In 1921, a strange incident occurred at Powick Mental Hospital…
Nine male patients were poisoned by ingesting belladonna. Three of them died, and an inquest into these deaths found the doctor who prescribed the medicine not guilty of any misdeed. Eight days later a fourth patient died, and a second inquest into his death reached the same verdict.
During the first inquest, which was reported in both Berwick’s Worcester Journal and the Worcester Herald, both published on Saturday 17 September 1921, Dr Henry Fenton, the medical superintendent at the asylum, testified that on the morning of 14 September, his attention was called to the nine patients. He called the doctor who had been in charge the previous night, Dr Alexander O’Flaherty, and together they examined the patients. Dr Fenton diagnosed them as suffering from belladonna poisoning. Two of them, George Newman and Herbert Peasley, were comatose. A third, John Jones, was not as badly affected. These were the three who died.
Berrow’s Worcester Journal, Saturday 17 September, 1921
Dr Fenton testified that he knew the patients had been prescribed purgative draughts the night before, and asked to see the bottles used. He concluded that they had been given a mixture of glycerine and belladonna, and immediately ordered that the patients be given emetics and antidotes.
To his credit, Dr O’Flaherty admitted his responsibility, but claimed that he had made an honest mistake. He had intended to give the patients a purgative of glycerine and cascara, but told Dr Fenton that he must have given them glycerine and belladonna instead. He testified that he saw the abbreviation ‘Glyc’ on a bottle and assumed that it was the glycerine and cascara mixture. He claimed not to have noticed that the bottle was labelled ‘Poison’ as it contained glycerine and belladonna.
The Coroner asked why he didn’t look closely at the bottle to ascertain its contents. The doctor replied that he did not expect that glycerine and belladonna would be used. The Coroner asked to examine the bottles, and the report mentions that apart from the labels and the level of the contents, the bottles were identical. The Coroner suggested that if the glycerine and belladonna had been in a ribbed bottle, it would have been immediately obvious that it contained poison and would not have been used. Dr Fenton agreed with this statement.
In his instructions to the jury, the Coroner said that they must decide whether Dr O’Flaherty had taken due caution in making up the purgatives, in which case the deaths were due to misadventure, or whether he was guilty of gross negligence, in which case he would be guilty of manslaughter. The jury took only a few minutes to bring in a verdict of Death by Misadventure.
On 21 September the fourth patient, George Frederick Bokenham, died. An inquest into his death was reported in both Berwick’s Worcester Journal and the Worcester Herald, both published on Saturday 1 October 1921. The Coroner went through the incident that had been the subject of the first inquest, and questioned the doctor who had performed an autopsy on the deceased. It was revealed that death was caused by pneumonia, which the doctor said was probably accelerated by the belladonna poisoning.
The jury went to inspect the dispensary, and closely questioned the assistant medical director, Dr Romer, who was unofficially in charge of the dispensary. Dr Romer had criticised the arrangement of the dispensary, but as he was not officially responsible, he did not feel able to insist on better security. The jury again brought in a verdict of Death by Misadventure, but added that there should be better supervision of the dispensary.
Note from the inquest held about George Frederick Bokenham’s death. Image taken from the patient’s mental hospital notes
At the time it was not mandatory to keep poisons in ribbed bottles for easy identification. There had been a Bill for Prevention of Accidental Poisoning in 1863, but it had failed to pass into law, although many institutions did take the precaution of using ribbed bottles. One cannot judge history by today’s standards, but one cannot help wishing that those in charge at Powick Asylum had taken similar precautions.
With thanks to Cathy Broad for researching and writing this article.