SUNNYSIDE MENTAL HOSPITAL (REPORT OF COMMISSION ON THE).

Appendix to the Journals of the House of Representatives, 1913 Session I, H-07a

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1913. NEW ZEALAND.

SUNNYSIDE MENTAL HOSPITAL (REPORT OF COMMISSION ON THE).

Presented to both Houses of the General Assembly by Command of His Excellency.

COMMISSION. Commission to inquire into and report upon the Treatment of certain Patients in the Sunnyside Mental Hospital. Liverpool, Governor, To all to whom these presents shall come, and to Victor Grace Day, Esquire, of Timaru, Stipendiary Magistrate : Greeting. Whereas it is expedient that inquiry should be made into the treatment of certain patients at the Sunnyside Mental Hospital: Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, in exercise of the powers conferred by the Commissions of Inquiry Act, 1908, and of all other powers and authorities enabling me in this behalf, and acting by and with the advice and consent of the Executive Council of the said Dominion, do hereby constitute and appoint you, the said Victor Grace Day, to be a Commission to inquire into and report upon the treatment in Sunnyside Mental Hospital of — (1.) The late William Alexander Tribe; (2.) The late James Howie; (3.) The late Sidney Lionel Barrett; (4.) Lewis Allan Gourlay; and (5.) Daniel Herlihy. And for the better enabling you, the said Commission, to carry these presents into effect you are hereby authorized and empowered to make and conduct any inquiry under these presents at such times and places in the said Dominion as you deem expedient, with power to adjourn from time to time and from place to place as you think fit, and to call before you and examine on oath or otherwise, as may be allowed by law, such person or persons as you think capable of affording you information in the premises; and you are also hereby empowered to call for and examine all such books, papers, writings, documents, or records as you deem likely to afford you the fullest information on the subjectmatter of the inquiry hereby directed to be made, and to inquire of and concerning the premises by all lawful means whatsoever.

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And, using all diligence, you are required to report to me, under your hand and seal, not later than the fifteenth day of October, one thousand nine hundred and thirteen, your opinion as to the aforesaid matters. And it is hereby declared that these presents shall continue in full force and virtue although the inquiry is not regularly continued from time to time or from place to place by adjournment. And, lastly, it is hereby further declared that these presents are issued under and subject to the provisions of the Commissions of Inquiry Act, .1908. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Member of the Royal Victorian Order, Governor and Comm-ander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this tenth day of September, in the year of our Lord one thousand nine hundred and thirteen. R. Heaton Rhodes, Minister in Charge of Mental Hospitals. Approved in Council. J. F. Andrews, Clerk of the Executive Council.

Commission to inquire into and report upon the Treatment of certain Patients in the Sunny side Mental Hospital: Extending Period within which Commissioner shall report. Liverpool, Governor. To all to whom these presents shall come, and to Victor Grace Day, Esquire, of Timaru, Stipendiary Magistrate. Whereas by Warrant dated the tenth day of September, one thousand nine hundred and thirteen, you, the said Victor Grace Day, were appointed to be a Commission under the Commissions of Inquiry Act, 1908, to inquire into and report upon the treatment in Sunnyside Mental Hospital of — (1.) The late William Alexander Tribe; (2.) The late James Howie; (3.) The late Sidney Lionel Barrett; (4.) Lewis Allan Gourlay; and (5.) Daniel Herlihy : And whereas by the said Warrant you were required to report to me under your hand and seal your opinion as to the aforesaid matters not later than the fifteenth day of October, one thousand nine hundred and thirteen : And whereas it is expedient that the said period should be extended as hereinafter provided : Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, in pursuance of the powers vested in me by the said Act, and acting by and with the advice and consent of the Executive Council of the said Dominion, do hereby extend the period within which you shall report to me as by the said Commission provided to the twentyninth day of October, one thousand nine hundred and thirteen.

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And in further pursuance of the powers vested in me by the said Act, and with the like advice and consent, I do hereby confirm the said Commission except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Member of the Royal Victorian Order, Governor and Com-mander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this sixth day of October, in the year of our Lord one thousand ninehundred and thirteen. R. Heaton Rhodes, Minister in Charge of Mental Hospitals. Approved in Council. J. F. Andrews, Clerk of the Executive Council.

INDEX OF FINDINGS. Pase Matters of Inquiry .. .. • • • • • • • • .. .. .. 4 Representation of Parties .. .. .. .. .. .. .. .. 4 Case of W. A. TribeComplaints, List of.. .. .. .. .. .. .. .. .. 4 Complaints 1-12 .. .. .. .. • • .. .. .. .. 5-7 The Death Certificate .. .. .. .. .. .. .. .. 7 Case of J. Howie —■ Complaints, List of.. .. .. .. . • .. .. .. .. 8 Complaints 1-6 .. .. • • • • • • • • • ■ .. 8 Case of S. L. BarrettComplaints, List of .. .. .. ■ • . ■ .. .. .. .. 8, 9 Complaints 1-5 .. .. ■ • • • ■ • • • • ■ .. .. 9 Case of L. A. Gourlay— Complaints, List of.. .. .. .. .. .. .. .. .. 9 Complaints 1-11 .. •• •• •• •• •• •• .. 9,10 General Comment .. .. . • • • . • . • .. .. 10 Case of D. Herlihy—Complaint .. .. .. .. .. .. .. .. 10 General Matters —■ Eeason for Complaints .. .. ... .. .. .. .. 11 Reception Ward .. .. ■ • • • • ■ • • . • .. ..11 Classification .. • ■ ■ • • • • • • • • • ■ • 11 Hospital Treatment .. .. • • .. .. .. .. .. 11 Medical Officers .. .. • • • ■ • • • • ■. .. 12 Attendants .. • • • • • • • • • ■ • • • • 12 Previous Reports .. .. .. .. . • .. .. .. 12 Inspection by Commission .. .. • • • • • • .. .. 13 Thanks 13 Costs .. .. •• •• • • •■ •• •• •• ..13 Conclusion .. .. • • • • • • • • • • . • 13 Minutes of Proceedings .. .. .. .. .. .. .. .. 13

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BE POET. To His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the most Distinguished Order of Saint Michael and Saint George, Member of the Eoyal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies. May it please Your Excellency,— In pursuance of Your Excellency's Commission bearing date the tenth day of September, one thousand nine hundred and thirteen, directing me to inquire into and report upon the treatment in Sunnyside Mental Hospital of— (1.) The late William Alexander Tribe; (2.) The late James Howie; (3.) The late Sidney Lionel Barrett; (4.) Lewis Allan Gourlay; and (5.) Daniel Herlihy, I have the honour to state that I have duly inquired into the several matters, and report my opinion as follows : — Mr. T. W. Stringer, K.C., appeared on behalf of the Mental Hospitals Department; Mr. S. G. Raymond, K.C., with him Mr. Johnston, appeared on behalf of Dr. Gow and Dr. Ramsbotham, the Medical Superintendent and the Assistant Medical Officer at the Sunnyside Mental Hospital; Mr. Dougall appeared on behalf of the relatives of the late William Alexander Tribe; and Mr. Davey, M.P., appeared to watch the proceedings on behalf of the relatives of the late James Howie, and on behalf of Lewis Allan Gourlay and Daniel Herlihy. The Commission sat and took evidence on eight days. A transcript of the shorthand report is forwarded herewith. One day was spent in visiting and thoroughly inspecting the Sunnyside Mental Hospital. No definite complaints were formulated in any of the cases, but the evidence shows what the causes of complaint were. I shall treat of the case of each patient in the order set out in Your Excellency's Commission. I. William Alexander Tribe. The complaints were— (1.) That friends were not allowed to see him for a month; (2.) Confinement in cold, comfortless cell, where he could not sleep on account of noises made by other patients; (3.) Being supplied with dirty,'ill-fitting, and ragged clothing; (4.) Being compelled to undress in corridor and compelled to sleep in a shirt; (5.) That he was not supplied with sufficient blankets; (6.) That he was not allowed to wear his own clothing; (7.) That there was no hospital treatment for physical ailments; (8.) That he received two black eyes; (9.) That lie received an injury to his foot, which caused inflammation and swelling, which was not properly attended to; (10.) That if he was unable to eat a meal he obtained no food till the next meal; (11.) That there is no proper classification of patients; (12.) That Dr. Gow was cold and callous when spoken to about the patient. Mr. Tribe when admitted to the Hospital was fifty-six years of age. He was suffering from confusional insanity and acute mania.

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Complaint (I): That friends were not allowed to see him for a month. — The custom of the Hospital precludes friends visiting a patient until the expiration of a month after admission, except in special cases considered advisable by the Medical Officer. This practice is apparently general in mental hospitals. Experience shows that it is of benefit to the patient, as it allows of his settling down without being disturbed by any outside influences. Mr. Tribe's relatives were informed that it would not be good for the patient to see them earlier. Complaint (2): Confinement in cold, comfortless cell, where he could not sleep on account of noises made by other vatients. —The room in which Mr. Tribe was confined at night, and from which he was removed when dying, was shown to me. It is situated on the south side of the building, and I should think that the sun never reaches it. There are no means of warming it, and it is absolutely cold and cheerless. Any warmth that could enter it from the corridor would -be infinitesimal. It is certainly not such a room as any person suffering from any physical ailment should be placed in for treatment unless in summer-time, and then only of necessity. Complaint (3): Being supplied with dirty, ill-fitting, and ragged clothing.—The clothing supplied to the patient was the same as used generally in the Hospital. When given out it was always clean. When it is understood that nearly four hundred patients have to be supplied with clothing it will be seen that it would be impossible to give each patient clothes which would fit as though they were made for him. The clothing is of good serviceable materials, and warm. Any difficulty with regard to clothing is accentuated by the fact that many patients lose control of their natural functions, and also dirty their clothes in other ways, thus rendering it necessary that their clothing should be changed three and sometimes four times a day. The lay mind has no conception of the depths to which persons afflicted with certain mental diseases descend. They lose all self-respect and self-control. The most fastidious in dress and appearance become the untidiest, and the cleanest the dirtiest. The utmost vigilance and closest surveillance fail to keep them clean and tidy. Mr. Tribe was one of this unfortunate class. The evidence shows that on visiting-days he always had clean and tidy clothes supplied him shortly before the time visitors came. On one occasion after he was dressed, and whilst other patients were being got ready to receive visitors, he undressed himself three times, and each time got into a bed. The evidence of the attendants is that the clothes put on him were always clean and tidy, and their explanation of his condition as described by his visitors is that he rmist have changed his clothes in the interval, either with another patient or he must have put on soiled clothes in the corridor which had been taken off other patients. It is hardly credible that the attendants, knowing that he was about to see his friends, would dress him in dirty or untidy clothes. Complaint (4) •' Being compelled to undress in corridor and compelled to sleep in a shirt. —The complaint of the patient being compelled to undress in a corridor is of little moment. The corridor in question is closed at both ends by doors about 40 ft. or 50 ft. apart. There is a fire in the corridor. Those patients who sleep in single rooms are compelled to undress just outside the doors of their respective rooms and leave their clothes there. This rule is necessary to prevent patients secreting anything which might be dangerous to themselves or others. Being compelled to sleep in a shirt was necessary with the patient on account of his habits. Complaint (5): That he was not supplied with sufficient blankets. —No complaint appears to have been made to any official at the Hospital that the blankets were not sufficient. The evidence shows that from four to six thicknesses of blanket were supplied to each bed, and that if a patient asked for more the attendant had power to give him further blankets. Complaint (6): That he was not allowed to wear his own clothing. —For several reasons it is not practicable in a mental hospital of the size of Sunnyside to allow all patients to wear their own clothing. Firstly, the clothing has

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to be washed repeatedly; secondly, the clothing could not be marked with the number of the ward in which a patient was confined; and, thirdly, the cost of looking after private clothing would be out of all proportion to any benefit that could accrue to the patients. The Hospital clothing is also a means of tracing a patient who might effect an escape. Complaint (7): That there was no hospital treatment for physical ailments. —The lack of hospital treatment for physical ailments is a very serious complaint. At Sunnyside there is a ward called the " infirmary ward," but, owing to the exigencies of the Hospital, it is occupied by epileptic patients to the exclusion of all others. The consequence is that patients who fall sick are of necessity treated in any one of the general wards or in single rooms. When Mr. Tribe had to be put to bed on account of his foot he was treated in the same room as he had used previously, and to which I have already referred. In my general remarks I shall refer to this subject again. Complaint (8): That he received two black eyes. —The black eyes received by Mr. Tribe are clearly shown to have been caused by another patient with whom Mr. Tribe had an altercation, and no blame can be attached to any attendant for the occurrence. Complaint (9): That he received an injury to his foot, which caused inflammation and swelling, which was not 'properly attended to. —It is not possible to decide from the evidence what caused the injury to Mr. Tribe's foot. About the sth or 7th June last (the witnesses do not agree as to the date) Mrs. Tribe and her sisters noticed that Mr. Tribe was limping. They took off his slipper or shoe, and found in the heel a pad of paper saturated with blood. They also state that there was blood on the heel of the sock. They do not appear to have taken off the sock to ascertain to what extent the heel was injured. They state the attention of the attendant was called to the matter, but they allowed Mr. Tribe to put on the slipper again, after placing another pad of paper in the heel. The witnesses do not agree as to which attendant's attention was called to it, and the two attendants (Mr. Harris and Mr. Condon) whose names are mentioned by the witnesses have no recollection of the occurrence. On the 12th June Mrs. Tribe called Mr. Harris's (the head attendant's) attention to the boot worn by Mr. Tribe being too small, and causing a mark across the instep. On the 18th June he was seen by Dr. Ramsbotham running about the airing-court without anything on his feet. On the 19th June, when Mrs. Tribe and Mr. Myhre visited Mr. Tribe, it was noticed that Mr. Tribe walked lamely. Mr. Myhre began to take off Mr. Tribe's sock, and when it was down two or three inches Mr. Tribe screamed with pain. The ankle and leg above nearly to the calf was swollen and inflamed. The leg was attended to by Dr. Ramsbotham and bandaged up. Dr. Ramsbotham states that he did not consider the condition of the foot and leg to be anything serious. The foot was dressed and bandaged on the three following days, and was seen by Dr. Ramsbotham on the 20th and 21st, and he states that on each occasion the swelling and inflammation had diminished. On the 22nd the foot was dressed by the attendant, who reported that the improvement continued. On the fourth morning, Monday, 23rd June, 1913, Mr. Tribe was removed to his home in a dying condition, and died about 1 o'clock in the afternoon. Dr. Gow (the Medical Superintendent) and Mr. Harris (the head attendant) last saw the leg very shortly before Mr. Tribe was removed from the Hospital, and they both state there was nothing unusual in the condition of the leg. Mr. Tribe was taken to his home—a distance of three miles—in the ambulance. He died within an hour of his arrival there. Immediately after death the body was laid out by Dr. Orchard and Mr. Thornton. Mr. Thornton states he noticed the bandage, and asked Dr. Orchard if it should be taken off, and Dr. Orchard replied that it was not necessary. He also states that the leg above the bandage was green to the knee, and that he never saw such a dreadful leg in his life, and that it was all the more remarkable because the other parts of the body were so wasted, and there was this big foot and leg looking dreadful. On the other hand, Dr. Orchard says, " The leg was quite all right, quite healthy

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in appearance, with the exception of about an inch above the edge of the bandage; there was a soft swelling of the tissues, nothing very much, there. There was no discoloration, and nothing to indicate serious trouble there." Dr. Orchard also stated there was no green colour there, and only the ordinary post-mortem changes. Mr. Mosley, who was called, stated that Mr. Thornton when he came out of the death-chamber said that Mr. Tribe's leg was in a very bad state. There is no evidence of any unpleasant odour being noticed whilst the body was being laid out, or afterwards. Gangrene could not have been present without such odour. It is impossible to reconcile the description given by Mr. Thornton with those given by Dr. Orchard and the Hospital doctors and attendants. The treatment of the foot in the Hospital appears to have been proper. Complaint (10): That if he was unable to eat a meal he obtained no food till the next meal. —The evidence establishes the fact that Mr. Tribe, in addition to having the ordinary meals supplied in the Hospital, received a special diet of eggs and milk two or three times a day. Complaint (11): That there is no proper classification of patients. —This is a serious complaint, and will be dealt with later. Complaint (12): That Dr. Gow was cold and callous when spoken to about the patient. —According to Dr. Gow, Mrs. Tribe must have misconstrued a remark he made. The Medical Superintendent always endeavours to spare the feelings of friends of patients as much as possible, and does not inform them of any details of the patients' faulty habits which might distress them. This reserve might be taken for callousness. In his own interests it might be better if the Superintendent let friends know the full extent of the patient's trouble. The Death Certificate. Mr. Tribe was discharged from the Hospital under the provisions of section 85 of the Mental Defectives Act, 1911, subsections (1) and (12), which read as follows : " 85. (1.) When the Medical Superintendent of an institution is of opinion that any patient detained in the institution is fit to be discharged he shall discharge him accordingly." " (12.) A patient shall be deemed to be fit to be discharged when his detention as a mentally defective person is no' longer necessary either for his own good or in the public interest." It is admitted that when Mr. Tribe was removed from the Hospital he was dying, and it was doubtful whether he would reach his home alive. He only arrived there less than an hour before he died. There is no doubt that his detention as a mentally defective person was no longer necessary for his own good as such, but as a dying man his detention was necessary for his own bodily good. His detention under all the circumstances was, in my opinion, necessary in the public interest, which demands that an inquest shall be held upon the bodies of all persons dying in a mental hospital. By his discharge an inquest was avoided, provided a medical man gave the necessary certificate of death. The Medical Superintendent, in my opinion, had no intention of avoiding the necessity of an inquest, but unwisely yielded to the importunities of the patient's friends, and allowed them to remove him from the Hospital. Even then an inquest would have been necessary had not Dr. Orchard given a certificate. It was suggested at the inquiry that Dr. Orchard was within his rights in giving the certificate. Now, what are the facts? Dr. Orchard saw Mr. Tribe in bed at the Hospital a few minutes before he was placed in the ambulance. Mr. Tribe was then unconscious. Dr. Orchard did not see Mr. Tribe again till about five minutes before he died, and he was unconscious all the time. A death certificate is given under the provisions of section 37 (1) of the Births and Deaths Registration Act, 1908, which is as follows : " 37. (1.) On the death of any person who has been attended during his last illness by a registered medical practictioner that practitioner shall sign and deliver to some person required by this Act to give information concerning

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the death a certificate on the printed form to be supplied for that purpose by the Registrar-General stating to the best of his knowledge and belief the causes of the death both primary and secondary." By no stretch of imagination can it be said that Dr. Orchard was the medical practitioner who attended Mr. Tribe in his last illness. To hold so would be to open a wide door to all manner of abuses and possibly crimes. Dr. Orchard was drawn into this as a family friend, and it was his desire to spare Mr. Tribe's relatives any unnecessary pain that induced him to give the certificate of death, which he based upon information supplied to him by the Medical Officers at the Hospital. Had he given the matter a second thought he would in all probability have refused to give the certificate. The Coroner would then have been called in, and a post-mortem examination made, when the state of the leg would have been noticed, and the irreconcilable differences in the evidence given before me coiild not have arisen. In my opinion Dr. Orchard had neither legal nor moral right to give a certificate of death. 11. James Howie. The complaints were — (1.) That he did not receive the care and attention he should; (2.) That he should have been in bed being nursed instead of being up in a chair; (3.) That his bedroom was comfortless; (4.) That his clothing was dirty, ill-fitting, and not warm enough; (5.) That he received several thrashings; (6. That he received a pair of black eyes. Complaint (1): That he did not receive the care and attention he should. — The evidence shows that Mr. Howie received all the care and attention that the Hospital in its present condition could possibly give to any patient. Complaint (2): That he should have been in bed being nursed instead of being up in a chair. —From the medical evidence there is no doubt that it was better that the patient should be up in a chair. He was an old man, seventyfive years of age, and to keep him in bed would have rendered him liable to contract hypostatic pneumonia. Complaint (3): That his bedroom was comfortless. —The bedroom complained of was very similar to the one in which Mr. Tribe was placed. The remarks I have made in Mr. Tribe's case apply equally in this. Complaint (4): That his clothing was dirty, ill-fitting, and not warm enough. —The evidence is that Mr. Howie was supplied with clean, warm clothes, and that if they were dirty it was the patient's own faulty habits caused this. As previously stated, it is really impossible to give every patient a well-fitting suit, especially where frequent changes are necessary. Complaint (5): That he received several thrashings. —ln my opinion the thrashings existed only in the patient's mind. His relatives state that prior to his admission to the Hospital his memory was failing, and he was not always to be depended on. It is probable that any soreness about the body was caused by his restless habits. Dr. Ramsbotham suggested that impending pneumonia might cause pain in chest and back. Mr. Howie died from pneumonia. Complaint (6 ): That he received a pair of black eyes. —The black eyes were caused by the patient himself falling about his bedroom. The room in question is not a suitable one in which to place a restless old patient. A rectangular covering to a hot-water pipe runs along one side of the room, three or four inches above the floor, and the architraves of the door project considerably more than most. The interiors of single sleeping-rooms should be without such angles or projections. 111. Sidney Lionel Barrett. The complaints were — (1.) That he was not given light employment; (2.) That he was placed at night near Lionel Terry, who kept calling out all night, so that he could not sleep for the noise;

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(3.) That he was not given milk and nourishing food; (4.) That attendants used to tease him; (5.) That his relatives were not notified of his being injured before he died. Complaint (1): That he was not given light employment. —This patient was a lunatic criminal and a sexual degenerate. He had suicidal tendencies, and consequently had to be under constant supervision. Hence he could not be given employment. Complaint (2): That he was placed at night near Lionel Terry, who kept calling out all night, so that he could not sleep for the noise. —lt is true that he was at one time placed near Lionel Terry's room. Terry was very noisy at nights. No blame is attachable to the Medical Officers or attendants : it was due to the overcrowding of the Hospital. Complaint (3): That he was not given milk and nourishing food. —The complaint that the patient was not given milk and nourishing food rests solely on a statement made by the patient to his sisters. No question was asked the Medical Officers or attendants about this. The evidence, however, shows that the patient gained in body and strength whilst in the Hospital. Complaint (4) ■' That attendants used to tease him.- —This also rests solely on statements made by the patient to his sisters, and is denied by the attendants. Complaint (5): That his relatives were not notified of his being injured before he died. —The patient's friends were expected to visit him the day he was injured. They did not pay a visit, and a letter was written them the next day, as the injuries were not then considered serious. The day after that he died suddenly, and a telegram was at once sent. The Medical Officers could not have been expected to do more. It appears from the evidence that the patient told his sister he intended to commit suicide by placing his head under the wheel of a dray. It is to be regretted that none of the patient's relatives realized the importance of informing the Hospital authorities of this threat. Had they informed the authorities, more precautions would have been observed to ensure the patient's safety, although he was under special observation at the time. IV. Lewis Allan Gourlay. The complaints were as follows : — (1.) That he was placed with the worst cases; (2.) That he was supplied with blankets covered with filth from other patients, and the attendant refused to change them; (3.) That the bedclothes were not adequate for a cold night; (4.) That the blankets were not washed during the six months he was detained; (5.) That sufficient towels were not provided in the lavatory; (6.) Had difficulty in getting milk when ill with dysentery; (7.) That the classification of patients is not sufficient; (8.) That Dr. Gow spoke fiercely, and said, " Oh, you are out of your mind." (9.) Urinal too close to dining-room in F ward, and stench from it came into the ward at meal-times; (10.) That the food supplied was not fit to eat most of the time; (11.) That he was locked up in a closet by Attendant Groskie. Complaint (1): That he was placed with the worst cases. —This is a grave complaint, but the necessity for placing a new admission with refractory cases arose from the deficiencies of the Hospital, and cannot be blamed upon the Medical Officers. I will refer to this again in my general remarks. Complaint (2): That he was supplied with blankets covered with filth from other patients, and the attendant refused to change them. —This complaint about filthy blankets rests solely on the patient's own statements. It is denied by the attendants, and Attendant Sykes states, " He complained about dirty

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blankets, so I asked him where they were. I opened the bed and pulled the blankets out, and they were all right, and I said there was nothing on the blankets; but he said it was in the blankets. I told him the blankets were perfectly clean, and that he was not to worry about it, and,he went to sleep comfortably then." From my inspection of the Hospital I should think it very unlikely to have happened. The patient made no complaint either to the Medical Officers or the head attendant. Attendants have nothing to gain by allowing dirty blankets to be used, as there are ample laundry facilities in the Hospital. Complaint (3): That the bedclothes were not adequate for a cold night. — The patient never asked for more bedclothes, or they would have been given him. Complaint (4) ." That the blankets were not washed, during the six months he was detained,. —The blankets are washed once a year, or as often as any are soiled. Complaint (5): That sufficient towels were not provided in the lavatory. — To a clean patient the insufficient supply of towels in the lavatory would be a real grievance. In the lavatory where the patient had to wash there were eight or nine roller-towels for the use of between sixty and seventy patients. As all the patients are not equally clean, and all have to wash within a few minutes, it is evident that the supply of towels would not be sufficient. Complaint (6): Had difficulty in getting milk when ill with dysentery. — This again rests solely on the patient's statement. From the whole of the evidence it is evident that milk is not stinted in the Hospital. Complaint (7 ): That the classification of patients is not sufficient. —I shall refer later to the classification of patients. Complaint (8): That Dr. Gow spoke fiercely, and said, " Oh, you are out of your mind." —Dr. Gow denies having spoken fiercely to the patient and saying, " Oh, you are out of your mind." Complaint (9): Urinal too close to dining-room in F ward, and stench from it came into the ward at meal-times. —I saw the urinal referred to by the patient. It is at least 45 ft. from the door of the corridor where the patients had meals. There is plenty of cross-ventilation in the passage, but it is possible if the wind was blowing from the south-west or south-east, and the door into the corridor was open, that the smell from the urinal might penetrate into the corridor. This is one of the many defects in the construction of the building. Complaint (10): That the food supplied was not fit to eat most of the time. —That most of the time the food was not fit to eat is merely the patient's opinion. In other cases inquired into it was stated that the food was ample and wholesome, and no fault was found with it. Co7nplaint (11): That he was locked up in a closet by Attendant Groskie. —The attendant stated that it was possible for a patient to get locked into the closets, but not into any particular closet, as they had no doors. He said if the patient was locked in it was not done intentionally. Any value that might be attached to Mr. Gourlay's evidence is greatly discounted by the fact that he states he saw two of the attendants brutally ill-treat a patient named Brian or Bryant; yet when Mr. Gourlay left the Hospital he wrote to one of the two attendants, asking him to take a brother of Mr. Gourlay's out to work. If this attendant had ill-treated a patient in the manner described by Mr. Gourlay, it is hardly credible that he would have asked that particular attendant to look after his brother. V. Daniel Herlihy. The complaint was — (1.) That he was hit over the head with a bunch of keys by the attendants, and generally made a source of amusement. This patient is a very old inmate of the Hospital, and is stated by all who have given evidence to be a general favourite not only of the other patients, but of the attendants. All the attendants repudiate the idea that the patient could have been ill-treated in the manner alleged by Mr. Gourlay.

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General. The foregoing remarks dispose of all the complaints arising in the course of the inquiry of ill treatment or neglect of patients by the Medical Officers or attendants. In my opinion they all arise either from the disorganized state of the mind of the patients, or from the ignorance of the patients' friends of the pitiful state patients get into, not by reason of any ill treatment or neglect on the part of the Hospital authorities, but by reason of their mental ailments. I shall now deal with certain complaints arising during the inquiry, which arise from the deficiencies of the Hospital itself, and for which the Hospital staff is in no way responsible. 1. Reception Ward. On the male side of the Hospital there is not, nor has there been for many years past, any ward for the reception of new admissions. Patients on arrival have to be placed in the refractory ward with the worst class of patients in the Hospital. This, I submit, is improper, and should not be allowed, as it cannot tend to improve the condition of a patient, and in many cases must be harmful. The Medical Officers state that owing to the overcrowded state of the Hospital it cannot be avoided at present. I understand, however, that provision is made for the erection of a reception ward in the near future. 2. Classification. Owing to the overcrowding it is impossible for the patients to be properly classified, and so receive proper care and attention. For instance, patients whose mental derangement does not affect their table manners have to sit at the same table as patients who slobber into their food. The patients cannot be classified according to their various mental derangements. A suggestion was made during the hearing that patients should be in some way classified according to their social status, but this is obviously impossible. Something, however, should be done to separate the coarse or foul-mouthed from those of more refined instincts. Lunatic prisoners from time to time are sent to mental hospitals, and I understand no special provision is made for their custody apart from the other patients. This is obviously improper, and requires no further comment. A large class of patients are those who are certified as mental defectives on the ground of " senile decay." I am given to understand that in Great Britain the majority of these cases are to be found not in mental hospitals but in the workhouses —in fact, they are not classed as lunatics or mental defectives at all. These patients should be placed in a separate institution, as the majority of them only require a limited amount of care and attention, and do not require the services of trained mental nurses to look after them. 3. Hospital Treatment. For sick patients at Sunnyside there is absolutely no proper hospital accommodation. There is a ward called the " infirmary ward," but this has to be occupied by epileptics to the exclusion of all others. If a patient falls sick the only place to put him is in one of the single rooms which I have already commented upon in Mr. Tribe's case. This should not be in an institution such as a mental hospital controlled by the Government of the country. Friends of mental defectives have the right to expect all reasonable care, comfort, and attention for the patient, which would include adequate hospital treatment when necessary. In this connection the Medical Officers are of opinion that when a proper infirmary ward is provided, where sick patients can be cared for, it would be better to employ female nurses to look after the sick.

3—H. 7a.

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4. Medical Officers. There are two Medical Officers in the Hospital —Dr. Gow, the Medical Superintendent, and Dr. Ramsbotham, the Assistant Medical Officer. Under their charge they have approximately seven hundred patients of both sexes. Upon the Medical Superintendent devolves the whole work of supervision of the Hospital, and also of the farm of 350 acres attached to it. He, therefore, has little time to devote to the medical work, which almost wholly devolves upon the assistant. Naturally, a number of the patients require very little, if any, medical attention. The attention, however, required by the others, and to which they are entitled, appears to me to be too much to ask from one or even two Medical Officers. I understand that in a hospital of this size in England the medical staff would consist of the Medical Superintendent, two Assistant Medical Officers, and a Pathologist, who would act as Relieving Medical Officer when necessary. The Sunnyside medical staff is at present deficient. Dr. Hay, Inspector-General of Mental Hospitals, stated that an Assistant Medical Officer is being provided. If this is done it will relieve the position to a great extent. 5. Attendants. The rules and instructions laid down for the guidance of attendants are as near perfection as possible, and they appear in the main to be faithfully obeyed and carried out. At the Sunyside Mental Hospital there are 370 male patients and a staff of forty-five attendants, including the head attendant. Of these, two are always on night duty, and at the present time two others are on night duty in charge of one case. This leaves forty available for day duty. Of these forty, 25 per cent, are always on leave, which leaves thirty on duty. According to the evidence, the proportion of attendants to patients should be one attendant to every eight or ten patients. As it is, there is only one attendant to every twelve patients. This proportion is often increased, owing to sickness amongst the staff. It is in evidence that the attendants work thirteen hours and a half one day and eleven hours and a half the next, and have three half-hour periods off during the day for meals. They have ninety-two days' leave during the year. The number of hours worked by an attendant during the year is 3,411, equal to nine hours and a half each day for 365 days; or, allowing meal-times off, for the actual days worked, it comes to over eight hours for each day of the year, including Sundays. The work of the attendants is not heavy physical work, but during the hours they are on duty they are almost constantly on their feet, and have to be on the alert watching those patients under their charge. It is admitted that the work is nerve-racking, and probably a greater strain than mere physical work. Only two attendants are on duty during the night in the Sunnyside Mental Hospital. One remains in the infirmary ward, where the epileptic patients sleep, and the other patrols the building once an hour. This patrol takes threequarters of an hour. For the proper care of the patients there should be an attendant on duty on each floor. The size of the building can be imagined from the fact that it takes the attendant three-quarters of an hour to make his round. I am of opinion that the staff is inadequate in numbers and is overworked. It cannot, therefore, be possible that patients receive the care and attention they are entitled to. The lack of a reception ward and a hospital ward at the Sunnyside Mental Hospital was brought under the notice of the Government as far back as 1904 —nine years ago —by the then Inspector-General, Dr. MacGregor, and all that has been done since is to build a reception ward on the female side of the Hospital and to acquire a site for one on the men's side. In the meantime the number of patients has increased, thus accentuating the overcrowding of nine years ago. The State has assumed the care and control of mental defectives, and it should be the first duty of the State to provide what is necessary for their well-being.

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In company with those engaged on this inquiry, I spent a most instructive day in inspecting the Mental Hospital, and especially the rooms and wards mentioned in the evidence. I was greatly impressed with the cleanliness of the huge building and its orderly appearance. We went all through the Hospital, visiting every part. A number of beds were taken haphazard and stripped. In every case the bedding was clean and sufficient. We saw the patients at dinner, and afterwards partook of a meal taken from the same dishes. There was abundance of food, which was well cooked and nutritious. We saw the new annex on the female side, and" were pleased with its light and cheerful appearance, which was in great contrast with the older parts of the Hospital. It shows much thought on the part of the designer. I have to express my appreciation of the valuable assistance afforded me during the inquiry by each of the counsel engaged, by Mr. T. H. Davey, M.P., and also by Miss Rout, the stenographer, the accuracy of whose reports was favourably commented upon by the counsel engaged. In my opinion the costs incurred by the Medical Officers should be paid by the Mental Hospitals Department, and I would recommend that any reasonable costs incurred by other parties be also paid. In conclusion, I think that the result of this inquiry, lengthy and exhaustive as it has been, should allay any fears that may have arisen in the public mind that patients are subjected to ill treatment in the Mental Hospital, as it has been fully shown that any cause of complaint on the part of patients or their friends arises not from any laches on the part of the Medical Officers or attendants, but from defects of the Hospital itself. Given under my hand and seal at Timaru, this 23rd day of October, 1913. Victor Grace Day, Commissioner.

MINUTES OF PKOCEBDINGS. Thursday, 25th September, 1913. —At 11 a.m. Commission opened. Mr. Day read Commission. Appearance of parties and their legal representatives. Evidence taken till 12.45 p.m. Luncheon adjournment, 12.45 to 2.15 p.m. 2.15 p.m., Commission resumed. Discussion re representation of Department. 2.25 p.m., Commission adjourned till 10.30 a.m. next day. Friday, 26th September, 1913. —10.30 a.m., Commission resumed. Department represented by Mr. Stringer. Evidence taken till 12.20 p.m. Luncheon adjournment, 12.20 to 2 p.m. Evidence taken, 2 till 4 p.m. Commission adjourned till 10.30 a.m., Monday, 29th September. Monday, 29th September, 1913. —10.30 a.m., Commission resumed. Evidence taken till 1.5 p.m. Luncheon adjournment, 1.5 till 2.30 p.m. Evidence taken, 2.30 to 4.15 p.m. Proceedings then adjourned till 11 a.m. next day at Sunnyside-Mental Hospital. Evidence to be resumed following day at 10.30 a.m. Tuesday, 30th September, 1913. —Commission inspected Mental Hospital. Wednesday, Ist October, 1913. —10.30 a.m., Commission resumed. Evidence taken till 1.5 p.m. Luncheon adjournment, 1.5 till 2.30 p.m. Evidence taken, 2.30 till 4.30 p.m. Proceedings adjourned till 10.30 a.m. next day. Thursday, 2nd October, 1913. —10.30 a.m., Commission resumed. Evidence taken till 12.35 p.m. Luncheon adjournment, 12.35 to 2.30 p.m. Evidence taken, 2.30 till 3.50 p.m. Commission ajourned till 10.30 a.m. next day. Friday, 3rd October, 1913. —10.30 a.m., Commission resumed. Evidence taken till 12.10 p.m., when proceedings were adjourned till 10.30 a.m., Thursday, 9th October, 1913. Thursday, 9th October, 1913. —10.30 a.m., Commission resumed. Evidence taken till 12.50 p.m. Luncheon adjournment, 12.50 to 2.30 p.m. Evidence taken from 2.30 to 5.5 p.m. Proceedings adjourned till 10.30 a.m. next day. Friday, 10th October, 1913. —10.30 a.m., Commission resumed. Counsels' addresses heard by Commission till 1.5 p.m. Luncheon adjournment, 1.5 to 2.30 p.m. Counsels' addresses, 2.30 to 4 p.m. (including addresses from Mr. Davey, M.P., and Dr. Hay, Inspector-General).

Authority : John Mickay, Government Printer Wellington.—l9l3.