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.