Warne, Elizabeth

Warne, Elizabeth              1889 March 30th


Verdict of Manslaughter Against the Midwife

On Monday morning an inquiry was opened in the porter’s room at the Council Chamber, Salisbury, by the Deputy Coroner (Mr G W Gater) for the purpose of ascertaining the cause of death of Elizabeth Warne, a married woman, residing at -7 Green Croft Street, who expired of her condition at seven o’clock on the morning of Saturday last. Mr G Bartlett was chosen foreman of the jury.

The Deputy Coroner said he was sitting there that day for the Coroner (Mr G Smith) who was unfortunately absent. He was under the impression, from the little indication he had had of the nature of the case, it might present a very serious aspect, and therefore, considering the hour of the day and the fact that this came upon him rather suddenly, he would ask them to accompany him to Green Croft Street to see the body of the deceased, and that they should adjourn the inquiry until Tuesday. He would like to have an opportunity of carefully considering the matter and also of seeking counsel with Mr G Smith, as, of course, his (Mr Gater’s) experience in these matter was not great, and he would like to thoroughly prepare himself in the case ere evidence was before them.

The inquiry was accordingly adjourned, and resumed at the Council Chamber at 10 o’clock on Tuesday.

John Warne, husband of deceased, was first examined. He said deceased was his wife and he had been living with her up to the time of her death. He was not in when his wife was first taken ill; in fact, he had taken some work home to Mr Rawlings, and did not get back to his residence till 11 o’clock. This was on Wednesday night. He went upstairs and his wife asked him to fetch Mrs Bunsell. After putting on his boots he went down the street to Mrs Bunsell’s but she was not there then. He afterwards saw her, and she went at once to his wife, who was in bed in the upstair room. Mrs Bunsell was up there about an hour. She made some gruel, and he went and fetched some brandy at the “Barley Mow.” Mrs Bunsell came downstairs and said she did not think his wife was in any pain, but if she was wanted during the night witness was to call her. He went up to his wife after Mrs Bunsell was gone. He did not get into bed, but sat up all night. He asked his wife if she wanted anything, and she said she would like a little drop of brandy with a little water. After taking this she laid down and went to sleep. About half-an-hour afterwards she woke and he asked her how she felt. She said she felt all right, adding that she should like him to make her a cup of tea, which he did. About two hours afterwards he gave her some more brandy. Mrs Bunsell came in about six o’clock on Thursday morning. She wanted to know how deceased was and said she would make her a basin of gruel. Mrs Bunsell attended to her and he went down stairs. He heard what Mrs Bunsell had to say when she came down.

He next saw his wife between eleven and twelve o’clock. She was sleeping then, and did not appear to be in any pain at all. Nothing had occurred to call his attention to his wife’s condition. Mrs Bunsell remained all day and went away in the evening. He himself did not leave the house. Mrs Bunsell said when she came down that she had made her nice and comfortable and that she would go home. That was about eleven o’clock on Thursday night. Up to that time nothing had been said about sending for a doctor. During the night he gave his wife a drop of brandy, which she vomited. That was about half-past twelve or a quarter to one on Friday morning. He asked her if he should make her a basin of gruel, and about two or three hours afterwards he made her a cup of tea. About seven o’clock deceased said to witness, “Will you do me a favor,” and he replied, “Certainly I will.” She said, “Get up and get me half a pint of beer, put it in the saucepan and make it hot.” This he did but his wife after drinking it threw it up again. When Mrs Bunsell came about 7.50 he told her what had occurred. She said, “I will make her a basin of gruel.” She made this and took it to deceased and when she came downstairs she said, “She has kept that down.”

Between 10 and 11 o’clock in the morning witness said, “This is an awful concern, throwing up all her victuals,” and he went up to his wife and said, “Elizabeth, shall I go and get a doctor, you ought to have a doctor.” Deceased replied that she did not want a doctor. Mrs Bunsell was in the room at the time. Mrs Bunsell said, “If it goes on like this she shall have to have a doctor.” Witness replied, “If she wants one I will go and fetch one.” About two o’clock in the afternoon Mrs Bunsell said to witness, “You had better go down to Mr Newbery’s (the relieving officer’s) and ask for a confinement order.” Witness went, obtained an order, took it to the Dispensary in High Street and gave it into Mr Terrill’s (the dispenser’s) hands. Previous to doing this he did not examine it. Mr Terrill looked at it and said, “Mrs Gough is out on a case.” Witness said that his wife was very bad and wanted one at once. The dispenser asked him to wait for a minute and he would see where she was gone. On returning he said she was gone to a person by the name of Wilkinson or Wilson (witness could not remember which name it was) in Ivy Place, Castle Street. Witness went where directed but could find no person there with such a name. After having further inquiries in the neighbourhood of Castle Street he returned to Mrs Bunsell, who said she did not want a midwife but a doctor.

Mrs Wright (a neighbour) was despatched for a doctor as Mrs Bunsell said she would go faster than he could. Dr Gordon came about seven o’clock on Friday evening and remained upstairs for about half an hour. At the end of that time he came down and said to witness, “Mr Warne, run to Dr Wilkes and ask him to come to me at once. If he is not at home ask Mr Kelland to come.” At the same time Dr Gordon asked him to fetch a piece of paper, and, scribbling something upon it, asked him to take it into Messrs Read and Orchard’s. Witness went to Dr Wilkes, who said he had an appointment at eight but would come as soon as he could. Witness told Dr Gordon of this when he arrived home. Dr Gordon went out and met Dr Wilkes at the bottom of the street, and they both came back together. His wife died about a quarter to seven on Saturday morning. No other persons came into the house, with the exception of a young woman, Caroline Bolwell by name, who came in to clean up the place.

A Juror : Was Mrs Bunsell engaged as a midwife?

Witness : Yes. She had attended my wife professionally before.

Mr Moore : Was there any difficulty in obtaining medical assistance?

Witness : Oh no! Sir.

Mr Yeatman : Did your wife take any solid food?

Witness : She did not take anything solid from Wednesday until the time of her death, except a little gruel.

Mr Yeatman : Did you see your wife when the doctors were upstairs?

Witness : No, they would not let me go up.

Mr Yeatman (warmly) : Fifty doctors would not prevent me from seeing my wife if she was dying.

In reply to further questions witness stated that when the doctor came down he said it was a very bad case and that he ought to have been fetched twenty four hours before he was. Subsequently he was informed that his wife was gone.

Catherine Bunsell was then called. She said she lived at 30, Green Croft Street, and was a midwife, but not a certificated one. Mrs Warne asked her if she would attend her when necessary, and that was all the arrangement entered into. That was a fortnight before her death. She was called by Mrs Warne’s husband at half-past eleven on Wednesday night, and she went to Mr Warne’s house and saw Mrs Warne upstairs. Witness found her in a bad state. Deceased was very weak but had no pains. Witness said she had better have a doctor as she was so ill, but Mrs Warne asked her not to alarm herself, she did not want a doctor. She gave a little brandy and water two or three times. Witness did not take her clothes off all night. The next morning deceased was better. About six o’clock on Thursday morning she went to see Mrs Warne again. Her condition then was about the same but witness considered that she ought to have a doctor. One of the things she noticed was that Mrs Warne was bleeding very fast. She did not do anything to stop the bleeding but said she ought to have a doctor. Witness had attended her twice before successfully, and without a doctor. Mrs Warne asked witness not to alarm herself as she been like it before. Witness had seen cases of this sort before and therefore was not so frightened as she might have been under other circumstances. She noticed in addition to the bleeding that deceased was sick several times. She remained about two hours and then left for a few minutes.

During the day she told Mr Warne they ought to have a doctor, in fact she mentioned it four or five times. Mr Warne said he would go up and see his wife and when he came down he said that Mrs Warne said she did not want the doctor. It was between 10 and 11 o’clock she left on Thursday night. At that time she did not seem to be any worse, she was in the same condition as in the morning. Witness was there again early next morning, before breakfast, about six o’clock she should think; at that time the bleeding was abated a little and the sickness had stopped. She did not examine deceased then but she was generally much weaker. Between that time and nine o’clock she gave her some gruel and made her clean and comfortable and then went down and told the husband he must go and fetch a doctor. He did not go, but said that by the time he was ready and got to Mr Newbery for the order Dr Gordon would be out. She never said any more to him until one o’clock. During the intervening time deceased was sleeping. She did not ask for a doctor, in fact she said she did not want one, more than once. At one o’clock she told Mr Warne that he had better go and see Mr Newbery, and he would be able to catch Mr Gordon before he went out. He was at home between two o’clock and half past two. Witness remained there until Dr Gordon came about seven o’clock, and there was no change in the patient. She did not examine her during that time.

James Henry Gordon, medical practitioner, of Salisbury, next gave evidence. He said he knew the deceased by sight but not as a patient. He was called to her on Friday, the 22nd. The first he heard of it was when he arrived home between six and seven o’clock in the evening. Mrs Wright brought the order to him. It was made out in the name of the midwife but the husband explained that in his evidence. Witness did not go at once, as he had to attend a patient, in similar circumstances. He was not, however, detained there and on leaving went to deceased. Mrs Bunsell was with the patient, who was in a state of collapse. She was suffering from one of the gravest complications that could occur before the birth of a child. Mrs Bunsell informed him that deceased had been suffering from hemorrhage but that had ceased before he arrived there, he should say some time before. There was no recurrence of the hemorrhage from that time until her death. She did not complain that he had not been sent for before. He had to press her to converse even the little she did, but at midnight she spoke rather more freely. He sent for Mr Wilkes and he came shortly after eight o’clock, soon after he was sent for. They agreed as to the treatment of the patient and were successful to a certain extent in endeavouring to restore her vital powers. Mr Wilkes staid with him for about two hours and as deceased seemed better witness went home for a few hours. The Dispensary nurse had arrived by this time, but Mrs Bunsell was still there assisting. He saw deceased again about six o’clock on Saturday morning, and indications of approaching death, the nurse informed him, had set in shortly before he arrived. She died shortly before seven o’clock. Sometimes persons would die under the most favorable circumstances, but judging from previous cases he should think deceased’s life would have been saved had medical assistance been summoned in time. Of course he could not speak with absolute certainty.

By a Juror : It was not likely that the deceased could have suffered from the same thing in previous confinements.

By the Coroner : The midwife ought not to have left the patient from 2 to 6 o’clock on Thursday morning. The midwife ought to have obtained medical assistance as soon as she noticed what she did.

By Mr J Moore : Such cases did not usually end fatally if taken in hand in time.

By the Coroner : Mrs Bunsell evidently did not recognise the full danger of this case.

In reply to a further question from the Coroner witness stated that although Mrs Bunsell had had considerable experience in these matters she might have mistaken the symptoms.

Witness, in answer to another question, would not state definitely that deceased’s life would have been saved had medical assistance been called in earlier.

William David Wilkes, surgeon, of Salisbury, the next witness, said that a little before eight o’clock on Friday evening, John Warne, the husband, came to his house with a message from Dr Gordon asking his assistance. The man himself was very urgent that he should go directly, as his wife was in great danger. Witness was able to go very shortly after eight and met Dr Gordon at the house of deceased in Green Croft Street. Dr Gordon told him the facts of the case from his examination, and he found, like himself, the poor woman suffering from loss of blood, no pulse at the wrist, faint, and conscious. He had a short consultation with Dr Gordon and agreed that the only thing to be done was to try and restore the powers of life by administering food and stimulants. The case presented one of the most serious complications of midwifery. Witness remained with Dr Gordon until about 10.30. Deceased had then rallied a little with a slight flickering pulse. Witness took Warne with him to the Dispensary to fetch Mrs Gough to go and assist. He did not see deceased afterwards.

The Coroner : Dr Gordon said death might have been prevented by summoning medical aid earlier. Do you agree with that?

Witness : In all probability life might have been saved had medical assistance been called in earlier, but I cannot say definitely.

In answer to a juryman, he said it was “the negligence of ignorance.”

By another juryman : Altogether they could hardly imagine such a complication of difficulties.

Another juror : Don’t you think a doctor ought to have been sent for?

Witness : Well, the mere fact of deceased’s losing blood ought to have been enough reason for sending for a medical man.

The husband of the deceased was re-called.

The Coroner : Did your wife have a complication like this in her previous confinement?

Witness : My two children were born at Yenstin on Somersetshire. I was not at home at the time. I was staying at Sherborne.

The Coroner : Did you ever hear your wife say?

Witness : She said she had a bad time and was ill two or three days.

A juryman : Was it true that Mrs Bunsell asked you two or three times to go for a doctor before you really did?

Witness : Previous to Friday at two o’clock Mrs Bunsell did not ask me.

Another Juror : Did she mention a doctor’s name at all?

Witness : No, sir.

Another Juror : Did you say you would not be able to catch the doctor?

Witness : I did not say it, sir.

In reply to further questions witness still adhered to his statement that nothing had been said about a doctor until Friday.

Catherine Bolwell, a charwoman, of Green Croft Street, was next examined. In her evidence she stated that she was not at deceased’s house on Wednesday but she was there Thursday and Friday. She saw Mrs Bunsell about ten o’clock on Thursday morning. She did not hear any conversation between Mrs Bunsell and Mr Warne. She was there for about half-an-hour, and returned again in the evening about six o’clock. Both Mrs Bunsell and Mr Warne were there downstairs. She did not hear any conversation then, as she went upstairs to see deceased. She was there about half-an-hour and then left. She was there again Friday about half-an-hour. She did not hear any conversation about fetching a doctor. She was there again in the evening. Witness heard Mrs Bunsell say to Warne on Friday morning that they wanted a doctor and he said that if they wanted a doctor he would go and fetch one.

This was all the evidence. At its conclusion the jury adjourned for refreshments, and on assembling again the Coroner proceeded to sum up, having first called in Warne to ascertain the age of the deceased, who was found to have completed her 35th year.

The Coroner said the question for the jury was whether death was accelerated by the action of Warne or Mrs Bunsell, or by both of them; and then were they guilty of gross criminal neglect? “If they answered these questions affirmatively, it was their duty to find a verdict of manslaughter, if not they could only bring in a simple verdict. But whatever doubt they had in their minds as to the legal position of the matter they could hold but one opinion as to where the blame rested morally.

The jury retired, and upon returning, after an hour’s absence, gave the following verdict : “We find that Elizabeth Warne died from loss of blood during confinement, and that her death was accelerated by Catherine Bunsell not calling in medical aid earlier.”

The Coroner then informed Mrs Bunsell that she was committed for trial at the next Assizes on a charge of manslaughter.

At the request of the jury, the Coroner censured the husband for neglecting to get a doctor when he was made aware of the dangerous condition his wife was in.

The juror’s fees were handed by the foreman, at the request of the jury, to the secretary of the Dispensary (Mr Southby) for the benefit of that institution.

Mrs Bunsell came up before the Mayor (Mr S Parker) yesterday (Thursday) and was formally charged with the crime of manslaughter. She was then remanded until today (Friday) when she was brought before the Mayor at the Police Station and liberated on her own recognizance to appear when called upon.

The Coroner bound her over to appear at the Assizes – herself in £50 and two sureties in £25 each. The two bondsmen are Mr T Hall, of 43, Winchester Street, and Mr Cookman, of Scot’s Lane.

Assizes Hearing 1889 July 6th

A short paragraph at the end of this unusually large newspaper item:

No Bills

No Bills were returned in respect of Wm Willshire, bailed, indicted for unlawfully attempting to have carnal knowledge of Catherine E Wilkins, aged nine years, at Keevil, on 23rd April, and Catherine Bunsell, bailed, midwife, of Salisbury, who was indicted on Coroner’s inquisition for the manslaughter of Elizabeth Warne.


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