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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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