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The Bendigo Advertiser Monday April 17, 1871
An inquest was held by the District Coroner on Saturday, at the Hospital, on the body of Mary Moran, wife of a miner residing at Raywood.
Dr Macgillivray, Hospital Surgeon deposed that the deceased was admitted on 28th March, suffering from cancer for the purpose of having an operation performed. The operation was performed on the 12th inst. And the deceased progressed favorably. Deceased generally had a quarter grain of morphia entered in the prescription book either by the witness or Dr Penfold. On the evening of the 14th inst., witness visited deceased but did not order any draught for her. A little before 10 o'clock, the night nurse, Mrs Frost, called him and said the deceased had taken very ill after getting her draught:- She said she knew that the witness had not ordered the draught that night but supposed it had been sent from the dispensary. Witness looked at the bottle in which the deceased's draught had been. It then contained half an ounce of carbolic acid. He immediately went to deceased and found her insensible. The stomach pump was applied, and the stomach thoroughly washed with warm water and oil. Deceased sank rapidly, and ammonia was then injected into a vein in the arm, but no effect was produced, and at 11 o'clock deceased died, about an hour from the time she took the draught. That evening he had order carbolic acid as a disinfectant for the upstairs male ward, No.4, where Humphrey Buckler was night wardsman. The prescriptions that night were made up by John Barker, the dispenser's apprentice, except one containing hydrocyanic acid, which he did himself. The carbolic acid ordered as a disinfectant ought to have been put in a bottle with a label stating what it contained and marked "Poison" as well as the number of the ward for which it was intended, instead of which it was put in the bottle which usually contained deceased's draughts, and the bottle had still the old label upon it, and the No. 9 of the deceased's ward. The word "carbolic" was written at one end of the label. The rule in the hospital is strict that everything not intended for internal use must have a label with "poison" printed on it and had that rule be carried out in this instance this accident would not have occurred. The apprentice, John Barker, had been two years in the hospital, and was an excellent dispenser. Since he had been allowed to make up prescriptions this was his first mistake. Prescriptions requiring particular care were not left to him, but were made up by either Dr Penfold or witness. Barker is a very sober well-conducted lad, sixteen years of age, and all the dispensers in the hospital have spoken highly of his character and his capability to dispense. In writing prescriptions, witness at the beds of patients, always pointed out to the wardsman or nurse what each patient was to get until next visit. The wardsman, Humphrey Buckler, was a considerable time wardsman in the Melbourne Hospital, and brought an excellent character from Dr Moloney some four months since, and had fulfilled the character whilst here. The nurse, Mrs Frost, had considerable experience in the Lying-in Hospital and Melbourne, Asylum and had given satisfaction since her employment. The quantity of the fluid taken by the deceased was 230 grains of purchrystalised [sic] carbolic, and the medicinal dose would have been three grains.
Humphrey Buckler deposed that he was wardsman in charge of Nos. 7, 8, 2 and 4 wards. Between nine and ten o'clock on the 14th instant he went to the dispensary for medicines that Dr Macgillivray might have ordered for No. 4 ward. J. Barker gave him eight or ten bottles of medicines for the patients. The bottle with the deceased's name was amongst them. Witness remarked to Barker, "there is some disinfectant fluid ordered," and he said "all right", and putting the bottle (produced) with the others he went on making up two or three more draughts, and placed them with the rest. Witness knew one of the bottles contained carbolic acid for disinfectant purposes. He took the bottles from the window, and seeing deceased's name and the No. 9 ward on one (produced) took it to nurse Frost, remarking that it belonged to her ward. He then distributed his bottles to the patients, and in a quarter-of-an-hour missed the carbolic acid bottle, and went to see Barker, who told him the carbolic acid was in a small draught bottle, and witness remarked that it must have been in the deceased's bottle, and he had given it in mistake to the nurse. Witness went to Dr Macgillivray, who showed him the bottle and asked for explanations.
Oliver Penfold, assistant surgeon and dispenser, gave evidence agreeing with Dr Macgillivray's. He considered Barker a competent dispenser and particularly careful, and was not aware that he had ever made a mistake before. Buckler and Frost deserve the characters given them by Dr Macgillivray. Barker should have hidden the label on the deceased's draught bottle by a label over it with the word "carbolic acid" printed on it, and another label under it with the word "poison" printed.
Margaret Frost, nurse in No. 9 ward, deposed that she received the bottle from Buckler. It was the bottle deceased's draught had been in on the two previous nights. She knew it because her name was on it. Witness gave it to deceased's daughter, who was with deceased, and then went to her room. In a few minutes deceased's daughter came and said her mother had taken ill, after taking the draught, and that her mother on swallowing it said she was poisoned. Dr Macgillivray was at once sent for. Dr Macgillivray did not tell her to give deceased any draught that night, but when she got the bottle she thought it was intended for deceased. Witness did not notice the word "carbolic" on the label, the writing was blotted as with a damp finger, and not distinct.
Mary Moran, daughter of deceased, deposed that she was permitted to be with her mother. Nurse Frost gave her the bottle for deceased, and then went out, witness handed the bottle to deceased, and she drank the contents and immediately handed it back saying she was poisoned. Witness ran for Mrs Frost. She and her mother had been kindly treated at the hospital.
Constable Wm. Kavanagh, of Raywood, deposed that he knew the Moran family, and they were always well conducted. He had visited deceased, who was a friend of his wife, and she spoke in the highest manner of the attention paid her by the doctors and nurse Frost, also gratefully at her daughter being allowed to be with her.
John Barker deposed that he was apprenticed as a dispenser at the hospital. Buckler came for the medicines for his ward about 9.30 o'clock. Witness filled the bottle (produced) with carbolic acid, and told Buckler, and gave it to him. After writing the word "carbolic" on the label, witness did not observe the name, Moran or No. 9 upon it then. He knew there was no draught for deceased that night. On the two previous nights she had morphia draughts, which witness made up, and put the label on. It was his duty to put a label on everything containing poison, and if there was previous label on a bottle to take it off, or cover it with a fresh label. Buckler asked at the dispensary window for disinfectant fluid, and witness filled the bottle and gave it to him, telling him it was carbolic acid for that purpose. It was the last bottle he handed to Buckler. When he gave Buckler his medicines witness went on filling up two or three other bottles. He could not tell why he omitted putting a fresh label on, except that he was in a hurry to go out with a message for Dr Macgillivray. Carbolic acid was in constant use throughout the hospital. He always found the medicines safe with the wardsmen and nurses.
The jury gave a verdict that deceased came suddenly by her death from accidental poisoning by carbolic acid, and added "at the same time we must deeply regret that the dispenser, John Barker, and the wardsman, Humphrey Buckler, were not more careful in obeying the instructions of the resident surgeon."
Inquest held on 15th April AD 1871
Mary Moran at the Hospital Sandhurst.

Received at the Crown Law Office April 18th 1871. Forwarded by direction for the attention of the Crown Solicitor Sandhurst County of Bendigo, Colony of Victoria.
The Bendigo Hospital Sandhurst.
[the cover contains an annotation " Chief Clerk says did not go IB"].
John Crowley (foreman)
Walter Bolitha
Lawrence H D'Arcy
Samuel Brown
James Gilmartin
John Wells
John S:Eastwood
James Trimble
Charles Bridges - Patrick Kain
Jim Dowell - James Knights
Thomas J Dynau (?) - William Lovelace
A Faulkner Chalmers and George Barker.
Mary Moran aged about 60 - about 11 o'clock … on the 14th April 1871, The deceased Mary Moran came suddenly by her death in the Bendigo Hospital Sandhurst from accidental poisoning by carbolic acid - At the same time we must deeply regret that the dispenser John Barker and the wardsman Humphrey Buckler were not careful in obeying the instructions of the resident surgeon - there were no marks of violence externally upon the deceased's body.
Deposition Paul Henry MacGillivray resident surgeon to the Bendigo Hospital, Sandhurst, Colony of Victoria.
The deceased Mary Moran from Raywood was admitted into this hospital on the 28th March suffering from cancer, and was admitted for the purpose of having an operation performed, her daughter Mary was allowed to be with her daily, and to remain as long as she liked. The operation was performed on the 12th instant, and deceased progressed favourably afterwards, she generally had a night draught containing ¼ [ozs] of morphine. The order for such had been written by me in the prescription book in the ward in the usual way, or in my absence by Dr Guildford [Penfold?] if he visited at night the patient. - On the evening of the 14th yesterday, I visited the patients myself about 9 o'clock and did not there order any draught for the deceased - a little before 10 o'clock I was called by the night nurse, Mrs Margaret Frost, who told me Mrs Moran had been taken very ill immediately after taking her draught. The nurse said she knew I had not ordered the draught that night, but supposed that I had sent it up from the dispensary. She then gave me the [brown?] bottle I produce which was the one deceased draught had been usually sent up in. It now contains about half an ounce of liquid Carbolic Acid. - I immediately went to No. 9 deceased's ward, and found Mrs Moran insensible. I used a stomach pump, and washed the stomach thoroughly out with warm water and oil. After this, finding she was rapidly sinking, I injected ammonia [?] into a vein in one of the deceased's arms, but no effect was produced - and she expired at 11 o'clock, about an hour from the time she took the poison. That evening I had ordered Carbolic acid as a disinfectant for the upstairs male ward where Mr Humphrey Buckler was night wardsman and in the prescription book belonging to No. 4 ward it was for the use of the night stools - The prescriptions I ordered last night were made up by the dispensary apprentice John Barker, with the exception of one which I dispensed myself, containing hydrocyanic acid - The carbolic acid I ordered as a disinfectant ought to have been put in a bottle with a label stating what it contained and marked poison as well as the No. of the ward for which it was intended - instead of which it was put into this bottle which usually contained Mrs Moran's draught, which bottle has still the old label upon it and the No. 9 of the deceased ward. The word Carbolic is written at one end of the label. The rule in the hospital is very strict, that everything not intended for internal use must have a label with Poison printed on it, as by the bottles produced now now in use in the different wards, and had that rule been properly carried out last night this incident would not have occurred. The apprentice, John Barker, has been in the hospital about two years. He was appointed to this hospital to be trained as a dispenser, and is now an excellent dispenser.
Since he has been allowed to dispense prescriptions he has not made any mistakes previous to this occurrence, although now a good dispenser, any prescription requiring particular care is not left to him, but is made up by the assistant Surgeon, or personally superintended. On last night, he Barker, had nothing to do more than he has done for many months past, he is a very sober, well conducted lad - between 16: or 17 years old - Since Barker came here all the dispensers at this hospital gave me a very good character of him as to his capability to dispense and of his good character and conducts. In writing prescriptions at the beds of patients I always point out to the wardsman or nurses what each patient I to get until my next visit, morning, day or evening. The wardsman Humphrey Buckley was a considerable time a wardsman in the Melbourne hospital and brought from Dr Moloney there an excellent character to me, he has been here some 4 months and has fulfilled the gd. Character given of him whilst here - The nurse Mrs Frost was brought from Melbourne where she had been for a lengthened time a nurse in the Lying in Hospital and in the Benevolent Asylum Melbourne. She also was strongly recommended by Dr Avents of the Lying in Hospital, and Dr Smith [?] of the benevolent Asylum in Melbourne - She has given satisfaction here since she was employed - These people are all sober persons and were so last night to my knowledge. The quantity of the fluid taken by the deceased would be half an ounce, containing about 230 grains of pure crystallized Carbolic acid. The medicinal dose would be from one to 3 grains/ I have read of two cases (in France) where 150 grains was given by mistake for several successive days, largely diluted, and in these cases the patients did not die there from - A strong solution is a powerful caustic as well as being a poison, when given internally it must always be diluted largely with water. In this case the cause of death was poisoning by carbolic acid. Very few cases of carbolic acid poisoning are known.
Precise Oliver Penfold assistant surgeon to the Bendigo Hospital, Sandhurst, Colony of Victoria. Was t superintend the medicines but one was made up in his absence (by Macgillivray). He agreed a label should have been put on the bottle.
Precise Margaret Frost Bendigo Hospital, Sandhurst, Colony of Victoria.
…I brought them back together with 2 pills for the deceased Mrs Moran - I gave Mary Moran - deceased's daughter - the wine and the pills for her mother, she usually gave her mother her medicines when I handed them to her - About half past 9 o'clock last night Humphrey Buckler, the wardsman gave me at No. 9 ward door the bottle before me which had for the 2 previous nights held the deceased's night draught. I knew it by the deceased name and handed it to Mary Moran for her mother. I then went to my room to change my clothes for the night, and in a few minutes Mary came there, saying her mother was taken very ill and for me to come see her. I went to the deceased's bed and saw her very much changed and not sensible, I gave her a little wine. Mary told me her mother had taken what was in the bottle, and that she threw the bottle to her saying she was poisoned - I quickly took the bottle to the dispensary to John Barker, he was not there, and I ran to Dr MacGillivray telling him what happened, he immediately came and attended the deceased until she died…thought bottle was intended for her…did not notice the word Carbolic written on the label. The writing is blotted as with damp fingers and is not distinct…
Deposition by Mary Moran at Inquest held on 15th April AD 1871
Mary Moran at the Bendigo Hospital Sandhurst.
I am the daughter of the deceased Mary Moran residing at my father Thomas Morans, at Raywood (a digger). I came from Raywood with my deceased mother Mary Moran when she was admitted here and I have been permitted to be with her every day. Since mother came I generally gave her the medicines handed to me by the Nurses - I was with her last night [14 April 1871], when Nurse Frost gave me this draught bottle for mother as I got them the 2 previous nights. Nurse in giving it told me, if mother was asleep not to waken her, but mother was not asleep. Nurse was in her room and a little after she had given me the bottle I handed it to mother to take. She took what is out of it and immediately she threw to handed it back saying it she was poisoned. I said, no mother it isn't poison, Dr Macgillivray would not give you poison. - I gave her the wine bottle saying, it will cool you - She put it to her mouth and then returned it to me - she commenced moaning. I said do not moan mother to wake the other patients - after that she did not speak to me - I then ran to Mrs Frost - Mother and I were most kindly treated here by all - Dr Macgillivray and the Nurse were very quick in coming to attend mother after she had taken the fluid from the bottle.
Extract from deposition by Constable William Kavanagh, Police Constable stationed at Raywood.

For two years I have known at Raywood the deceased Mrs Mary Moran and her husband Thomas Moran, and also their daughters Mary and Kate…

(source: Family Research & Records of Bruce English.)

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