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PUBLIC RECORD OFFICE

TTI

Reference

C.O. 885

4 PUBLIC RECORD OFFICE, LONDON

ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC-

COPYRIGHT PHOTOGRAPH—NOT. TO

72.

If the impression derived from the above-mentioned distinction in the Rules has had an influence on the Medical Officer's conduct, it is not greatly to be wondered at. But, whether or not, it is remarkable that the fault such an impression is calculated to produce, is precisely that which we have described as marking the character of the medical attendance at the Town Hall.

We make these remarks not for the purpose of heaping censure on the Medical Officer in regard to his recent error, but of pointing out, as it seems our duty to do, the defects of a system for the existence of which the Medical Officer is not the only person responsible, and the faults of which must be clearly recognized, in order that the proper remedy may be applied to them.

Where a system known to be inadequate and imperfect is permitted to continue unchallenged and undisturbed, the officers working under it can scarcely be regarded as

• solely to blame for the mistakes and shortcomings which are its natural and inevitable

fruit.

To prevent absolutely the occurrence of mistakes may be an impossible thing, but to improve a system which tends to promote them, is a task to be accomplished, we may hope, without great difficulty.

As to the way in which this may be done in the present instance, we think that we need offer no further advice to the Executive.

Bridgetown, August 20, 1875.

(Signed)

J. SEALY, Jun.

F. B. SMITH. B. INNIS.

Proceedings taken before the Commissioners appointed to inquire into the Circumstances connected with the Death of a man called Henry Hurdle, while in confinement at the Town Hall Gaol, on the 26th July, 1875.

James H. Mapp states, that I am the gaoler at the Town Hall Gaol. I remember the death of a man called Henry Hardle; he died on 26th July, 1875, while in confine- ment at this prison. He became an inmate of the prison in August 1874, having been convicted at the August Sessions. He went into hospital on 20th August, 1874, and was under treatment for a bruise on his instep, caused by the tread-wheel, until 3rd December. For the last thirteen days of this time he was well enough to do light work during the day, returning to the hospital each night, and remaining under the doctor's supervision until he was finally dismissed on 3rd December. On that day he was put to hard labour, and continued to perform his daily work until 13th January, 1875. On that day he complained of pain in his stomach, and on the doctor seeing him the next morning, he was dismissed by him and sent back to work. He complained of an ulcerated toe on 8th February, 1875, and was sent into hospital, and treated (as on a former occasion) as an outside patient till the 5th July, 1875, on which day he was dismissed from the doctor's list. During these last five months his only complaint was the sore toe. He On being called out to continued after the 5th July till the 21st July to break stone. work on the morning of 22nd July he complained of sickness, and on being seen by the doctor soon after, told him, in my presence, that he had Demerara fever in the head. The doctor then recorded his name in the journal as having "fever in the head," but directed no medicine, nor did he examine him, or give me any instructions about him of any kind. I asked the doctor no questions, but ordered the prisoner into hospital, where he remained till bis death, the usual prison fare being supplied to him. He did not appear fo get worse, though I saw him daily; he did not complain of being worse; he ate the prison fare up to the morning of 20th July. I did not know that he had refused his evening's food until after his death, on his ration being found in his cell. Hurdle, while ill, lay on a hammock and blanket spread on the floor. bedsteads for the hospital use available for seven cases of illness, but Hurdle was not given one. I did not give him oue, as I received no instructions to that effect, nor The doctor attends did I in my own judgment consider him so ill as to require one. twice a week, unless called specially or in attendance on an urgent case. known the doctor attend as often as three times in one-day. Being called on to do so, I now produce the doctor's Journal and Prescription Book. On the 22nd July there appears no entry of any instructions as to medicine or other treatment. have no authority to order any change in the diet of a prisoner, though he be in hospital,. but the doctor's power to do so is unlimited, as shown by Rule 52, relating to the

There are

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Common Gaol. I returned Hurdle to the hospital on 22nd July, because there was no special direction by the doctor that he was "dismissed."

(Signed) J. H. MAPP.

James Patterson states: I am a prisoner at the Common Gaol. I was in the hospital when Hurdle died. I entered the week before he was admitted. Hurdle was admitted on a Thursday. I went in on a Thursday evening, and he came on the following Thurs- day morning, 22nd July. On the evening of that day I was put into the same room with him, and I heard him complain of a pain in his stomach. I never heard him make any complaint to the gaoler until about 9 o'clock on the night previous to the morning of く

his death. He ate his prison fare up to Sunday, 25th July. On that morning he refused some of his ration, and in the evening he ate none at all. Neither the keeper nor the turnkeys knew that he had left his food, as he did not complain. He did not ask to be allowed to see the doctor, as he knew he would be there on the following day (Monday), saying that he would then ask him to change his ration. At 8 o'clock on Sunday night, the 25th, Hurdle complained of a pain in his stomach, and I called out to Butler, one of the turnkeys. He came into the room with a light, and stood over Hurdle, and asked him what was the matter. Hurdle said he had a pain in his stomach and head, that he knew he had to die, and should not like to die in prison. Butler told him to cheer up, morning would soon come, and he would see the doctor. Hurdle asked me to assist him to the tub, which I did in Butler's presence, and he relieved his bowels, and then returned to his bed. He then asked Butler to give him some tes in the morning, which Butler said he would do, and locked the door and went away. About half-past 9, Mr. Mapp and Butler came to the window outside the room, and Mapp asked Hurdle what was the matter. Hurdle replied he felt faint. Mapp said he would send him some tea in the morning, and then both went away. Butler returned to the window at half-past 12 and asked if all was right. Hurdle was asleep, and I said "all right." Butler went away. Between 2 and 3 o'clock I heard Hurdle groan, and I called to him, but got no answer. I called again; and, on getting no answer, I went up to his bed, and found him breathing shortly. I then called for the turnkey, and Butler and Marshall came with a light into the room and, on going to Hurdle, found him dead. When Hurdle first came into the hospital, he had no cough. I heard him cough for the first time on the Saturday.

JAMES PATTERSON.

(Signed)

Samuel Greaves states that I am a prisoner at the Town Hall Gaol. I knew Hurdle and I remember his death. I was in hospital with him, and he came there after me. I was in the same room with him. I heard him complain on the day he first came into hospital of a pain in his stomach and head. The gaoler was not present. He came in on a Thursday morning. He seemed to eat his food very well fintil the Sunday morning, when he did not eat at all, and in the evening he ate none of his ration. About 9 o'clock he complained of feeling worse, and Butler was called, and he came and asked Hurdle what was the matter, and he said he felt faint. Butler looked at him, and told him he hoped he was not going to "make a die of it." Hurdle said "Oh, no, I trust I'll live, till morning!" Mapp came round soon after and called to him through the window, and Hurdle said he still felt faint, and Mapp said he would give him tea in the morning. I fell asleep, and when I awoke I was told Hurdle was dead. I noticed he had a slight dry cough when he came into hospital.

(Signed) SAMUEL GREAVES, his mark.

C. M. Butler states that I am a turnkey at the Town Hall Gaol. I remember the death of Hurdle. He went into hospital on the morning of 22nd July. I took his food to him in the hospital on the morning of Sunday, 25th July, and also on the same At a quarter evening, at which time I asked him how he felt, and he said "not worse,'

to 9 o'clock on the night of Sunday, 25th July, I heard a call, and went to the hospital, and was told that Hurdle felt faint; I got my lamp and went into Hurdle's room, and asked him what he meant by feeling faint, and if he felt worse; he replied, "Oh, no, no worse, more than the usual feeling in my stomach!" I told him I suppose he would I then asked him what he cheer up, and he said, “I am not going to make a die of it." wanted me to do for him; he replied, to get him some tea in the morning; I said I would; he then got up and went to his pan in my presence, assisted by one of the prisoners, and returned to his bed. I then left, and reported the matter to Mr. Mapp, and be and I returned to the window outside at 9 o'clock. Mapp inquired of Hurdle how he felt, and Hurdle complained of a pressing in his stomach, but said he was not worse.

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