H.—7a

6

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