Hampshire Independent – Saturday 29th January 1859
MIDWIFERY.–IMPORTANT INQUEST AT LOCKERLEY.
SUPPRESSION OF A SURGEON’S LETTER BY THE POLICE.
An Inquest was commenced at the house of Mr. S.H. Yeats (the King’s Arms) Lockerley, on Wednesday last. before J.H. Todd Esq. [John Henry Todd], County Coroner, and a highly respectable Jury, with Mr. Clarke as foreman, to enquire into the cause of death of Mrs. Compton, a young married woman. The reason for holding the inquest, and the nature of the points involved, will be best learnt from the evidence which follows :
Louisa Southwell, wife of George Southwell, of East Dean, Hants, woodman, said: The deceased, Ann Matilda Compton, was my sister. She was 24 years of age last October. She was the wife of William Compton, of Ampfield, labourer. They were married about Michaelmas last. My sister was not afflicted in any way. She lived with her father and mother at Lockerley. Her father is a grocer and baker, and keeps a beershop. Her husband is staying with his friends at Ampfield. He has no home of his own.
My sister had the influenza about three weeks ago, a cold, and sore throat. She had no medical attendance, and did not keep her bed. She expected to be confined about the time it happened. Mrs. Sims, a midwife at Mottisfont, had been bespoken to attend her, but no medical man. I saw her on Friday, the 7th of January, in the afternoon. She was then at needlework at her father’s house, and, except her cold, seemed pretty well, and as cheerful as I had seen her at all.
Between eight and nine o’clock on Saturday morning, I went to my father’s house with some goods which they wanted, and not finding my sister down stairs as usual, I thought there was something the matter. I, therefore, went up to her room with my mother and found my sister there, sitting in the room. She was dressed. She seemed very poorly and very low spirited. She thought she was in labour.
I told her to help me make the beds, thinking it would do her good to move about; she did so. My mother came in and out of the room, and asked if she had better send for Mrs. Sims. I said yes, and she was sent for, but did not arrive while I was there. I left between nine and ten that morning. She was then in mother’s bed-room, in much the same state as when I first saw her. I did not think she would be confined before night. She wished me to see her again as soon as I could, and I promised to do so.
About four in the afternoon of the same day (Saturday) I went down again to see my sister. I then found her in her own bedroom, crying and in much pain. Mrs. Sims was then with her. I then thought her confinement would be before long. I ordered she have some tea. Mrs. Sims would not give any opinion about it, saying she never liked to force anything upon anybody. I made some tea, and my sister drank two or three cups of it. She was then very sick, while Mrs. Sims was gone downstairs to warm herself. She then felt easier.
Her pains then became harder, and I was in hopes it would be over before I left, as I was obliged to go home at six o’clock, which I did, leaving her still in her room lying on the bed, and as I thought very near her confinement.
I returned at about eight the same evening, and found her still lying on the bed. Her mother said: Mrs. Sims was with her. The pains were then very severe. I could hear her groans before I got to the house. She was still very low spirited. She had never had a child before. I have had six.
Nothing particular occurred for about two hours, only that her pains still got harder. About ten o’clock my sister said: “How about sending for a doctor?” Her mother, being rather deaf, did not hear her. I heard her and repeated the words to my mother. Mother then said: to Mrs. Sims “Do you think there is a doctor needed?” Mrs. Sims said: “No; I can tell as well if it was my own self ; her pains are trifling. The fact is, she has got no patience.” My sister then said. “Then I don’t understand this case.”
After that her pains got herder, and she seemed to have a better heart. The waters broke early in the morning, before I went there, and I was afraid it would be a long business on that account. The pains gradually increased, and were very severe for the last hour. Mrs. Sims was there, and assisted all that time.
At last the child was born, about a quarter past eleven. It was collared by the cord two or three times round its neck, and could not breathe for some time, and was rather dark in the face. It was a very large female child. Mrs. Sims attended to it, and wrapped it in flannel, and breathed into its mouth. After a minute or two it breathed, and cried, and then went to sleep. The child is still alive, and appears likely to do well.
I did not see what Mrs. Sims did to the child before she removed it from my sister. I believe she pulled the cord off. There were no scissors handy, and she sent my mother after them, and told her to make haste. The child was then removed into another room. My sister then seemed rather more cheerful, and raised herself up, and tried to sit up in the bed to see the child, but I pushed her back. Mother then showed her the child, just before she carried it away. That was all she ever saw of it.
I then went down to get some gruel, leaving Mrs. Sims in the room and my mother. On my return, in a few minutes, I found my sister still lying in bed, and nothing particular the matter more than usual. She took the gruel, and asked for some more. She also bad a small piece of toast.
About half-an-hour after, flooding came on. Mrs. Sims said: ” Here is a terrible job.” I asked her if she had ever seen anything like it before, as I never had? Mrs. Sims said: she had. When mother came in, Mrs. Sims said: “If this does not stop soon, we must have some vinegar and water.” My mother then got about a half-pint of vinegar, and put it into two quarts of water, which Mrs. Sims applied to my sister with cloths, but the flooding still continued. At that time the afterbirth had not come away, and it never did.
A second quantity of vinegar and water was used in the same way; then the flooding abated. Mrs. Sims said: it was stopped. Mrs. Sims then said: she must use means to get away the after-birth. She said: she must force it. I said: “what means must you use then?” and she said: “Pass my hand.” I said: “Do you ever do such things as that?” She said: she always did if it did not come within an hour. I said: I never knew it done. I was sure Hannah Pragnell did not. She is another midwife, living near me.
Soon afterwards, Mrs. Sims passed her hand, as she had stated, some inches below the wrist. I saw her draw her hand away after about five minutes, during which time my sister kept crying out as if in great pain, and kept begging me not to let her do it. She said: she was sure mother would not let her if she was there but my mother was at the lower corner of the bedpost at the time, and did not interfere. I think she was full of alarm.
Before Mrs. Sims put her band in, she pulled at the cord several times. My sister told her to take care, and seemed to suffer very much, and kept on saying “What a shame it is.” While Mrs. Sims was putting her hand in, I said: “If there is anything of that sort wants doing, Mrs. Sims, do get a doctor to do it.” Mrs. Sims then said: to mother, “What shall I do, shall I get it or leave it?” I forget what mother said. When something was said about a doctor before the baby was born, Mrs. Sims said: a doctor would only call them a set of fools.
After she had left off trying to get away the after-birth, she said: she wished my sister would not make such a noise, she could get it away as well as a doctor if she (my sister) would be quiet. After she had tried with her hand, she tried again several times, by pulling at the cord, which seemed to hurt very much, as she screamed out every time, and begged her to get away. By the time all this bad happened it was nearly one o’clock. Mrs. Sims and mother then went down stairs together, to carry things out of doors, and I was left with my sister by myself.
I then said: to her, “Ann, what was it Mrs. Sims did just now?” She said: “I don’t know what she did, but I am sure I am going to die.” She asked me to get her some water, which I did, and on going to her with it, she was sinking from the pillow with her face downwards, as if she was dying.
I put some water into her mouth with a spoon, and called and rapped for assistance. After some little time Mrs. Sims and my mother returned, and we rubbed her temples and hands with vinegar and water. Her hands then got cold, and never got warm again. She came to herself after a few minutes, and soon after called out “Doctor Nunn.”
I said: I wished we had some brandy, and Mrs. Sims said: she thought it would do her good. Afterwards some brandy was sent for, and I told my father that a doctor ought to be sent for. He asked if there was anything particular. I said: yes, more than I had ever known. He then said: a doctor should be sent for, and could not think what mother was about not to send before.
At 20 minutes past one on Sunday morning, my brother went for Mr. Nunn [Dr. Arthur Joshua Nunn], of Whiteparish. He got back at half-past three, and brought a small bottle, – half to be given directly – if no difference, the other half to be given in an hour and a half, and if that did no good, he was to be sent for, and he would come. I gave her one half of it as soon as it came.
While my brother was gone, Mrs. Sims tried at the cord again, and then went and dressed the baby, which took very nearly an hour, and returned to my sister, and pulled at the cord again. While my brother was gone my sister became very restless, and threw herself about very much, and frequently said: she should die. After I had given her the draught, I went down stairs to warm my feet, and send up another sister (Kitty) whom she wished to see. She went up directly I went down. I was gone about ten minutes.
I heard her groaning while I was down stairs, and on my return (having heard my sister Kitty call my mother in a hurry), I found Mrs. Sims, and Kitty and my mother there, and my sister Ann insensible, and dying, with her head leaning forward on the bed. She did not move or speak afterwards, but expired in about a quarter of an hour. We were all there at the time. She was dead just before four o’clock.
Mrs. Sims never said: she was in danger till just before she died. She then said: she had never seen such a case before. She did not say anything to account for it. She never expressed a wish to have a doctor, and made no remark when Mr. Nunn was sent for. Mrs. Sims seemed quite sober and collected till just at the last. My sister expressed no wish to see her husband, but said: before the child was born she hoped he would not come, and never mentioned his name afterwards.
Mr. Nunn did not come at all, and did not see my sister either before or after death. We sent to let him know she was dead. After her death I was sitting with my father down stairs, while they were laying her out, and I said: ” What an unpleasant inquest it would be,” thinking there would be one in consequence of her having died without a doctor, but mother did not think so. She seemed quite satisfied with Mrs. Sims.
I went home at daylight, and went down again in the evening, when I heard that my brother had been to Mr. Nunn again to know what was to be done, and that Mr. Nunn had said: it rested with the police. On Monday, between one and two o’clock, while I was there, the policemen came–the superintendent (Sparshott), and Wigwise and Barnes, two policemen. They were all three at the gate. Mother went out to them. The superintendent then came in doors. I asked him if there was going to be an inquest, and he said: “No; he had enquired into the case, and found nothing particular in it. It was a case that often did and would occur. The poor thing was dead, and nobody could help it.”
He asked me nothing about it, and I told him nothing. He told me to go Mr. Bayley [John Bayley], the Registrar, for a certificate of the death, and to tell him there was to be no inquest, and if he did not give me a certificate, I was to let him know. He said: I need not say anything to Mr. Bayley about the letter. I said: “What letter ?” He said: it was a letter sent by the police to him, to be forwarded to Todd (meaning the Coroner), but that he should have nothing to do with it. He should not be Mr: Nunn’s servant.
We might burn it, do what we liked with it. I said: to him, “Are you sure there will be no Inquest ?” He said: “No; for Todd won’t come without my orders, for, if he does, he won’t get paid for it.” In consequence of what Mr. Sparshott said: Mr. Nunn’s letter was not opened, but sent back to him by post.
That evening I and my brother went to register the death at Mr. Bayley’s at Romsey. He asked if we had a doctor’s certificate. I said: “No; it was a case of a woman who had died in childbirth without a doctor.” He then asked me if she was not low-spirited. I said: she was. He seemed to hesitate about giving a certificate, and said: he did not like an Inquest after he had registered the death. I then told him the Superintendent said: there was to be no Inquest. He then said. “What do the people in the parish seem to think about it ?” My brother answered we had not been round to ask them.
Mr. Bayley then asked me whether I thought it was debility. Thinking that meant lowness of spirits, I said: I thought it might be. I did not know the meaning of the word. He then wrote down “debility, not certified,” and I signed it. He then gave me a certificate, and that was all that passed. Mr. Bayley knew she died in childbirth, and asked me “How long she lived afterwards?” I told him about four hours and a half, and he then said: “He thought that could have nothing to do with it.”
My sister was buried at the Baptist Chapel, at Lockerley. where all our family have been buried before, on Thursday afternoon. Her husband and all her relatives followed her. Her husband went back to Ampfield on the following Monday, and I have not seen him since, I always thought there ought to be an Inquest on the body, not that I thought that Mrs. Sims had wilfully done wrong, but that, if she had, it should be proved, or others might suffer in the same way.
Luther Owen Fox, Esq., of Broughton, surgeon, said: I had nothing to do with the case during the life of the deceased. I have attended today at the request of the Coroner to hear the facts, and give my opinion on them, having previously heard something of the case from Mr. Nunn, who told me he had written a letter to the Coroner, suggesting the propriety of an Inquest, which letter had been returned to him unopened, and he could not understand it.
I have not seen the body of the deceased. I have today heard the whole of Mrs. Southwell’s evidence, from which I am of opinion that the death of the deceased was caused by haemorrhage during childbirth, caused by the imperfect separation of the after-birth, which would not have occurred if a medical man had been present, because, upon the haemorrhage occurring, he would have removed the afterbirth and, in all probability, the life would have been saved.
I am of opinion the haemorrhage was increased by the repeated pulling at the cord, and also by the unsuccessful attempt made by the midwife to introduce her hand Into the womb of the deceased. If any portion of the afterbirth is left in the womb it is highly dangerous. Of course, therefore. if the whole of it is left in, the women has hardly any chance. The immediate danger is haemorrhage; the secondary consequences would be fever and inflammation.
I consider that the death of the deceased was accelerated by the acts of the midwife, and that the death occurred from the want of proper assistance. The midwife was quite incompetent to manage such a case, and ought to have called in medical aid as soon as she found the haemorrhage came on, and the afterbirth not away. An uneducated midwife is totally incompetent to deal with such a case.
A post-mortem examination of the body would enable me to speak positively as to the cause of death, and I do not think too long a time has elapsed to enable that to be done.
The court was then cleared, and the jury left by themselves to consider what course they would desire to be adopted as to the further investigation of the case, after which they expressed their unanimous desire to hear further evidence, and that a post-mortem examination should be made of the body, for which purpose the Coroner issued a warrant of disinterment, and the inquest was adjourned until the following day.
On Thursday morning, the enquiry was resumed, and the first witness called was Keturah Southwell, who said: The deceased was my sister. l am seventeen years of age, and live with my father and mother. I was at home when my sister was confined. I heard her moanings at times while Mrs. Sims was with her. I was not in the room till about a quarter to four on Sunday morning, when my sister, Mrs. Southwell, sent me up, saying Nancy (the deceased) wished to see me. When I entered the room, I found my sister lying on the bed. Mrs. Sims was with her. My sister was sensible, and knew me after I looked in her face. She had called my name two or three times before that. When she saw me, she said: she was dying, after which she was unable to say any more. Mrs. Sims did nothing to her while I was there. I remained with her till she died; in about a quarter of an hour. I had seen the baby before, and have seen it every day since, and it is going on well.
Mrs. Martha Southwell, wife of Mr. W. Southwell, said: Deceased was my daughter. Mrs. Sims was engaged to attend her in her confinement, but no doctor. It was her own wish to have it so. I first heard of her being in labour between eight and nine on Saturday morning. I then sent for Mrs. Sims, who came about eleven o’clock the same morning, and remained with her till she died. I was with the deceased all the time while Mrs. Sims was there, except going out of the room occasionally to fetch things. The child was born at half-past eleven on Saturday night, and was a fine female child, still alive. My daughter rose herself up to look at it when I took it away. All seemed to go on very well till then. My daughter was very low spirited during the day, and about half an hour before the child was born, she said: “How about a doctor.” Mrs. Sims said: “Your pains are not sufficient, and he would only laugh at us if he came” The deceased then said: “Then I know nothing about it.” I was not at all alarmed myself.
Some time after the child was born, and taken out of the room, I went down stairs, and when I returned, I found flooding going on, which was alarming. Mrs. Sims asked for vinegar and water, which I got, and she applied it, and it seemed to stop the flooding for a time. I then gave my daughter some tea, and a small piece of toast.
Soon after that she had a violent attack of diarrhoea. but it did not continue long. The flooding then came on again. and I asked Mrs. Sims whether we had not better have a doctor? She answered, “Please yourself; I won’t say a word against it.”
My daughter, hearing what we said: mentioned the name of Mr. Nunn; meaning Mr. Nunn, of Whiteparish, and we directly sent my son Alfred for him. He went on foot. It is about four miles. He started between one and two, and returned in about two hours with a bottle of medicine; one half to be taken immediately, and the remainder in an hour and a half. She took the first half about half an-hour before her death. My son brought a message from Mr. Nunn that he had two or three bad cases in Whiteparish, and could not leave. While my son was gone the flooding returned, and Mrs. Sims applied the vinegar and water.
[The witness corroborated the statement of her daughter as to the treatment of the deceased by the nurse.]
For three hours before her death she was in a cold perspiration. At last she became very restless, except for a time when she was calm, and we thought she was going to sleep. She was sensible the whole time. I was with her when she died.
Mrs. Sims did not state the cause of her death. She seemed to know no more about it than ourselves. Before she tried to bring away the afterbirth with her hand. She said: she had had other cases the same as that, and that she understood it. I placed every confidence in her, thinking she knew what to do. The afterbirth did not come away at all. I think Mrs. Sims did her best. If she did wrong I am sorry for it. I did not hear my daughter cry out as if she was hurt, until Mrs. Sims introduced her hand.
Alfred John Southwell said: Deceased was my sister. I was at home at my father’s when my late sister was confined, till I went for the doctor. I did not see her after seven on Saturday evening, when she came down stairs for a short time. After that, in the course of the night, I heard her groaning several times, but did not hear anything she said.
Mrs. Sims came down stairs after the child was born, and said: it would be all right presently; but soon after one the next morning, she came down again, and said: she did not know what to make of it. I said: “There ought to be a doctor sent for,” and she said: “I had better go for one.” Directly after that, my mother told me to go for Mr. Nunn, and to tell him there was something they could not get away from her.
I started immediately, on foot, to Whiteparish, about five miles. I got there about a quarter past two, and saw Mr. Nunn in his house. I delivered the message, and he gave me a bottle of stuff, which, he said: he had prepared for such cases. The bottle contained two doses, one to be taken immediately, and the other in one hour and a half, if required. Mr. Nunn said: he could not leave then, as he had other cases he was obliged to stop at home for. I said: “If the medicine did not do, I should come after him again,” and he said: in that case he would come.
On my return, about 20 minutes past three, I gave the medicine with the directions to my mother or sister. About five or ten minutes before she died we were all called up. She was then speechless and insensible. After I returned, I heard her groaning a little. I have not heard Mrs. Sims say anything about it since.
Sunday morning I went to Mr. Nunn again, to tell him of my sister’s death, and to ask him what was to be done about an inquest, as I considered it necessary to have one. Mr. Nunn said he thought so too, and I had better go to Mr. Todd, the Coroner. On my way home, Mr. Nunn’s servant overtook me with a letter for the Coroner, which I was to send or take to him. When I returned, I went to Barnes, the policeman, for him to take the letter, and I saw no more of it till about the middle of the next day, when Superintendent Sparshott brought it to me at my father’s house. He said it was no use to him. I asked him what I was to do with it. He said I might do what I liked with it. He said there was no inquest required; I might put it behind the fire if I liked. I then told him I should send it back to Mr. Nunn. He said that would be as good a plan as any. I then sealed it in another envelope, and sent it back by post to Mr. Nunn that afternoon. The letter was not opened at all.
My sister had been poorly and low-spirited for some time, and complained of a pain in her right side.
Luther Owen Fox, Esq surgeon, was then further examined, and said I have this morning made a post-mortem examination of the body of the deceased in the vestry-room of the Baptist Chapel, in this parish, adjoining the place of interment. I found the body as little decomposed as if it had been dead only two or three days, and the features were so little changed that her sister recognised and identified her in a moment. The external surface of the body showed no marks of injury or violence. From the examination of the body, and from the evidence I have heard in this case, I am of the opinion that death arose from bleeding of the womb in child-bed; that this bleeding was caused or increased by the neglect of proper measures, which, if adopted, would have saved the woman’s life.
Upon the whole, I have no hesitation in saying that if the deceased had had proper attention from a competent person, she might be alive at the present moment. It was not a case of real difficulty of any kind. Mr. Nunn was present at the post-mortem examination.
Elizabeth Sims, who said she was the wife of William Sims, of Mottisfont, labourer, having had the depositions read over to her, and being duly cautioned, said: I did not do anything more in this case than I have done in others. Times and times I have done it. I would have got it away in a minute, very safely, if she had not squeaked so.
She was very tired. I asked her mother whether I should get it away or leave it? She said: “Well, I would not.” I said: “I will do just as you like”, and I did not meddle any more. I have been a midwife four-and-twenty years. I am 69 years old next March. I have attended great numbers of women, some with six, and some with seven, and one with ten, and never had one die under my hands before.
The evidence being concluded, the Coroner summed up the case, and left the Jury to consider their verdict, which. after an hour’s deliberation, was delivered by the foreman (Mr. J. W. Clark), to the following effect:
“That the said Ann Matilda Compton, on the 8th day of January instant, was delivered of a female child, which is. still alive. That shortly after the birth of such child, violent haemorrhage ensued for several hours, and ultimately caused her death, which took place early the following morning. That the haemorrhage was occasioned or increased by the omission of Elizabeth Sims, the midwife. to perform with sufficient firmness the duties of her office, but that she was not guilty of any wilful neglect, or gross misconduct requiring the Jury (having due regard to her great age and good character) to return a verdict amounting to a criminal charge; but they strongly recommend her not to practice as a midwife in any case hereafter, except ender the superintendence of a medical man.
And the Jury further say that, in their opinion, an inquest in this case was necessary and proper, and generally expected by the neighbourhood as well as the friends of the deceased; and that, if the parish officers or some of the principal inhabitants had been consulted in the first place, much painful feeling, delay, and expense would have been avoided.”
Hampshire Telegraph – Saturday 5th February 1859
ROMSEY.
Lockerley (near Romsey).—A coroner’s inquest has been held in this village under very peculiar circumstances.
A young married woman of the name of Ann Matilda Compton was delivered of her first child in the night of Saturday, 8th January, and died early the following morning. She had no medical attendance, and there was reason to suspect that the midwife had misunderstood the case, and either done or omitted some act which had cost the deceased her life.
The case excited a good ileal of conversation in the parish, and it was generally expected that an inquest would be held upon the body. With this view, notice of the death was given to the police, and a letter was sent to them to be forwarded to the coroner, which never reached its destination. The superintendent and two policemen afterwards visited the house, and decided that no inquest should be taken, nor any notice of the case given to the coroner; but the relatives were directed to apply to the registrar of the district for a certificate the cause of death, in order that the funeral might take place without an inquest. The brother and sister of the deceased accordingly went to the registrar and informed him that the deceased had died in childbirth. He asked if they had a medical certificate ; they said they had not, but that the superintendent of police had desired them to say there was to be no inquest. He then asked them how long she had lived after her confinement; they replied about four hours, upon which he said, ” Then, that could have had nothing to do with it.” He then asked if she had not been low-spirited, and upon their saying she had he suggested that ” debility” should be entered as the cause of death, to which they assented, and it was registered accordingly !
On the Thursday the body was interred in the Baptist burial ground, and everything seemed to be quietly disposed of.
In the meantime, however, the case continued be talked about in the neighbourhood, and information of the circumstances was forwarded to Mr. Todd, the coroner, who made further inquiries, the result of which induced him to consider it his duty to lay the case before a jury.
Accordingly, on Wednesday morning the coroner and jury, consisting of the two churchwardens and thirteen other respectable inhabitants of the parish, who chose Mr. J. W. Clark as their foreman, assembled at the King’s Arms Inn, and proceeded to take evidence of the circumstances, after which the jury unanimously desired that further evidence should be taken, and that a post mortem examination should be made of the body.
In compliance with this request the coroner issued a warrant for the disinterment, in pursuance of which the body was exhumed early the following morning and placed in the vestry room adjoining the burial ground, for the purpose of being viewed by the jury and examined by the surgeon. On opening the coffin the body was found as free from decomposition as if it had only been dead a few hours. The inquest was then continued at the King’s Arms, where several more witnesses were examined, including Mr. Fox, of Broughton, and Mr. Nunn, of Whiteparish, the medical gentlemen who made the post mortem examination, and concurred in the opinion that the death of the deceased had been occasioned by the want of proper treatment after the birth of the child, which was attended with no difficulty that a competent person might not have removed in a few minutes, in which case her life would have been saved.
At the conclusion of the evidence the coroner summed up the case and left the jury to consider their verdict, which, after an hour’s deliberation, was delivered to the following effect:
“That the said Ann Matilda Compton, on the 8th day of January instant, was delivered of a female child, which is still alive. That shortly after the birth of such child violent haemorrhage ensued for several hours, and ultimately caused her death, which took place early the following morning. That the haemorrhage was occasioned or increased by the omission of Elizabeth Sims, the midwife, to perform with sufficient firmness the duties of her office, but that she was not guilty of any wilful neglect or gross misconduct requiring the jury (having due regard to her great age and good character) to return a verdict amounting to a criminal charge ; but they strongly recommend her not to practice as a midwife in any case hereafter except under the superintendence of a medical man.
And the jury further say that in their opinion an inquest in this case was necessary and proper, and generally expected bv the neighbourhood as well as the friends of the deceased, and that if the parish officers or some of the principal inhabitants had consulted in the first place much painful feeling, delay, and expense would have been avoided.”