H. -7a

8

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;