DEATH OF JOHN WILSON IN INVERCARGILL GAOL (CORRESPONDENCE RELATING TO).

Appendix to the Journals of the House of Representatives, 1880 Session I, H-14

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1880. NEW ZEALAND.

DEATH OF JOHN WILSON IN INVERCARGILL GAOL (CORRESPONDENCE RELATING TO).

Return to an Order of the House of Representatives, Wednesday, 9tk June, 1880. "That there be laid before tlie House all correspondence relating to the treatment and death, and the inquest held on the body, of John Wilson, who was found dead in his cell within Her Majesty's gaol at Inyeroargill."— {Mr. MoCaugTian.)

No. 1. P. K. McCatjghan, Esq., M.H.R., to the Hon. Mr. Rolleston. (Telegram.) Dunedin, 16th April, 1880. John Wilson, prisoner, gaol, Invercargill, found dead in cell sth instant. Circumstances point great neglect part some one. Inquest held, including six prisoners, contrary Statute 1873. Coroner refused evidence to carefully examine treatment. Great public indignation. Bain and self strongly urge fresh inquest; free men according to law. Please instruct. The Hon. the Minister of Justice, Wellington. McCaughan.

No. 2. The Hon. Major Atkinson to P. K. McOaughan, Esq. M.H.R. (Telegram.) Government Buildings, 16th April, 1880. lie prisoner Wilson's death, making inquiries. P. K. McCaughan, Esq., M.H.R., Invercargill. H. A. Atkinson.

No. 3. The Fndeb-Seceetaet, Department of Justice, to the Resident Magistrate, Invercargill, (Telegram.) Government Buildings, 16th April, 1880. Did prisoners sit as jurors in inquest on prisoner John Wilson, deceased? H. McCulloch, Esq., R.M., Invercargill. R. G. Fountain.

7 No. 4. The Resident Magistrate, Invercargill, to the Hon. the Minister of Justice, Wellington. (Telegram.) Invercargill, 16th April, 1880. Yes ; I was misled by Justice of the Peace, third edition, p. 337, vol. i. Mistake not discovered till inquest over. Inquest proceeding, and full explanation posted to-night. The Hon. the Minister of Justice, Wellington. H. McCulloch, R.M.

No. 5. P. K. McCAuaHAN, Esq., M.H.R., to the Hon. Major Atkinson. (Telegram.) Invercargill, 17th April, 1880. The prisoner was most sadly neglected, if not cruelly treated. Received no medicine, put on half rations, and punished as a malingerer until he was found dead in his cell. The post mortem was ordered to be made by a personal friend of gaol doctor, and there is strong difference of opinion amongst the doctors on the result. Again, Coroner refused to go fully into prisoner's treatment, and had serving on jury six prisoners, whose verdict would be influenced through fear or spleen. Great dissatisfaction and comments. Please direct a fresh inquest, to allay public indignation and suspicion, Hon. Major Atkinson, Wellington. McCaughan,

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No. 6. The Hon. Mr. Roixeston to P. K. McCattghan, Esq., M.H.R. (Telegram.) Government Buildings, 20th April, 1880. Be inquest on prisoner. The Resident Magistrate was telegraphed to immediately on receipt of your telegram of the 16th instant. He answered that he had just posted inquest proceedings and report on case. As soon as these are received, Government will at once take matter in hand. Thank you for your telegram. P. K. McCaughan, Esq., M.H.R., Invercargill. W. Rolleston.

No. 7. The Resident Magisteate, Invercargill, to the Hon. the Minister of Justice. Sib, — Eesident Magistrate's Office, Invercargill, 16th April, 1880. I have the honor to forward by this mail a copy of the Southland Times of the 15th April instant, containing a letter signed " P. K. McCaughan," commenting on an inquest held by me at the gaol, Invercargill, on John Wilson, lately a prisoner in the gaol, and also a copy of the Southland News of the same date, in which is an article referring to the inquest mentioned above, and to one on Robert Curtis, a lad of ten years of age, who was killed by the discharge of a gun, then in the hands of Arthur Cocks, another lad of fifteen. The inquest on John Wilson at the gaol is probably invalid, as the jury was composed of six prisoners and six good and lawful men, and as the latter part of " The Prisons Act, 1873," provides that " in no case shall any officer of the prison, or any prisoner confined in prison, be a juror on such inquest. In justice to myself I must explain that when the constable came to me for the precept, and being in some doubt as to how the jury should be constituted, I consulted the " New Zealand Justice of the Peace," new edition, 1879, and at page 337, found, " Where the death takes place in prison it seems doubtful whether the jury ought not to be composed of six prisoners and of six honest and lawful men of the neighbourhood, for although the Statute 4, Geo. IV., c. 64, s. 11, provides that prisoners should no longer be put on such juries, it can hardly be said that the Act was one which is applicable to New Zealand." On reading this, 1 directed the constable to summon six prisoners and six honest men of the neighbourhood, and I am sorry to report that I did not discover the mistake until the inquest was over. Had the provision in the Prisons Act been inserted in a Coroner's Amendment Act, as I think it ought to have been, it could hardly have been passed over either by Mr. Justice Johnston or by any Coroner. I may here state that Mr. McCaughan has, through the police, applied to have the body disinterred and a fresh inquest held, but I have declined, as it seems that the inquisition already taken must first be quashed, and an order obtained from the Supreme Court for the disinterment, which order is not, perhaps, likely to be granted in this case. As far as lam aware, Mr. McCaughan, and, perhaps, Mr. Joyce, the Editor of the News, are the only persons not satisfied. Beyond this unfortunate mistake, which I trust will be held excusable under the circumstances, I have to state that there is no truth whatever in Mr. McCaughan's statement that there was any indecent haste, or haste of any sort shown by me or the jury, and that all the evidence was taken carefully throughout on both days; and the verdict, as will be seen from the depositions, was in accordance with the evidence. In the other case, that of Robert Curtis, in my opinion, there was really no material evidence that could be depended on. Cocks had, as he admitted, told different stories before ; and at the inquest he and the constable were quite at variance in their evidence. Both could not be witnesses of truth, and, most likely, neither. However, I told the jury that if they believed the evidence of Cocks they could bring in "Accidental death;" and, if not, they had better return an open verdict, which I thought the safer course, and leave further proceedings to betaken before the Magistrates. As will be seen by the procedings, they returned a verdict of "Accidental death." The boy Cocks has since been committed in the Magistrate's Court on a ch^ge of manslaughter, and. it remains to be seen if the jury in the Supreme Court will arrive at the same conclusion as the Coroner's jury. I have only to add, in conclusion, that both these inquests were taken most carefully, and that I have at any time ample proof that the statements of Mr. McCaughan and Mr. Joyce, the Editor of the News, are utterly unfounded. I have, &c, Heney McCclloch, The Hon. the Minister of Justice, Wellington. Resident Magistrate.

Enclosure 1 in No. 7. Another View. — Died, at Her Majesty's Gaol, Invercargill, on Monday, the sth April, 1880, John Wilson, Aged 51. [to the editok.] Sic, —-The circumstances of the demise of this unhappy man are of a most painful nature. Deceased was a soldier in the 18th Foot —Royal Irish —and had therefore something to commend him to the generous feelings of his fellow subjects. He had seen active and honorable service in fighting the battles of his country, and, through good conduct and faithful discharge of his duties, had attained tlie rank of sergeant-major, from which rank he retired after sixteen years soldiering. In quest of employment he seems to have travelled south, and \v.as engaged rabbiting on some of the stations, until he accumulated a small amount of earnings, when he came to town, as most station hands do, and forthwith proceeded to spend his cheque. This was easily done ; and, presently, getting into a state of

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n toxication, he fell from that into drunken stupor and semi-imbecility. While in this state, and in an evil moment, he made two small purchases, and gave in payment equally small cheques, signed in the name of John Holmes, which, no doubt, in the eyes of the law was forging —but, let it be remembered, the forgery of a man stupid, and for the time imbecile, through intoxication. The name, moreover, of John Holmes was not intended to represent any resident in the district, on the strength of whose credit he could hope for payment of the cheque : and, if it is laid down as a fundamental principle that a man is not responsible for his acts whilst in a state of intoxication, then the crime of Sergeant "Wilson was not, after all, a very heinous one. Notwithstanding this, and that there were no previous convictions against him, he was tried, and sentenced by Judge Harvey, in effect, to two years' hard labour. Were Dr. Franklin now in the world, reviewing this man's punishment, he would doubtless pronounce it more than commensurate with his crime. But our interest lies in the sequel. In prison Wilson submitted obediently to the regulations and discipline. He worked with the hard-labour gang, complaining occasionally of being unwell, and of suffering palpitations of the heart. On the 6th and 17th March he was sounded, and, we may suppose, carefully examined by the doctor, and pronounced quite fit for work. On the 23rd he resumed work, but the wardsman said deceased was evidently in pain, and not able to do his work. Several times deceased had put his hands to his breast as if unwell. On the 24th the doctor saw him again, and made the following entry : " Prisoner Wilson complains of shortness of breath." This is brevity itself. On the 27th the doctor again saw him, and made this entry: " Prisoner Wilson is perfectly able to work, in spite of his complaints of pains in his chest. My firm belief is that he is malingering." This is clear, unquestionably, but the succeeding entry is somewhat in accord with the previous ones : " April 5. —Found AVilson dead." I cannot but feel that this unhappy man was sadly neglected. It was alleged in evidence that the disease from which he died was one difficult to determine —difficult, I presume, without implicit reliance being placed on the patient's statement; and, so far as appears in this instance, the sick man's statement was utterly disregarded. He was denied, what is necessary in almost every case requiring medical aid, some credence to the patient's description of his own malady. This was not to be given to Prisoner Wilson, and as the stethescope did not indicate disease, he was, as a patient, allowed to die unheeded, unattended, and neglected. What \do not understand is how, after McKillop was satisfied that deceased was in pain and unfit for work, the doctor, if unable to detect disease, should so persistently have disbelieved deceased's statement, and neglected to treat him, at any rate in his rations, as an invalid. Was not the shadow of death slowly and perceptibly creeping over the unhappy prisoner ; and, whilst the patient again and again complained of pain in the region of the heart, did it never occur to Dr. Button that there was such a malady as angina pectoris, which, although difficult to detect, would account for the spasms and pains; and why, whilst satisfied prisoner was in pain, did Warder McKillop order him on half rations ? However worthless the prisoner's life might seem, it is sad to think that a dying man was refused a cup of tea, and that the only comfort extended to him was a drink of hot water! If the statement of the cook be true, what, we would ask, was the governor's idea of the prisoner's state, when, from Grood Friday to the day he died, he did not eat half a pound of solid food ? Was that characteristic of a malingering scoundrel ? A consideration of the whole matter would point to the conclusion that the gaoler rashly satisfied himself that Wilson was malingering ; that this idea was conveyed to the doctor, who, under its influence did not, so nicely as he would otherwise have done, endeavour to discover the presence of disease, but, by a foregone conclusion, became convinced of and certified its absence. Meantime from amongst them the spirit of poor Wilson fled, to find "in Hades better men, and juster judges, and truer judgment than he found on earth." Were it possible to consult his spirit, he would doubtless ask that his memory and his ashes were alike allowed to remain in peace. I regret that so it may not be, for, as the closing scenes of his life were surrounded with blunders, so also was to be the inquest into the cause of his death. More than ordinary care and fidelity are demanded in the inquest on a prisoner dying in gaol. The statute law on gaol and gaoler provides, among other things, " that a surgeon or apothecary shall be appointed, with a salary," who perforce, becomes an officer of the goal. "If the gaoler keeps the prisoner more strictly than he ought of right, whereof the prisoner dieth, this is felony in the gaoler by the Common Law; and this is the cause that if a prisoner die in gaol the coroner ought to sit upon him, and if the death were owing to cruel and oppressive usage on the part of the gaoler, or any officer of his, it would be deemed wilful murder on the part of the person guilty of such duress." —3rd Inst., 91 Fost., 321-322. Burns's Justice says : " Forasmuch as the gaol is intended in most cases for custody, and not for punishment, and confinement itself in such dismal abodes is sufficiently afflictive and disconsolate, human nature will plead for these miserable objects that their condition be rendered as tolerable as the case will admit of." The Coroners' Law by the same author, says : "He ought also to inquire of the death of all persons who die in prison, that it may be known whether they died of violence or any unreasonable hardship, for, if a prisoner by the duress of the gaoler come to an untimely death, it is murder in the gaoler, and the law implies malice in respect of the cruelty."—3rd Inst., 52-91. The colonial statute, 1873, repeals, in the following respect, all former Acts, and says, in Law of Prisons —Inquest on Prisoners: " And in no case shall any officer of the prison or any prisoner confined in the prison be a juror." lam not aware that this Act has been repealed. If it has not, how can Mr McCulloch justify the presence in the jury of six prisoners ? One feature of the inquest was the apparently indecent haste shown by the Coroner, and his seeming aversion to probe thoroughly the course of treatment which, in this instance, it devolves upon the jury to dissociate from the cause of death. The position I hold is this. There has been no duly legal inquest, through the Coroner's blunder. The deceased has been interred, and a fresh inquest must be held, and the body exhumed for the purpose. Few will therefore dispute that the first inquest is in keeping with the treatment and death of the unhappy, and I believe, ill-used, Sergeant-Major Wilson. I am, &c, Invercargill, April 14th, 188 Q. P. K. McCatjghtan.

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Enclosure 2 in No. 7. Be the late Sergeant-Major Wilson. [to the editor] Sib, —I observed with surprise and regret your leading article of 23rd instant, touching the death of Sergeant-Major Wilson. Your article may be divided into four cardinal points, and its effort is to exonerate everybody from blame in connection with this unhappy man's neglect and death. I will deal with the four in the order iv which they come. Tour first assertion is : " Except as revealing an undoubted error in practice, and as serving to call attention to the real state of the law, little benefit, we think, can accrue from this matter occupying the mind of the public." It is sad to find such an expression of opinion in the columns of a leading and respectable journal. Instead of fearlessly assailing the guilty, and insisting that the error and neglect, which in this case amounted to little short of a crime, shall be commensurably atoned for, you endeavour to hush up and smooth over the matter. If such things pass with two or three newspaper articles, and a letter or two of protest, the authorities meanwhile looking on with indifference, what, I ask, must be, the inevitable result ? You next say : "It may not be generally known that a new inquest could not be held until an appeal should be made to the Supreme Court to quash the inquiry already made." I will here point out to you that there was either a legally-constituted inquest in the eyes of the law, or there was no inquest at all, no provision being made for any degree or measure of an inquest; and, insomuch as the existing statute law of this colony distinctly says, " No prisoner shall serve on the jury," and as a jury must consist of a given number of free men, but not a portion or part thereof, it follows, and need hardly be added, that legally there was no jury, no verdict, and no inquest; and the body of deceased prisoner was interred as though the Coroner had never been acquainted with his dissolution. The unfortunate man's remains may be exhumed and an inquest held on the order of the Colonial Secretary, or that of the Coroner, if he chooses to admit his own error. You next proceed to exonerate the Coroner from undue haste. You say: "We pass by as unworthy of attention imputations that have been made on the Coroner's haste in conducting the inquiry, and his seeming unwillingness to probe to the bottom the conduct of all connected with the gaol." It was I who made that charge, and it now behoves me to sustain it. I made the charge after a careful perusal of the entire proceedings. A further perusal strengthens rather than weakens my opinion, and I will now lay before the bar of public opinion part of the evidence and Coroner's remarks, and let the public judge. The case which the Coroner was called upon to inquire into was —to ascertain the cause of death of a prisoner in the Invercargill Gaol, who was found dead in his cell. The investigation demanded at the Coroner's hands more than ordinary care, and required mature consideration of all the available evidence. I speak now of a time as the inquiry proceeded, and at that stage of the inquest before the medical evidence and result of the post-mortem examination wrere adduced, throwing some light on the probable cause of death. All that appeared before the Coroner at the stage of which I speak was, that a prisoner who was certified in the prison records then before him in sound health and fit for work, on the occasion of the doctor's last visit of inspection, as late as the 27th March, was found dead in his cell. It was thus no ordinary death, but rather extraordinary, mysterious, and inexplicable, and therefore it became all the more imperative to trace not only the true cause of death, but as well any surrounding circumstances which may not improbably have accelerated it. For aught, then, before him in evidence to the contrary, the man may have been murdered, or have died from neglect, or over-punishment, or from insufficiency in the quantity or quality of food supplied, or perhaps from having been "kept more strictly than he ought of right." Such untoward events have happened before, and may doubtless happen again. The history of Invercargill records a case where a cowardly policeman carried a drunken man to the police cells, and there, if not halfmurdered, at least most cruelly beat and punished, a defenceless handcuffed prisoner—but I am diverging. Any of the treatments to which I have referred might have exercised cither direct or indirect influences in causing death ; yet, notwithstanding this, the Coroner refused to take evidence bearing on such surroundings. I will now quote the Coroner's words addressed to the constable conducting the inquiry: "It vould appear we are making this more an inquiry into the gaol management than as to the death of the unfortunate man Wilson. This is a Coroner's inquest, the object of which is to ascertain the cause of death. No evidence of this kind can possibly alter the verdict, unless indeed, it is a case of manslaughter or murder." And why might it not, in the absence of evidence to the contrary, be a case of manslaughter or murder? Again, the Coroner said, "The gentlemen of the jury have met here to ascertain the cause of this poor man's death, and I don't think it is right to go into the question of gaol management. All this evidence can be of no use." I viewed this widely different from the Coroner. I held, and still believe, that all the evidence relating to the gaol management, so far as that management bore on or affected the deceased, was of the highest possible importance in determining the cause of this mysterious, sudden, and unaccountable death of a prisoner, certified in good health and fit for work, in his cell. I made the charge of indecent haste and unwillingness to probe to the bottom the conduct of all connected with the gaol; you invite your readers to pass it by, as unworthy of notice. Let the public judge between us. To borrow your words, I would " pass by as unworthy of attention," your apology for the Coroner's ignorance of the law, were it not to remind you that it is an abstract and fundamental principle that all are familiar and acquainted with the laws by which they are governed. Now, if so much is expected from the lowly and unlettered, we can, and will, demand that our Judges, magistrates, and coroners —■ whilst they occupy such positions —shall, at any rate, have a correct knowledge of the laws they are the mouthpieces to expound. Having now alike disposed of your article and your arguments, I pass to the main question, and to the notice of a letter, I believe signed " Citizen," in your columns last Monday. It was my opinion, from the first, that most of the blame lay at the hands of the gaolers, and nothing has since come to

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light to alter that opinion. On perusing again the evidence, I find Warder McKillop stated : " Deceased was a long time in the army, and had some disagreeable ways with him," but the Coroner never took the trouble to inquire what those ways had been. May they not have been due to the man's illness ? Again, when the doctor was called to examine deceased, Warder McKillop informed that gentleman that " deceased had taken his food regularly, and had frequently eaten the meals left by other prisoners." It is a pity, in the interest of veracity and decency, Warder McKillop did not produce, in support of his statement, those most generous prisoners who so readily parted with their prison meals. Mr. Eraser, the chief gaoler, also informed the doctor that deceased was a disappointed applicant for the position of gaol cook, and thus accounted to the doctor for his malingering. Here we find that, for some reasons which will probably remain for ever in the dark, deceased had drawn upon himself the ire of his gaolers, and nothing after this that he said or complained of was materially heeded. It cannot, from the foregoing, be wondered at that Dr. Button was off his guard (if, indeed, not misdirected), and naturally did not give that attention to the prisoner's statements which, under other circumstances, he would undoubtedly have done. I profess the greatest respect, in common with all those who know him, for the professional skill, and kindly, generous nature of Dr. Button. I believe no physician in Otago is more competent to determine or better qualified to treat disease. That he did not discover this particular patient's malady, from its very nature, and under the prejudicial circumstances stated, is not surprising, but it is equally unfortunate that he should so allow himself to be deceived by the misdirecting statements of the gaolers, and, in a measure, endanger his professional name by relying too much on their representations. Again, glancing at the evidence, Warder McKillop satisfied himself and the chief gaoler, that, on the 23rd, deceased was "in pain and unfit for work." Now, although both were thus satisfied, it has not yet been explained why prisoner was put upon half rations. Such is not the gaol treatment awarded a sick prisoner. The evidence of Middleton states: " Several times when he (Wilson) came in from work he was hardly able to speak, and his face was contracted like that of a man in a fit. He used to complain of a pain in the heart, and was sometimes hardly able to move. Witness was positive that deceased went out to work on the 25th lilt., and said that while they were at tea that evening the warder took deceased to the Governor, and he was afterwards locked vp —why, witness did not know, but he regarded it as punishment. Some time after, witness received orders not to give deceased tea with his food in future, and put him on half, or No. 2, rations." Does not this require strict investigation ? " I have," said deceased, " been before the doctor, and they brought a witness to say that I ate the food of two men." This was McKillop's statement to the doctor on the 27th ; but it was proven by another witness for a fortnight before he died (sth April) he did not eat half-a-pound of solid food. Where, we may well ask, was the gaoler during all this time ? Will any one deny that a man of the most simple observation could fail to notice the steady but regular change which gradually creeps over a man fast approaching his demise ? We are told even by the Coroner : " On the day of his death he appears to have had more than usual attendance, as he was seen by four different persons." His coming dissolution, then, was known ; now, if his state were sufficient to awaken so much curiosity, anxiety, and attendance, why, I ask, was the doctor not sent for? Could it possibly be that the gaolers were aware of deceased's state, and wilfully allowed him to die as he pleased ? The gaoler must have known that he was seriously unwell, for his heart of kindness was so far moved that, during the whole daylong, he was permitted the exceptional use of his blankets, but, forsooth, all comfort and medicine were still denied, No. 2 rations rigidly enforced, and, locked in his solitary cell, a veteran soldier of the Empire—a man worthy of a better f a t e — was allowed to die, unheeded, untended, and neglected. There is no class of our fellow subjects more deserving of sympathy and consideration than the retired soldiers of the British army. Unlike the soldiers of ancient and modern Europe, whose path lay, when sent forth on missions of conquest and of war, in genial climates, amongst the fig trees and the vine, our soldiers are inured to a harder and more bitter fate. Enlisted into service, the men by whom the British army is kept fresh and ypung undergo, generally, but a short period of drill in England, from whence they are ordered abroad to serve in portions of that Empire whereon the sun never sets. In the words of Whiteside: "The scorching sun of the East and the pestilence of the West they endure, to spread our commerce, to extend our Empire, and to uphold our glory." These brave men, alike the envy and the admiration of the world, follow the roll of the drum and the colours of their country "wherever danger is to be faced or honor won" in confronting hostile guns and spears. And how does a great, free, enlightened, and wealthy country requite them ? After a period of service, during which a generation comes and frequently passes away, and at a time of life when men employed in civil occupations have earned a small competency and are supported and cheered with home and friends, the poor soldier, now grown old and unfit for work, often with maimed limbs, broken health, or a ruined constitution, is cast adrift on the world to gather a scanty crumb abroad, or, if he returns to the scenes of his boyhood, to find perchance his friends dead, companions scattered, and he himself in his native land a stranger. To such a class Wilson belonged, and, out of the creine de la creme of the ranks of that illustrious regiment in which he served, attained the honorable and somewhat distinguished rank of sergeantmajor. In a moment of drunkenness he committed a misdemeanour; and you, sir, will excuse me, and every man who bears a generous heart and loves justice and humanity will support me, in demanding a fresh investigation to assure ourselves that the veteran soldier, now no more, was not wilfully submitted to cowardly and cruel treatment. With this letter I dismiss the subject, and before taking final leave of the question I should perhaps state that deceased was for a time in my employment, and I found him an honest man and a good servant.

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I crave your indulgence for the space I have occupied, and I here must express my regret if any remarks of mine have unjustly aroused the susceptibilities, or unnecessarily pained the feelings, of any one. I regard what I have done as something which, ought not to have been necessary, and what lam doing as necessitated only by the failure, neglect, or indifference of those whose duty it was to have taken action immediately upon the publication of the report revealing the state of things I have challenged. Tours, &c, Invercargill, April 26th, 1880. P. K. McCattghan.

No. 8. Copt of Inquest Peoceedings. Colont of ~) Informations of witnesses severally taken and acknowledged on behalf of our New Zealand, > Sovereign Lady tbe Queen, touching the death of John Wilson, at the gaol, Inverto wit. J cargill, in the Province of Otago, in the colony above mentioned, on Tuesday, the 6th day of April, 1880, before Henry McCulloch, one of the Coroners for the said colony, on an inquisition then and there taken on view of the body of John Wilson, then and there lying dead, as follows, to wit :— William Eraser, being sworn, saith :I am the gaoler at Invercargill. The deceased was received into the gaol on the 29th February, 1879, on committal for trial. He was tried on the 29th April, and sentenced to two years' penal servitude on each of two charges of false pretences; sentences to be concurrent. He complained very shortly after his admission of feeling unwell. He said he thought he had palpitation of the heart. He said if I would give him a dose of house medicine, it would sot him right. He took a dose, and did not apply for some time again. He applied at intervals several times after that, and I gave him the same. On the sth March last he complained of being unwell. I sent for the medical officer, Dr. Button, who called the next morning, as the deceased said it was not urgent. It was on the sth March the doctor came, so it must have been the evening of the 4th when deceased complained. About the 17th he applied to me again. The doctor in the interval several times saw him. The doctor saw him on the 17th March. The doctor examined his chest three times. I am not sure of the dates. On 17th March the doctor entered in the medical officer's visiting book [produced], " Prisoner Wilson perfectly fit to work." The deceased went out to work off and on up to the 23rd March. I did not wish him to go out that day. I told him not to go oat. The following morning I found he had gone out to work. In the evening when the wardsman brought the men home, the warder complained he was not doing his work, and that he had put his hand to h;s breast several times as if he were ill. I called Wilson into the office. I asked him why he went out after I told him not to go. He said he would sooner be out at work. I told him he had no business to go when I told him not. He did not go out to work after the 24th March. The doctor saw him that evening and made entry in the book [produced] : " Prisoner Wilson complains of shortness of breath." The doctor saw him again on 27th March, and made entry in book [produced] : " Prisoner Wilson is perfectly able to work, in spite of his complaints of pains in the chest. My own opinion is that he is malingering." The doctor next saw him on the sth April, and entered in book [produced] : " Visited gaol about five minutes past 4. Found with Mr. Fraser prisoner Wilson lying dead in his cell. For report of this case see previous entry." On the 3rd April, when I called the roll in the evening, deceased was standing at the door, he saluted and appeared as usual; and the same on Sundav,the4th, in the forenoon, he appeared as usual. Apout half-past 10 on Monday, the sth, I passed through the corridor and looked into his cell. He was lying on his bed. Had a book in his hand, and appeared to be reading. He had not been taken out to work since the 23rd March. In the Description Book his birthday is stated as having occurred in 1829. To the Jury: Doctor Button sounded the chest of deceased in my presence three times. The deceased was not treated as a malingerer—that is, not punished; he was treated as a prisoner not doing hard-labour. I heard no complaint of his not taking his food till the day ho died. I did not think he was ill. When he first came in I thought he was ill, as he complained, and 1 gave him light jobs, such as cleaning arms, &c. Latterly he had nothing to do. By the Police: If the deceased, had been certified by the medical officer as being ill I would not have allowed him out. About a week ago, the warder told me that prisoner had been groaning, but that he had ceased on going to sleep. Deceased occupied a cell by himself. Some time ago he was occupying a cell with several others, among them a prisoner named Allan Toung. James McKellop, on his oath, saith as follows : I am a warder in the gaol at Invercargill. The deceased was a prisoner in the gaol. Since he was sentenced, he has been working under my charge up to the 24th March. On the evening of the 23rd I made a report, verbally, to Mr. Fraser, the gaoler, that he had stood for an hour after dinner, and did not do anything at all during that time. He stood up and rubbed his breast as if he was ill; he made no complaint to me to that effect. I heard him long before that speaking to the prisoners to the effect that he had a weak chest and could not do the work ;he made no direct complaint, but murmured about it. On the 23rd of March it was my opinion that he was not so ill as he pretended to be. I never made him work as I would another man. When he was standing doing nothing on the 23rd I just left him alone, thinking he would turn-to afterwards, and there would be no more about it. He made no complaint; he did not go out after the 23rd. Frank Whiddon, on his oath, saith as follows : I am a prisoner awaiting trial in the Invercargill Gaol. Yesterday, sth March, I brought the deceased, John Wilson, his dinner to his cell, between 1 and 2 p.m. I saw him in his cell; he was lying asleep on his bed, as I thought. I did not speak to him ; he did not speak or move ; I left his dinner there. In about three-quarters of an hour or an hour I returned to his cell; the dinner was there untouched; he was lying in the same position. I took the dinner, shut the door, and came away. I thought he was still asleep. I had been taking his meals to him for more than a week. Since he had done no work he eat his meals sometimes, and sometimes not; he always eat some.

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John Harbourd, on his oath, saith as follows: lam a prisoner awaiting trial in the Invercargill Gaol. I last saw deceased, John Wilson, alive yesterday morning, about 9 o'clock; he was in his cell. We spoke together ; he seemed about the same as usual. Thomas Edward Armstrong, on Ms oath, saith as follows : I am a prisoner in Invercargill Gaol. I have known deceased for two months. Have heard him complain several times. Had a conversation with him on Sunday last, 4th April. He was lying on the floor in the washhouse. I asked him if he was worse. He said, " Tes ; very much." He said they would have to carry him out of the door feet first very soon. I asked if he had not better see the doctor. He said the doctor told him he was " gammoning." I asked him if he would have a drink of tea. He said I would not be allowed to give him any. Allan Charles Toung, on his oath, saith as follows: lam a prisoner in Invercargill Gaol. I have known John Wilson for twelve months. I have heard him complain frequently of being ill. He was on different occasions occupying the same cell as I did. On or about the 22nd March he was out with the gang, and not able to keep up to time with the other men ; ho was behind with his barrows. Warder McKellop was with us. He said he must keep his time with the other men, or stop in the next day. He staid in. When I came in that night, I asked him how he got on. He went out with the gang on the 25th March, the day before Good Friday. As far as I remember, he was at work on the 25th March. He had his hands on his chest on that day, stooping almost to the ground. When he was moved from my cell he was put into the next cell to me. I heard him nearty every night moaning, and one night saying, "My God !My God ! " I heard the night-wardsman visiting him nearly every night. Last Saturday week, the 29th March, deceased told me he was brought before the doctor. On the same night he asked me for some of my medicine. He said he would lay his death at the governor's door, if he died. I have seen him begging tea of the cook, and hot water; he got it. I saw the cook give him tea in a pannikin. They always said he was scheming. He was not getting the nourishment a sick man ought to get. When we were coming home from work the last day we wore out —the evening of the 25th, I believe —in Warder McKellop's charge, I saw him lie up against the wall of the gaol with his hands to his chest, panting. Warder McKellop saw him. By the Jury : I do not think he saw the doctor on the 23rd March. Frederick Middleton, on his oath, saith as follows: lam a prisoner in Invercargill Gaol. I have been in the gaol three years come June. About three weeks ago, 16th March, deceased complained of being very ill, and wished to see the doctor. He told the warder he was not fit to work, and asked to be allowed to stay in; and the warder told him if he stayed in he would have to be locked up in his cell, on which he said he preferred to be out at work. He continued at work for a short time, but was very ill when he was out at work, getting worse during the last three weeks. He went out to work the day before Good Friday; he came in very ill, and said he was nearly dead. In the middle of tea Warder McKellop took him before the gaoler. From there he was taken to his cell and locked up —I should say as punishment. I was cook then, and half an hour afterwards Warder McKellop came to me and told me to put him on half-rations and no tea for the future. When I say half-rations, I mean No. 2 rations—our men not doing hard labour. From 25th March he never eat a half-pound of solid food —his rations were brought back as I gave them to him. I told Wheddon he ought to tell the warder of it, and he said he always did. He asked me to give him a little drop of tea, and I gave it him. This was on Sunday, the night before he died. He laid up for a week some time ago; he was locked up in a cell, and he said he would sooner go to work. The sth April, the day he died, was the only day he was allowed blankets and pillow ; they were taken out at morning and put in at night. It is usual to take away the bed-clothes in the day-time.

Colony of ") Informations of witnesses severally taken and acknowledged on behalf of our New Zealand, > Sovereign Lady the Queen, touching the death of John Wilson at the gaol at to wit. ) Invercargill, in the Provincial District of Otago, in the colony above mentioned, on Monday, the 12th day of April, 1880, before Henry McCulloch, one of the Coroners for the said colony, on an inquisition then and there taken on view of the body of John Wilson, then and there lying dead, as follows, to wit : — William Fraser (recalled), being sworn, saith : I produce rations scale for prisoners as provided by the regulations. If a prisoner is certified to 4>y the surgeon as being a malingerer, it is the usual practice to bring him before a Visiting Justice for pretending illness, under the 62nd regulation. I made no charge. I intended to make a charge when the Visiting Justices should come to investigate charges against other persons already on the book. The bedding of the deceased was not taken away from him at any time. On referring to the books I find ho did go out on the 25th March, contrary to instructions. ]STathan Potter, on his oath, saith as follows :lam a prisoner in the Invercargill Gaol. I have known the deceased for about five months—since I came into the gaol. I was in the habit of messing, sleeping, and working with him. I have heard him complaining of feeling ill several times. He said he had a pain in his chest. I never heard him at any time complain of ill-treatment from any of the officials of the gaol. I did not think the man was very bad. I never heard him complain of any illtreatment in the gaol. He ate his food as well as any of us. He was not a large eater. Horace Gooch Button, on his oath, saith as follows : I am a duly-registered medical practitioner, and medical officer to the gaol. I first saw deceased on 3rd September, 1879, and prescribed for him for a cough. I next saw him on sth March, 1880 ; he then complained of a pain in his chest. I made him take his shirt oif, and examined his chest carefully. I could find no indications of disease in any of the organs of the chest. I prescribed for him a blister on his chest. 1 saw him on the Bth, and he said he was better. I prescribed a tonic mixture. On 13th March I again saw him and repeated his medicine. On 15th I again saw him ;he said he was no better. On 17th I again examined him carefully all over the chest, back and front, and I could find nothing the matter with him, and on that day entered that he was quite fit to work. On 25th March I again saw him, and prescribed for him on

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that occasion. I thought he might be hypochondriacal. On 27th March I again saw him, and again examined his chest, and entered as my firm opinion that he was malingering. I visited the gaol on 29th, but did not see deceased. On the sth April, I, in company with Mr. Fraser, found him in his cell dead, at five minutes past 4 p.m. The deceased was a tall, upright, spare man, with by no means a look of ill-health. My reasons for supposing he was pretending were, that he had not the look of ill-health, and not being able to find anything abnormal the matter with him about the chest, of which he complained. I heard he had applied for and had been refused the place as cook, and I thought that supplied a motive for his wishing to annoy the officer of the gaol; and that, when in the presence of others, ho put his hands to his chest and appeared to be ill, and when they had gone he resumed his position again. He might have been suffering severely in his chest and I might not have been able to detect it by sounding, or by any recognized means. The "house medicine" was black draught. I visit the gaol sometimes once or twice a week, and as often as I think requisite. On the 27th March Warder McKellop told me he could prove that he not only ate his own rations, but those left by other prisoners. Arthur Sedgely Hanan, on his oath, saith as follows : I am a duly-registered medical practitioner residing at Invercargill. I made a post-mortem examination of the body of the deceased John Wilson. I examined all the organs of the body. They were all healthy, except the organs contained in the chest: the right side of the heart was soft and full of venous blood, and the small artery supplying that side of the heart (the right coronary artery) was blocked, causing the softening I have described. The lungs, as a consequence of this weak heart, were congested with blood, and therefore the deceased died of angina pectoris, commonly called breast-pain. In this disease it is quite possible to find no symptoms to indicate disease. That is the opinion quoted by the authorities on angina pectoris —the best medical men who have written on the subject. Rest is one of the best things for it. Hard labour would have produced more spasms. His case was incurable. Muscular exertion was the thing. To keep the patient from ordinary diet would be the best in such a case. Congestion of the lungs would be caused a short time before death in this case. The disease in this particular case would not affect the pulse. The want of nourishment would not have caused the softening of the right side of the heart. No. 2 scale of rations would have been very suitable diet. The body of the deceased was well nourished. The rest of the muscular system was in a tonic state. The want of a doctor between the 27th February and sth March did not accelerate his death.

Colony op ") The above-named depositions of William Eraser, James McKellop, Prank Whiddon, New Zealand, > John Harbourd, Thomas Edward Armstrong, Allan Charles Young, Frederick to wit. ) Middleton, Nathan Potter, Horace Gooch Button, Arthur Sedgely Hanan, written on thirty-one pages of paper, numbered consecutively from one to thirty-one, and by me affixed together, were taken and sworn before me, at Invercargill,in the said colony, on the 6th and 12th days of April, 1880. H. McCulloch, Coroner.

Colony of )An Inquisition indented, taken for our Sovereign Lady the Queen, at Invercargill, New Zealand, > in the said Colony, on the 6th and 12th days of April, in the year of our Lord 1880, to wit. ) before Henry McCulloch, one of the Coroners of our Sovereign Lady the Queen for the said colony, on view of the body of John Wilson, then and there lying dead, upon the oaths of Louis Hume, William Horatio Hall, John Geoghegan, Alexander Dean, John Hunter, Nicholas Johnson, Henry Hawkins, Robert Charles Arnold, Frederick Prcssnell, Charles Wilson, Daniel Rierson, William James, good and lawful men of the neighbourhood, duly chosen, and who being there and then duly sworn and charged to inquire for our Lady the Queen, when, how, and by what means the said John Wilson came to his death, do upon their oaths say that the said John Wilson, on the sth day of April, in the year aforesaid, and for a long time before, did labour and languish under a grievous disease of body— to wit, angina pectoris —and on the sth day of April, in the year aforesaid, the said John Wilson, by the visitation of God, in a natural way, of the disease and distemper aforesaid, and not by any violent means whatsoever to the knowledge of the said jurors, did die. In witness whereof, as well the said coroner as the said jurors aforesaid have hereunto set and subscribed their hands and seals the day and year first above written. H. McCulloch, Coroner. Louis Hume, Foreman. H. Hawkins. W. H. Hall. Robert Charles Arnold. John Geoghegan. Fredk. Pressnell. Alexander Dean. Charles Wilson. John Hunter. Daniel Rierson. Nicholas Johnson. William James.

No. 9. The Hon. Mr. Rolleston to the Resident Magistrate, Inyercargill. Sib,— Department of Justice, "Wellington, 30th April, 1880. I have the honor to acknowledge the receipt of your letter of the 16th instant, covering depositions taken at the inquest on Robert Wilson. I have now to inform you of the view taken by the Government on the principal questions raised by a consideration of the case as placed before it by you. There is no doubt that the proceedings at the inquest were informal, on account of the half of the jury being prisoners; and that, if there appeared* to be sufficient cause, it would be competent to the Crown, or to a private individual, to institute proceedings to quash the inquisition, or to proceed by way of indictment, should that prove necessary.1

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The first point, therefore, which it appeared to the Government to be its duty to determine was whether, upon the evidence given, there was ground for believing that a fresh inquisition would lead to a different conclusion as tr> the cause and manner of prisoner Wilson's death. In order to decide this point, the Government has itself carefully considered the evidence forwarded by you, together with your report upon the case, and it has taken the best medical and legal advice thereupon. On a review of all the circumstances it is of opinion that, though it is very unfortunate that a mistake should have occurred in the constitution of the jury, yet another jury would not be likely to come to a different verdict, and that the interests of justice do not call for the quashing of the inquisition. With regard to the manner of the prisoner's death, the Government is of opinion that, while the evidence would not justify a conclusion that it was accelerated by neglect or ill treatment, yet a consideration of the depositions shows undoubtedly that there was an error in judgment on the part of the medical officer in his diagnosis of the symptoms related to him, and leads to the conclusion that greater care should have been taken both on the part of the gaoler and medical officer to obtain fuller information as to the real condition of a prisoner who complained of pain and inability to move, and was at the same time suspected of malingering. It would further appear that, had all the facts which were disclosed in the evidence at the inquest been previously collated and brought under the attention of the medical officer, they might and probably would have led to the conclusion that the prisoner was suffering from the disease of which he afterwards died. Before finally communicating to the medical officer and gaoler the decision of the Government upon a matter of such grave moment, I think it right to ask you to inform those officers of the conclusion to which the Government, as at present informed, considers the evidence points, and to give them an opportunity of making such statements as they think fit. I have, &c, H. McCulloch, Esq., E.M., Invercargill. W. Eolleston.

No. 10. Memorandum for Dr. Johnston and Dr. Skae. Throu&h an informality in the constitution of the jury, the proceedings of the Coroner's inquest in the case at which the attached evidence was taken have been called in questiou. Before determining as to whether a fresh inquisition should be instituted, the Government is desirous of obtaining your opinion upon the evidence which was taken, as to whether, from a medical point of view, any different verdict would be likely to be arrived at if fresh proceedings were taken. In furnishing your opinion I should be obliged if you will, in addition to any other points which may occur to you after reading the evidence, state — 1. Whether you consider there is any doubt as to the cause of death ? 2. Whether you concur in the statement "That it is possible to find no symptoms to indicate the disease" (anginapectoris) ? 3. Whether you consider that the prisoner's death was accelerated by any neglect, or the absence of precautions which ought properly to have been adopted ? 23rd April, 1880. ¥h. Eolleston.

No. 11. Alexander, Johnston, Esq., M.D., to the Hon. the Minister of Justice. Wellington, 23rd April, 1880. He Coroner's inquest on the body of John Wilson. I do not believe that a different verdict would be returned in the case if fresh proceedings were taken. In my opinion there is no doubt as to the cause of death being angina pectoris, but I cannot concur with the statement that it is quite possible to find no symptoms to indicate the disease. The evidence of the gaol warders, and other witnesses who saw the deceased during several severe paroxysms, clearly gives the usual symptoms of angina pectoris. It does not, however, appear from the evidence that the medical officer was present during any of these attacks, and if the symptoms were not as clearly given by the patient as they were by the witnesses, it probably would not be possible for him to detect the presence of the disease by stethescopic examination ; and, finally, I do not think that John Wilson's death was accelerated by neglect or the absence of precautions which ought to have been adopted. The Hon. the Minister of Justice. Alexander Johnston, M.D.

No. 12. Inspector of Lunatic Asylums and Hospitals, Wellington, to the Ministeb of Justice. BlE,— Wellington, 23th April, 18S0. I have the honor to acknowledge receipt of your memorandum of the 23rd instant, regarding the inquest in the case of a late prisoner in the gaol at Invercargill, named John Wilson, and have to reply as follows : — 1. I do not think it is likely that any different verdict would be arrived at if fresh proceedings were taken. 2. I do not think there is any doubt as to the cause of death having been angina pectoris. 3. I do not concur in the statement that it is possible to find no symptoms to indicate the disease (anginapectoris). I think it right to point out that this question has apparently been asked owing to 2—II. 14.

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a misapprehension of Dr. Hanan's meaning. In making that assertion, it seems evident that he was alluding not to symptoms such as pain or breathlessness, which were certainly present in this case, though suspected by the medical officer to be feigned, but to those physical signs of heart disease for which the medical officer was looking, and which he was unable to detect when he examined the patient's chest, and which it is quite correct to say may be absent in a case of angina pectoris. 4. I do not consider that the prisoner's death was accelerated by any neglect or absence of precautions which ought properly to have been adopted. There is no evidence to justify the conclusion that, as a matter of fact, death was accelerated. It is evident, however, that the prisoner would have had a better chance of escaping pain and prolonging for a short time his life, had the disease under which he was labouring been recognized, and a suitable line of treatment adopted, instead of that to which, as a suspected malingerer, he was subjected. It is therefore an important question whether the medical officer had sufficient reasons for believing that the man was malingering. Ido not think the evidence shows this to have been the case. The reasons which he alleged for thinking that the man was shamming were certainly not conclusive; and it would have been but just to have given the man the benefit of the doubt, and rather have required conclusive proof of shamming than conclusive proof of heart disease. I think the medical officer is to be blamed for his error of judgment. 5. Assuming the uncontradicted assertions of his fellow prisoners to be true, it would appear that they had seen much more convincing evidence that the prisoner Wilson was seriously ill than either the gaoler or Warder McKellop (so far as one can judge by their evidence) had seen or been made aware of. Thus the gaoler stated that he heard no complaint of Wilson not taking his food till the day he died ; and Allan Charles Young's account of Wilson's illness of the 25th of March, that " he had his hands on his chest on that day, stooping almost to the ground," is much more calculated to have impressed the medical officer with the idea that Wilson was really ill than anything which McKellop stated in his evidence. I think it was a serious oversight, both on the part of the gaoler and of the medical officer, not to have taken steps to be supplied with the fullest information regarding a prisoner who was complaining of pain and inability to work, and was at the same time suspected of feigning. 6. Eeferring to the evidence of the prisoner A. C. Young, that he heard the prisoner Wilson moaning nearly every night, and one night saying, " My God, my God!" I think it was an omission not to have examined the night wardsman, who was said to have visited him nearly every night. 7. I think it is also to be regretted that Warder McKellop was not examined regarding the important statement of the medical officer that he had told him (the doctor) that " he could prove that he (Wilson) not only ate his own rations, but those left by other priso7iers." Feed. W. A. Skae, The Hon. the Minister of Justice, Inspector Lunatic Asylums and Hospitals. Wellington.

No. 13. The Resident Magtstbate, Invercargill, to the Hon. the Minister of Justice. Sib, — Eesident Magistrate's Office, Invercargill, 14th May, 1880. I have the honor to acknowledge the receipt of your letter of the 30th April last, acknowledging the receipt of my letter of the 16th April, covering depositions taken at the inquest on John Wilson, at the gaol, Invercargill, on the 6th and 12th April last, and to state that, in accordance with your instructions, I have communicated to the medical officer and gaoler the conclusions to which the Government, as at present advised, consider the evidence points, by forwarding to each of those officers a copy of the three last paragraphs of your letter. With reference to this portion of your letter, I think it but right that you should be informed that it was considered, both by myself and the jury at the inquest, that very little reliance could be placed on the evidence given by prisoners Middleton and Young. The punishment-book, which was on the table, showed that several charges before the Visiting Justices for breaches of the gaol regulations had beeii brought against each of these men ; and we considered that, in giving their evidence they were very likely to bo actuated by a desire to injure the officers of the gaol. I may add, of my own knowledge, that Middleton seems to be mixed up in all the charges at the gaol1. Some of the charges against him have been brought before me as a Visiting Justice, and he has given evidence against other prisoners, but I have always felt that his evidence was altogether unreliable. I have. &c, The Hon. the Minister of Justice, Heney McCulloch, "Wellington. Eesident Magistrate.

No. 14 The Gaoleb, Invercargill, to the Hon. the Minister of Justice. Sir, — H.M. Gaol, Invercargill, 17th May, 1880. 1 have the honor to acknowledge the receipt of Mr. McCulloch's letter of the '6th instant, containing an extract from a letter received by him from you in reference to the manner of the prisoner Wilson's death, which was the occasion of an inquiry before Mr. McCulloch, on the 6th and 12th of April last. "While thanking you for kindly affording me the opportunity of making a statement as to the cause of the prisoner's death, I have the honor to state that, on a full consideration of the circumstances, it does not seem to me to be necessary to add anything to the evidence I gave at the inquest, except in reference to the expression of your opinion, " that greater care should have been taken, both on the part of the gaoler and the medical officer, to obtain fuller information as to the real condition" of the prisoner; and, that "had all the facts that were disclosed in the evidence at the

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inquest been previously collated and brought under the attention of the medical officer, they might, and probably would have, led to the conclusion that the prisoner was suffering from the disease of which he afterwards died." On these conclusions I beg most respectfully to remark : — 1. That all the information which I had any reason to suppose could be obtained was obtained by me, and brought under the notice of the medical officer. 2. That had the medical officer, in order to assist him in his diagnosis, suggested any further inquiries, or had the prisoner expressed a wish for inquiries to be made of his fellow-prisoners, I would have felt it my duty at once to have instituted such inquiries. 3. That, in the absence of such suggestion or desire, and seeing the medical officer had, after careful examination, arrived at the conclusion that there was nothing the matter with the prisoner, it did not appear to me to be my duty to institute further inquiries, especially as such proceeding would, in the circumstances, appear to be an undue interference with the functions of the medical officer. 4. That, after giving all the circumstances of this unfortunate event my fullest reconsideration, I do not, with the utmost submission to your opinion, feel conscious of having neglected my duty ; and I venture to hope that you will not take an unfavourable view of my conduct. I have, &c, William Ebasee, The Hon. the Minister of Justice, Wellington. Gaoler.

No. 15. Dr. Button" to the Hon. the Minister of Justice. Sib, — Southland Gaol, InvercargilL Having been handed by Mr. McCulloch, E.M., Invercargill, an extract from a letter received by him from you, re the death of prisoner John Wilson in the Invercargill G-aol, I beg to submit the following brief history of this case to you : — The prisoner, who was a tall, upright, healthy-looking man, came to me complaining of pain in his chest. I examined his chest, but found nothing wrong with it. I, however, prescribed for him a blister. I saw him again in a day or two, when he said he was better, and I ordered him a tonic. Some days afterwards I saw him, as the warder informed me he did not do his fair share of work. I again examined his chest, but could find nothing wrong either in the size or sounds of the heart or character of the pulse. The respiration also was quite normal. I then made the entry in the visiting surgeon's book that he was fit to work. At these examinations I questioned him with regard to his symptoms, but could arrive at nothing beyond the complaint of pain in the chest. I subsequently again saw him and re-examined his chest with a similar result. I then considered him a malingerer, and made an entry to that effect in the visiting surgeon's book. I did not see him again alive, although I was in the gaol, he not having applied to see me. He died nine days afterwards, and on post-mortem examination he was found to have occlusion of the right coronary artery of the heart. Mr. McCulloch informed me that you had taken medical advice on this matter. Tour medical adviser would doubtless tell you that while some cases of angina peotoris, one of the causes of which is occlusion of the coronary arteries, are comparatively easy to diagnose, others present actually no symptoms, and it is only on the sudden death of a person necessitating a post-mortem examination that the cause of death is found. Wilson was seen by several persons on the morning of his death, and was then apparently in as good health as he had been for months. I would submit that, while the post mortem goes to prove that the prisoner did suffer from the pain of which he complained, in the absence of all physical signs, his own statements and general condition, and of any other circumstances to corroborate his statement that he was unwell, I quite fail to see how I could have come to any other conclusion than that he was malingering ; for I hold that it would be manifestly wrong, without some further proof, to jump to the conclusion that every prisoner who complained of pain in the chest was suffering from angina peotoris. I have, &c, Hoeacb G-. Button, The Hon. the Minister of Justice, Wellington. Surgeon, H.M. G-aol, Invercargill.

By Authority: Geobqjj Dedsbtoy, Government Printer, Wellington. —1880. Price 9d.]