Friday 1 July 2016

Early Asylum Death - Coroner's Warrants

The West Yorkshire Archive Service, Wakefield holds a very interesting book which tells us more about early asylum life, or in this case, death. The Coroner’s Warrant Book (C85/1117) is a small pre-printed book used to record the conclusion reached in a Coroner’s inquest as to the cause of death of Asylum patients and, possibly, Asylum staff. That inquest was held in front of a jury and as today was required in the event of the sudden death of an otherwise apparently healthy individual or where there was any suspicion of foul play. From reading the causes of death, inquests at the Asylum were commonly held for deaths by suicide, epileptic fits, apoplexy, syncope and accident. The entry made in the book also served as the warrant for the release of the body of the deceased for burial. 
The Coroner’s Warrant Book will be of interest to researchers as it can add to our knowledge of the circumstances surrounding a death. For example, the warrant for Christiana HOWSON of Ecclesall Bierlow tells us that her death was “suddenly whilst walking in one of the wards, from a disease of the heart and not from any hurt injury or violence from any person or persons to the knowledge of the said Jurors”. 
Two hundred and forty five entries exist in date sequence between 1834 and 1879.  The first entry is for 76 year old widow Ann BUTLER from Wakefield.  Admitted to the Asylum on 12th August 1834 she had died only a few weeks later on 2nd September 1834. Coroner Thomas Lee recorded:

Whereas I, with my Inquest, have taken a View of the Body of Ann Butler late of the Township of Wakefield now lying dead at the Pauper Lunatic Asylum, in the above Riding, and find that she has come to her death there by the visitation of God.
These are therefore, by virtue of my office, to authorise and empower you to bury the Body of the said Ann Butler.
For which this is your Warrant.

Dated this 3rd day of September 1834

“Death by the visitation of God” is the early phrase used for “natural causes”. Later the records tend to add further detail, as in the case of Sarah HILLAM whose death in 1835 is recorded as “by the visitation of God to wit of consumption”. Sarah provides us with a mystery as she does not appear anywhere else in the patients’ records suggesting that she must either have been admitted with no paperwork or that she was possibly a member of the Asylum staff. The cause of her death, consumption, does not suggest a sudden death, yet an inquest was held. A puzzle to be solved.
The Coroner’s inquest, in taking evidence surrounding the circumstances of a death, also sought to establish if any blame for the death should be attributed to one or more individuals. The inquest into the accidental death of George GILL in 1835 tells us that “he has come to his death there by being accidentally suffocated in the drying house and that no blame attaches to the Keepers or any other persons”. The death of Thomas WILD in 1857 was caused by “being put into hot water by Timothy Waite an Idiot and scalded”. 
Sadly, despite the best efforts of the staff, some inmates were able to take their own lives. The warrant for James KAYE from Quick tells us that he came to his death “by hanging himself”. Human error did however contribute to Matthew BROWN being able to hang himself “with a sinew bandage in the Closet at the end of the Refractory in George Palfreyman’s ward. That the deceased got into the closet by the Keeper inadvertently leaving open the doors in his hurry to attend upon Mr Marshall the Surgeon.”
The suicide of Susy LUMB from Bradford in 1854, by hanging herself on a bar of a window with a neckerchief whilst labouring under melancholia, carries the additional note “The Jury requests that Mary Hebden should be reprimanded for neglecting to obey orders”. Mary Hebden was a nurse who in 1856 would also be mentioned in the case notes of Ellen KENDALL. On that occasion she had not followed the physicians orders regarding the correct positioning of leeches being used to treat Ellen. (See Proper People page 236.)
A tragic accident occurred in 1859 as a group of patients were returning from working in the fields. Two patients, Dominic KAVANAGH from Sheffield and William RAMSBOTTOM of Wakefield died. John D Cleaton, Resident Medical Officer and Director of the Asylum, described the accident in his Annual Report.
Two deaths were unfortunately due to an accident – the falling in of a portion of the tunnel, underneath the women’s wing, and which is used as a thoroughfare communicating between the farm-yard and the land in front of the asylum.
Owing to the excavations for the new domestic offices, one wall of the tunnel was deprived of adequate support, although stoutly propped, and believed by the contractor and clerk of the works to be perfectly secure. A heavy fall of rain during the preceeding night is believed, by disturbing the props, to have caused the accident. A number of patients were wheeling manure through the tunnel at the time, and the two last of the party were buried and instantaneously killed, by the falling through of the arch, and superincumbent earth.
Several of the Visiting Magistrates , who had come to attend a Committee Meeting, were upon the spot within a few minutes of the accident, and assisted in the investigation of all the circumstances, but no culpable neglect could be attributed to those who had the management of the excavations.
The Coroner also held an inquest the same evening when a verdict of “accidental death” was returned.
The Coroner’s inquest was also in a position to bring matters to the attention of the authorities. The death of George PALMER in Mar 1864 “by the visitation of God in a natural way from phthisis, pneumonia and pleurisy” is accompanied by a note stating that “A representation to be made to the Lunacy Commissioners of the defective state of the Law in allowing patients to be removed to an Asylum in an improper state of bodily health”. (See Proper People page 358.)
Coroner's Warrant for George PALMER. Courtesy West Yorkshire Archive Service.
In September 1868, John MITCHELL committed suicide “by cutting his throat with a Butcher’s Knife when labouring under Hypochondriasis” and the following year the suicide of James BREARLEY “by stabbing himself through the heart with a shoemaker’s knife while labouring under Mania” illustrate the dangers inherent in having mentally ill persons working with sharp tools which could so easily become weapons. 
There is a strange sequence of deaths recorded in 1871. In January, Thomas FIRTH of Dewsbury died from “suffocation from having while in an Epileptic Fit got on his face in bed”. The very same circumstances were blamed for the deaths of Horatio Oulton EDWARDS, James Vickers STACEY and John HASTIE later the same year. It is puzzling that no comments are made by the Coroner that the four deaths were caused by the same circumstances and today we would certainly expect to see an enquiry. Further deaths of the same nature were being brought before the Coroner as late as November 1878. Earlier in the century, epileptic patients were strapped to their beds at night to prevent just such danger but that practice was probably discontinued with the trend towards non-restraint.
In the 245 warrants, there is only one where the conclusion reached was that a criminal act had resulted in the death of a patient. The death of William BURRAN of North Bierley in November 1865 was caused by “loss of blood and shock to the system caused by injuries feloniously wilfully and of malice aforethought inflicted by Jonathan Waite”. The killer would spend 39 years in Broadmoor Criminal Lunatic Asylum. (See Proper People page 331 and 374.)

Coroner's warrant for William BURRAN. Courtesy West Yorkshire Archive Service.

I you get the chance to visit WYAS in Wakefield when it reopens its doors later this year, it will only take you an hour to browse through the Coroner's Warrant Book. Enjoy!