THE ASHBURN HAIL INQUIRY.

Otago Witness, Issue 2202, 14 May 1896, Page 30

THE ASHBURN HAIL INQUIRY.

REPORT OF THE ROYAL COMMISSION;.

The following is the report of his Honor [District Judge Ward, the Rx>yal ComtnisMoner who inquired inbo the management of- Asbburn Hnll private asylum, together with the anemo. on .the repoifc by D"r MncGregor, Inspector of Asylums. , The first &\x charges laia before me on opening.the -commission refer solely tcthe trea'm*Mit of the unfortunate lunatic Mncslistsr, the remainder in effect; t3 the general management of tbe Ashburn H ill Asylum With respect to th« former charges tbe following fact* have, in my opinion, feeen proved :—

On tbe nigbt' of the arrival of -MaealUter at the asylum (17th December) he was improperly locked Tip aloEe in a small 'bedroom where he bad the n&eane of injuriug himself, Although his suicidal m*nia was kilown to -the keepera. Mr Hume certainly led Macalister's relations to understand Ihat he would be pkced.in the charge oi «n experiemed attendant, .Mr Sesrle, who had bfi«n four years.at tbe asylum, and for whose .attendance £2 2s per week would be charged. This .attendant had previously given not oe of hi« intention to leave, and did leave onthelltb January. Macalister was then placed in the charge of a tstally inexperienced attendant, Mr Q-illespie, who olept in the snrne room with him Gillenpie carried a pocket kuife, and knew that M«c«ljster was aware of it. Notwithstanding tbi», GtUespie on each morning wen*, from the bedroom to the lavatory, leaving Macalister alone, and also leaving the knife in one of the pockets of his clothes, within reach of the patient. With this knife M^cali&ter committed suicide ou the 14fch February. Thsre can be no question of the gross 'carcLssnegs of Gillespie, and also of tins chef attendant (CampHell), -who should have Be«n that he (Gilleepie) did his duty properly. In justice to Gille pie, however, it must be said 'that he appears to have been usually most kind and attentive to the patieat.

No chtvrge of nnskilfdl treatment can be sustained Hgainet Drs Brown and John Macdonald, who 'attended Mac&lister at hi* '3ss.th. All that ak'tQ 'Could do was doae, but tie ewe was bops■leee from the flrsfc.

The only ' ' nnkind 'treatment 75 proved "is that on one occasion Macalister was brought xrat with other patients, both male and female, to be photographed. The photographer happened to be acquainted with him, and refused to include him in the sketch. Ib is hardly ncce»s*ry to poinb out tbe grave impropriety of allowing photographs to be tnken of who have been placed in this asylum xt considerable nx-.-pense in order that their terrible malady may bs treated in strict privacy.

With respect to the general status of the asylum, several witnesses were called on behalf of ftle»srs Hunjo and Alexander. Dts Truby King, Burns, and Fooks gave strong evidence in its favour, both ac to the management and ac to the fitness of the building for its present purpose. Two gentlemen who had relatives confined there testified as to the kindnexs with which these patients were treated, and their contentment with their position. Ths only grounds of complaint to be inferred from the evidence of the medical .witnesses appeared to be tbe want of night attendants and < f a telephone to Dunedin. It seems that in tbe aboflnce of a special arrangement every male patient in Ashburn Hall is locked up &t night in his separate bedroom and left there alone until the morning, unless he makes such & disturbance as to waken tha warder. This varies materially from the practice in the asylums under Government control.

As to the telephone, it may be questioned .'Whether any house should be licensed 'as a private nsylum if it be, like Asbburn Hall, three miles /and a-quarter from a town unless an approved medical practitioner is to reside io it. But if such a house be bo Uoeugod, then most assuredly the means of summoning a surgeon by telephone should be provided.

With these exceptions the evidence all went to show th*t tbe asylutn w»s well conducted and the patients well treated ; nor was any ca«e of neglect proved except that of MacalisUr. It appears also that the congestion of the Government asylums has been relieved by the existence of Auhburn HaU.

It is «with regret that I have now to bring to the notice of the Government the curious disregard of the " Lunatioa Act of 1832 " dihpl»yed id the management of this asylum. By section 73 of that aob the notice to be given to the Colonial Secretary by an applicant for a license to keep a house for the reception of lunatics must contain not only a full description of the applicants, but uloo that of a medical practitioner who is to be the medical officer of euqh house. In the first application of Messrs Alexander and Hume, dated September 19, 1882, the former is named as the intended medical officer. It was probably believed by the then Colonial Secretary (hat both of the applicants would reside at Athburn Hall, as required by section 80 of 'the set above cited. It may be oantended that this act contemplates the appointment cf a visiting medical 'offic-jr, who sball not 'be .one of the licengfes, one obviuus reason being that .the theories of an independent medical officer as. to ithe requisites for the accommodation of the patients may vary mnterially from those entertained 'by ,the party who have to pay for them. This contention is doubtless arguable. But of this at least there can bi» no question, that by the -said section 80.no license is of »ny validity unless the keepars or keeper of the "bouse licensed reside therein, and the house be visited as directed in the act iby" a medical practitioner— that is, in the present case, three times a week. The keepers of the house are the.persons licensed to keep it, and unless sj-eaiivlly authorised by statute, as in section 77, which refers eol«ly to houses containing over 100 Junatics, they ca.unofc delegate theix powers to, or devolve their responsibilities on, another person. It was contended by counsel that inasmuch 88 the license was granted to EQward William Aiexander, of Dunediu, as one ot the fcwo licensees, it conferred on him a right to *e»ide there instead -of at Ashburn Ha'U, Seeing

that the license wai granted iv this form year after year Dr Alexander can hardly be blamed for deeming that the Government practically authorised bis non-re»idence, but ' no liceune con waive an express provision of the act, and as Dr Alexander has -nev«r resided at Ashburn Hall, from this faeb alene it follows that the license granted jointly to himself and M*- Hume has had no validity whatever, ev,en assuming that Dr Alexander could Legally act merely as medical visiting of&oor. The theories he entertained of his dutieo were psculiar. Mr Hume kept no b-oks, saying ths.t he; ••left all that to his partner"; .and the books certimly were not properly kept, as required by the act. Dmiiig a great part o£ the' time since the firs>t licensing of Ashburn Hall-Dr Alexander has been absent from Danedin, -and even from the colony, visiting tbeNoith Island, Australia, and England. On his trip to Great Britain he was absent for 10 mot tbs, and during his absence arene-wal of the license for Ashburn ' Hall wms obtained by Mr Hutno lor himself aud; Dr Alexander, without meutioniog ou the appli- , cation that his co-licensee was absent from the ' colony. Dr Alexander stated that during,the«e . various absences -he arranged with Dr Macdonald to visit Ashburn Hall twice a wetk, and ofteuer ; if required. It is only necessary to refer to sections 78 and 80 of the " Lunatios Act 1882," to asourtuu that the neglect to vuit fche asylum '• three times a week would have invalidated the ' license had it not been already void during Dr . Alexander's non-tre«idence. It appears from Mr Hume's evidence that on • a recent occasion he received and detained for ' three weeks one male lunatic •beyond the. number that the license empowered the lioensaes to keep. He also stfctad that th» Inspector • of Asylums visits Aehburn Hall only once iv < B'X months, in*ti*d of at least once in three mofth", as required by section 131 of the "LutiAtics Aot 1882." I'he inspector was not called as a wituos-*, and doubtless he can give; some explanation of Mr Hume's utatemeut. Ou tbe question whether any private »sylums should be ietained I am not called upon to offer an opinion. The profits of the lioansees of A-hbuun 11*11 appear to be oonniderable, and ifi is difficult to sac why an establishment of this class should not exist under fio«nrM :it control for the benefit of any mentally <ii«'«B.>d persons whose r« lation* desire greater privacy and more comfort for them than the present ; 'public ssylums afford, and who are able and •willing to* pay accordingly. But if the law respecting private asylums remains unrepealed its provisiouß should at lea.«t be stringently enforced. I have appended hereto a memo «,ndum respecting subsection 8 of section 2 of "The Lunatics Act 1882 Amendment Act 1891." Certified uuder my hand and seal this 22nd of April 189 S. (SigLed) O. D. R Ward, Commissioner (l s ). Memoranilum on section 77 of " The Lumties Act 1882" and subsection 8 of Btctioii 2 of "Tbe Lunatics Act 1882 Amen<lm<'ut Act 1891 " — As Ashburn Hull is the o.»ly piivafce lasylum in the colony, I desire bri« flj ro refer . to rb amendment to section 77 of " The Lunatics Act 1882 "" which has been apparently inserted in " The LunaUcs Act Amendment Act 1891 " with a. view to provide for & Ijime when this asylum ai»y coatain over 100 patients. -By t-ection 77 above-meuticiied, it is en&ctcd fchtt everj licensed house containing above 100 lunatics >6hall have at all times a medical practitioner resident therein who shall not be a licensee or proprietor, but who shall be the keeper, and consequently no provision is mo/dc in the act for any viaitiag of such house by a medical practitioner. By subsection 8 above-mentioned it is enacted that the medical officer of such licensed house need not lvside thf-re unless reqnired to do so by the iuspeator. Tbe wsalfc i» that in the absence of any such requirement the medical Attendance on any licensed bouse containing over 100 lun»tics de-pen-'ls entirely oa the pleasure or leisure of the' non-resident medical keeper, and this although it has been deemed necessary to prescribe by statute the number of visits to be p*id by a visiting medioil officer to asylnma containing a smaller number of lunatici. The peculiarity of the eaid sub*f ction 8 is further shown by Bections 131 and 135 of the " Lunatics Act 1882,". which enacts (1) that the inspector is to visit every licensed house at least once io every three months without previous notice ; and (2) th»t the .keeper of such house shall show the inspector over it on bis arrival, «nd shall be guilty of a mißdenaeanour if he wilfully neglects to do go. These insidious subsections should be Bearchiugly Bcrutinissd. It is possible that the real intent of this one escaped the notice ■ of the Ministry and Legislature. (Signed) .. C. D. R. Wabd, Commissioner. Da MacGkegoh's Memo, on the Report, Wellington, lOSh May 189 S. Sir, — I -desire -to offer some explanation on that part of Judge Ward's report on Ashburn Hall House in which he states that "he has with regret to bring under the notice of the Government," what he terms " the serious disregard of * The Lunatios Acb 1882 ' displayed by the management of Asbburn Hall, in so far as fcheee observations contain a rtfiectiou on this department. First -oi all I would point out that the license to Dr Alexander and.'Mr Hume was originally ifißU"d long before I had anything to do with the department;, and that the then Government and all their responsible officers evidently acted in the beliof that section 77, on which the commissioner's criticism is based, had nothing to do with any licensed Jbouse which did not contain more than 100 patients. ,-Thftir vie* waa that section 78 wa*the one applicable to a house containing less than 50, and the only provision is that such 9, house shall be visited three times a week by a medical practitioner. Section 80 pro■vides that "no license shall be of any -validity unless the keeper of .the Jaouie licensed shall reside therein, drthe houss be visit«d by a medical prac' itioner as and at the times hereinbefore mentioned and provided." I am aware that there is a general rnle that in an act of Parliament a single word may be read, if necessary, in the plural. As a layman, however, 1 "have always .read the act as my predeopssors &\eo did, and as it has always been understood by the department to mean that the words "the keeper of the house" are met by the residence of one of the proprietors, .if there be more than one, I should, of courte, hesitato to press my opinion on such a subject agaiust an able lawyer like the commissioner, but I veiature to submit that section 134 shows that only one of the partners need be resident, while section 78 shows that the nudical officer is meant to be a visiting one. The commisf ioner proceeds to state : "Of this ' at least there c»n b3 no question : that by the said "action (section 80) no license is of any validity unle*s the keepera or keeper of the house reside therein, and the house be visited, as directed by the act, by a medios&l — that ia, in the present case, — thre« times a week." Ib will be noticed that iuthis paragraph the words " keeper " or "keepers" are used, and that moreover he us3B the word and where the acb uses or. Here, again, the section has always been understood by mypelf and my predecessors to mean what to a layman it BppeMn toTßean— thatis: '•' That this license is

invalid only* if the keeper did not reside or * medical practitioner did not visit as prescribed." That is -to say fchat *he "or" is disjunctive, • and not conjunctive. No one, so far as I know, ~ has construed the act as the commissioner bus done. With all deference I .still think that the meaning of the act is what I always took it to be. The commisaioner further says : •* Even assuming that Dt Alexander could legally acfc . .merely as medical visiting officer, the .theories - he entertained of hie duties were peculiar. Mr Hume kept no books, saying tie ltfball .that to his partner, and the b.ioks certainly were not properly kept, as required by (the act," A ' •reference to the evidence ■will show -that Mr Hume's words jrdferred only to the books required" to be kept by the medical officer. These booka (referring especially to tho medical visitation book) were issued when the act was introduced iv 1882, -and were drawn -up in strict accordance with'form 12, as Bpecwlly prescribed in section 99, and have ever sincj? been kept accordit'g to that form. Unfortunately, the prescribed form is not bo full as the worda of the act, and my predesessois . and myself have goue by the form. Attuning that the views as to the meaning of this ambiguous prescription hold by the department Me erroneous, and the interpretation of the commissioner correct, I ventune to submit thst th« honeßt, if mis^akVn, construe- ' tion of an obscure section of an exceedingly difficult, a>;t of Parliamsnt cum.oi in fairness be ' chaiMO'ierised as a curious dif<r< g*rd of the .act. ' The commissioner further says : "Mr flume, also st&terl that the in«prctor of asylums viaits , Ashburn Hall ouce only in six months initead of once In three month? at least as required by section 131." To this I have Bimp'y to reply that by the int -rpretition olausy " inspect jr" includes "deputy iu-psetor." It would "be impossible for me, as it was for my predecessors, to leave "Wellington during session, and usually for a month bafore it begins ; therefore to vi»it each a«ylum and licttnsod house once in three months is bf,yand ibe power of the inspector. In the case of Ashburn Hall visit) have been made at least four times- a yeer. 0 * ing to the necessarily unoe;t*ia dates of my visit-, the vi*tt9 of the deputy -inepector (Mr Chapman) havo been on same occasion* mid^-at intervals o[ more than tVireo month" from my own. This alight irregularity is largely owing to my ooi.fidence in the exceptional oare an£ good management of A»hburn Hall, aud has been guarded «g*iu»t for the past year by the appointment of Mrs Neill as deputy -inspe'tjr, ao th<<t tbere is no fear of its occurring io the 1 fut ira. The most serious charge contained in the report is that contained in fcbe memorandum attached to it. There the comroisMonsr gives it as his opinion that sub-section 8 of the " Luna,fcio3 Act Amendment Act 1891," has been apparently inserted in (he interests of | Me s sts' Hume and Alexfvndnr, with a view to ' provide for a fciooe whfn this aftylam (Ashburn Hall) may contain over 100 patients- a time which noither they hoc I shall ever see. The commissioner in this memorandum further recommends that '• these invidious subsections should be searcbingly scrutioised. It is possible th*t the real extent of this one («übseclion 8) escaped -the noMca of the Miui*try and Legislature." , Le 1 ; if be observed that the ■ootnaii-sianer begius by suggesting the motive as apparent, and concludes by ass-rtiug it to be the real intent of those responsible for the anvnurnenb. This amounts to an assertion that a section in a Lunatic* Act was insidiously inserted by a per«on or persons other than the Ministry of the day with a view to favour an existing private institution. I submit; that so grava a, dhuvge of frAndulent and underhand dealing again -t peisons not mentioned chould j not bo maJe without clear end coucluaive [ proof either by direct evidence or by necessary inference from the utatule itself. In the present case the commissioner does not pretend that he , hfts any evidence to support the insinuation, or rather the assertion, of misconduct. He states his reason for making it in these words : "As Ashburn Hall is tb.e only private asylum in the colony, J desire briefly ia refer to an fcineudment of section 77 of ♦ The Lunatics Act 1882,' which has been apparently inserted in ' The Lunutics Act Amendment Act; 1891,' with a view to provide for a time when this asylum may contain over 100 patients." Now it is impossible that 1 could have been actuated by any such motive, for it never occurred to me that section 77 had anything to do with A"hburn Hall, either now or in the future, m the G-werument btlievod when they granted the original license as I believe now, and alw&jb have done, that the restrictions regarding " residence " and a medical officer who shall not be interested in the property bad no bearing except on an institution containing over 100 patients, and th*r-=" has nr-ver bceu p.ny sue 1 ! in 4l i ( '>tion. ia New Zo^Und. Agaiu, had I ever entertained such a design, surely I should have altered the condition ,as to "interest," instead of altering that aB to residence. Residence of the medical man clearly was not thought of in section 78, for he w*s to be -a visiting officer. Taera w*s therefore no sense in striking cab residence and leaving in the other condition. Furthermore, surely before bringing such a charge without evidence (not a tittle of evidence was either given or asked for), the commissioner ought to have exhausted all possible explanations. Did it not occur to him that in drifting or altering a section of the Luuatics Act every care ought to be taken to state cleanly the condition under which othc 1 private asylums might be founded in this country ? Having shown that tbe sinister motive atari- i buted to me couM not have occurred to me, I rgo on to show how simply and naturally the invidious section 8 c»n be explained. In an amendment of section 51 of the aob of 1882 it was declared that in gome of the public asylums containing over 100 patients (meaning N«Von and Hnkitika) " a superintendent of an asylum (public) shall not necessarily be a jnedical practitioner "~i c., that there need only be a visitiug medical officer, as ha? always baen the case m these two institutions. The insidious alteration in section 77 was simply meant 'to harmonise, the provisions with regard to private I asylums with tfhe declaration regarding Nelson and Hokitika Aaylains, and it has and can have no other effect within any -time. In couclusion, I wish to paint -out that at -the inquiry I was present and tendered myself as a witness to the counsel oa b^h aides, and finally to the commissioner, and was not .called. Surely, if I was to be charged with such grave misconduct I should at least have been asked for explanations, instead of being left .with the ironical suggestion that doubtless " the inspector can give some erplanation." Now, bad the cornmi'iHirmrr taken this coarse I venture to say that his reflections ou tbe department -would either not have been made or would have 'been made in a very much modified form. Of oourse J invite the most searching scrntiny into 'this whole matter. I have the honour to be, sit, Yoar obedient servant D. MacGreqob, Inspector, It .is .understood ih*t Dr E. W. Alexander will take oharge of the institution as soon as MTisßgeDeente to that end can be completed.