose of identification by the patients. The Coroner, interposing, said it would not be right for the witness to relate this incident, and refused to admit it. Proceeding, witness said Day had&lived 18 davs after the accident. The Coroner: Was treatment in his case rather difficult? Yes, owing to his mental and bodily condi- tion. He was so restless and if yon touched him, he would get furious. He had, in additiol to a fractured jaw, two of his ribs fractured, but I cannot say that this had my effect in hastening his death very materially. The Coroner Did you, at my request, make a post-mortem examination ? Yes, Dr. Cox and myseif. We found that J the jaw and ribs had been iractured, and that he also sutiered from iniiamation of the lungs. I believe the ^mail's death was due to acute pneumonia, and some form of blood poisoning, owing to the foul matter from the mouth. The Coroner: And to the best of your knowledge, death was the result of the accident on the 8th May ? Without a doubt. The Foreman: Could the injuries be caused by an accidental fall? Witness: They could not have been caused by an accidental fall he must have been thrown violently, as they could not have been caused by the man's own weight. Mr. D. H. Davies: Could a blow with an open hand possibly cause a fracture of the jaw ? Witness: I don't think I. couid frature anybody's jaw with my open hand but I could with my closed fist. Mr. Barron Did the deceased make any statement to you? He said he had been struck, but subsequently during his illness he evidently referred to this, but his mental and bodily condition was such that you cjuld not understand him. His articulation was indistinct before the injury. The Coroner, having intimated to the jary that he did not propose to call any more witnesses, unless de- sired to do so, summed up the evidence. He said that the case was a most important one, and it was a matter of consolation for the friends of deceased to know that every care had b"en taken to ecquire fully into the matter. The Asylum authorities had done their best to bring the party who might have been suspected to have done wrong to justice. In this, the Committee were ably assisted by the staff. Undoubtedly, every care had been taken of this poor unfortunate man by the authoiit:es; and Mr. Webster, who was present on behalf of the family, would, no doubt, endorse that .view. The evidence was. on the whole, pretty clear and straight, considering thtra were so many witnesses In the case and these witnesses could not all be certain to a few minutes as to the time when such accidents as these occurred. Thomas Roberts and Joseph Roberts had given their version of the accident in a perfectly clear manner. They called the Doctor, and the patient was at once treated 111 a proper way by him. The next evidence was that of John Elias Jones, who was, more or lesa, the man charged of assaulting the deceased, It appeared to him (the Coroner), but the jary could believe it or not, that Jones' evldecce was also pretty clear; and he could hardly imagine that there was any man in that institution that could, in cold blood, throw an unfortunate patient about like a bundle of rags. and cause this it jury to him. His own inclination in the matter was to believe the evidence of Jones. --Unfortunately, he was the only attendant present at the time, and was surrounded by a good number of these demented creatures. Speaking as a medical man, he conld tell them that some men's bones were more brittle than those of others; and perhaps this slight fall on the bench might quite possibly caoee the fracture of the jaw. if the accident bad happened before three o'clock, it was rather extraordinary that tbe attendants bad not observed something wrong with the deceased, but they found nothing. The first intimation of the accident was given at about 4 20 and the house surgeon, who very ably attendpd to the ease, bad said there ahcl really been no displacement to cause i-ritation, &c. Having commented on the evMecce of the patient William Pritchard, the coroner went on to say that it would really not be right to place such evidence against that of a man. who. should such evidence be believed, would be charged with manslaughter. If they believed that John Elias Jociee struck Day so as to cause the injuries, of course the jury could do nothing but bring in a verdict of manslaughter; but he thought they should not do that, as the only evidence which they could accept was that the man had been pushed by another patient on to the bench. and that he afterwards fell twice on the side of his face. He thought the most reasonable verdict, and the one most in accord- ance with the evidence, would be that the man Day had been so injured that he died from the result. The jury then considered their verdict in private; and after about 15 minutes consultation, returned the following 'That Thomas Day died from injuries received on the 8th May, but that there is insufficient evidence to show how he came by these injuries.' The enquiry lasted three hoars and a half.



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