A further examination of the dreadful tradgedy of 1875
Drs. Tony and Gillian Waldron
The Norfolk & Norwich Hospital in 1879
as illustrated in The Building News June 13 1879
Sometime between four and four thirty in the morning of 13 December 1875, Robert Edwards, a 42-year-old patient in the Norfolk and Norwich Hospital, left his bed to walk a hundred and twenty yards through the hospital to the children’s ward. There he took up a heavy pair of fire-tongs from the hearth in one of the two rooms and started to violently attack some of the patients. He was discovered, unarmed, overpowered, and removed to Norwich Gaol leaving behind five seriously injured boys, three of whom died on the spot, one died a few weeks later, and one survived into old age. The murders precipitated a week of frantic activity for the authorities. Edwards came before the magistrates later the same day, apparently still with blood on his face and looking haggard with a shrunken ghastly face, with eyes darting about and making loud unintelligible utterances. A second hearing followed on Thursday 16 December, and on the 18th he appeared for the third time before the Magistrates and was committed for trial. The Inquest into the boys’ deaths opened on Tuesday 14 December and after an adjournment, resumed a week later. The Board of Management of the hospital met in an extraordinary meeting on Thursday.
The ‘dreadful tragedy’ was widely reported in the local and national press. An examination of the events and procedures leading up to Edwards’ admission to hospital, however, suggests that the tragedy might have been averted, but for the poor judgement, or possibly professional incompetence of at least two of the principals involved, the Rev John Gunton and Dr Frederic Little.
Robert Edwards came from Marsham, a small village on the outskirts of Aylsham and about thirteen miles from Norwich. Marsham was a minor centre of weaving, listing in the 1871 Census twelve weavers in eleven households. Edwards lived in Cranes Lane, Marsham, with his parents, James and Mary, his sister Sarah and her daughter, and a boarder, who was a labourer. Both James and Robert were cotton and worsted weavers.
Weaving in Norfolk, which was overwhelmingly carried out on handlooms in lofts above the living quarters of individual homes, had been in decline for many years by the middle of the nineteenth century, cotton weaving, for example, having been overtaken by the mechanised mills of northern England. As a result, many weaving families, including the Edwards, could not make a living and depended on financial assistance from the Poor Law, in a system of outdoor relief.
Events prior to admission
James Edwards gave evidence at the committal for trial saying that his son ‘was never much in constitution’. About three months before the attack he had noticed a despondency of spirit in him, and two months before, Robert had asked his father to remove his razor from the top of the bureau because he had no control over himself. He became weaker and more despairing over the next few weeks. During that time, he had been visited by the local general practitioner Dr Richard John Morton. In the week prior to Robert’s admission to the Norfolk and Norwich Hospital his condition appeared to have alternated between a calm ‘desponding’ state and agitation and violence to the extent that his hands had to be tied to keep him to his bed. Robert’s father reported that he said, ‘take care of yourself, I have no control at times.’
Harriet Edwards, a cousin of Robert’s mother, also gave evidence at the committal. She saw Robert in bed on the Tuesday evening before his admission and described him as trying to get away from her and his father. They had to work hard to restrain him in order to keep him in bed and he said he wanted to go away somewhere. The next evening, he was sitting up in bed eating plums and speaking very reasonably, but the following day he needed restraint again, including having his hands tied together for an hour or so at a time. The next day, the day before he was admitted to hospital, Harriet found his mood and behaviour varied greatly throughout the day. At some point in the day he dressed and went out, and later visited her at home for a few minutes although some of his relatives had asked him not to leave the house. Harriet had known Robert for about thirty years and she said he was always given to nervousness but more recently had become restless and uneasy and she had seen a deterioration in his mental condition over several weeks.
Admission to hospital
Postcard views of c 1905
During the course of his illness, Robert was seen by a number of doctors and clergy, all of whom had a part to play in his admission to the Norfolk and Norwich Hospital. The Rector of Marsham, the Rev John Gunton had known the family for at least thirty years and had been a frequent visitor, last seeing Robert on the day prior to his admission. At the inquest he said he had never himself seen any indication of violent or insane behaviour but he had heard of the recent need to restrain him.
In contrast to this, the Curate, Roger Wright, gave evidence to the committal that on his visits to the Edwards’ home in the previous six months, he saw Robert, ‘always excitable and very strange.’ He believed that Robert was gradually getting worse with symptoms of insanity. Wright visited as frequently as he did because Gunton was away on holiday for a number of weeks in the autumn. He gave evidence that on his return he told Gunton that, in his opinion, Robert was insane but he saw that Gunton was surprised to hear that opinion.
The church of All Saints Marsham
During this period Robert was seen by local general practitioners, the Drs Morton, father and son, and it is reported that Dr Morton junior believed him to be insane. Neither doctor took any further action, or is known to have recommended any treatment, and indeed, when James called in some distress at the beginning of December to ask for a visit for his son, Dr Morton junior was out, and Dr Morton senior refused to visit for reasons which are unknown.
James Edwards then turned for help to Dr Frederic Little who was the District Medical Officer for the Aylsham Union. He advised James to see Mr Roe, the relieving officer, who would sanction his visit under the auspices of the Poor Law and also to arrange for Roe and Gunton to meet him at the Edwards’ home the following day. James gave evidence that he said to Little that he thought that his son was insane and might have to go to the asylum. When Dr Little visited on Saturday the 4th of December, he found that neither of the other two men was in attendance. At the end of his examination he made out a recommendation for Gunton that Robert should be admitted to the Norfolk and Norwich Hospital as in his opinion, Robert would benefit from a period in hospital. Gunton being a subscribing governor of the hospital had the power to recommend patients for admission, this being the only means by which non-paying, non-emergency patients could apply for admission. Since Little appeared at neither the inquest nor the committal proceedings, we have no sworn evidence from him as to how he came to the conclusion that Robert was better treated in the general hospital rather than in the asylum.
James gave Little’s letter to Gunton on Monday the 7th and received the recommendation for admission the following Friday. He went with Robert to the Norfolk and Norwich Hospital on Saturday the 11th where Robert was seen and admitted by one of the hospitals admitting physicians, Dr Frederic Bateman.
In his evidence to the inquest, Bateman said that Edwards complained of stomach pains, particularly after meals, had to be careful about his diet, had been severely unwell for about six months, and generally unwell for much longer. He appeared to be entirely rational and Dr Bateman said he had no suspicion of insanity. When asked by one of the jurors, Bateman stated that he had considerable experience of dealing with insane patients. In response to further questioning from the jury he said that sudden attacks of homicidal mania in people who had previously appeared well ‘were not very uncommon’.
The fateful weekend
During his admission from the Saturday morning to the Sunday night Edwards’ condition was observed by the nursing staff and the house physician, Dr John Baumgartner. He was generally thought to be nervous and peculiar but it never occurred to any of those who saw him that he was insane. One nurse described him as looking rather wild and very unhappy. On Sunday morning Baumgartner saw him and said at the inquest that he felt that he had a nervous disease but there was nothing to suggest that Edwards could be dangerous. He continued to treat Edwards with medicine after meals as prescribed by Dr Bateman.
On Sunday night Edwards was unable to sleep and was found out of bed more than once and needed persuasion to return to bed. At about 4.30 on the Monday morning he was reported missing by one of the night nurses and Dr Baumgartner was woken. In their search for him 14-year-old Harry Frost, who had escaped from the children’s ward and was running in the corridor, told them Edwards was attacking a boy in the ward. Baumgartner entered and found Edwards assaulting a boy with fire tongs from the hearth. Baumgartner struck Edwards several times with the poker he had also picked up from the fireplace before seizing him by the throat and wrestling him to the floor. Two porters took Edwards away from the ward and he was subsequently remanded in Norwich Gaol. The end result of the attack was that two boys, Joseph Coleman (11) and John Lacey (10) died instantly from their head injuries, another, William Martin (11) died within the hour, while a fourth, Alfred Clarke (9) was badly injured but lived for another two months before dying in the hospital; nine year old Edward Lubbock survived into old age.
Norwich Castle at the end of the C18th.
The cells which housed Robert Edwards would have been built within the keep of the castle by John Soane in the 1790's
and retained when a more modern gaol designed by William Wilkins was built after 1819.
This print by Ladbrooke (father or son?) shows the next stage of the Castle Gaol and probably very recognisable to Robert Edwards
According to his prison records, Edwards was quiet and bewildered on arriving at the gaol. The next day he seemed ‘utterly deranged’ but no details were given. Two days later, on 16th of December he had a seizure, the only one recorded in his entire history.
Whilst in prison, Edwards continued to complain of pain and appeared emaciated but apparently ate well. His behaviour varied from complete rationality to ‘childish drama’, and from sitting quietly to moving about restlessly. He was able to give an account of the attack on the boys and it is noted in the record that this was done with a certain degree of savagery and he appeared unaffected by the awfulness of the crime.
After his appearances before the magistrates, Edwards was committed for trial on a charge of wilful murder on 18 December. On the 29th of December he assaulted a fellow prisoner by striking him over the head with a wooden clog. This attack appeared entirely unprovoked, both men had been lying on their beds immediately prior to the attack. When seen later by the prison doctor Edwards said he was very sorry and asked for his forgiveness. In the light of this latest development, an application was made to the Home Secretary for his committal to Broadmoor, and this was granted on 11 January 1876 when he was certified as insane by the Secretary of State for Lunatics.
Image from Illustrated London News p 208 August 24 1867 courtesy of the British Newspaper Archive
Broadmoor Hospital, in Crowthorne, Berkshire, opened in 1863 to deal with the problem of accommodating those criminals deemed insane and unfit to be held either in a prison or in a lunatic asylum. It was built following the passage of the Act for the Better Provision for the Custody and Care of Criminal Lunatics 1860. The Act authorised the building of Broadmoor which could confine and treat 400 men and 100 women. Its design was typical of a nineteenth century asylum and it would be indistinguishable from one were it not for the secure outer perimeter. From the outset it was staffed as a hospital and not as a prison, in order to provide a therapeutic rather than a punitive regime. Edwards made the journey from Norwich Gaol accompanied by two prison officers on 18 January 1876. The journey took them by train from Norwich to Liverpool Street Station, across London by cab to Waterloo Station and from there to Wokingham where the Broadmoor Omnibus took them the five miles to the asylum. One can imagine this journey to have been an alarming experience for all three men.
On admission, Edwards, five feet five-and-a half-inches tall, and weighing seven stone ten pounds, was described as weak, feeble, and emaciated. He continued to complain of abdominal pain and kept to his bed. His uncontrollable appetite is remarked upon. His mental state was clearly abnormal. He spoke ‘in a scarcely intelligible whisper’ on admission but subsequently became restless, noisy, beating on his door and shouting that they had killed his sister. He rocked on his knees and elbows. In February it is noted that he felt that he should be sent back to Norwich to be punished and sometimes asked if he was to be hanged. In fact, in April 1876, the Governor of Norwich Gaol wrote to enquire whether Edwards would be fit to stand trial to which the answer was no.
From the end of April 1876, Edwards was admitted to the infirmary ward where he was confined to bed, fed a light milky diet but remained in pain and was restless and agitated. He suffered delusions that his food was poisoned. During his time in Broadmoor his physical condition fluctuated, he was described as no longer emaciated and, on occasion, he was well enough to exercise outdoors.
There was a regular correspondence between Robert’s brother William and the Broadmoor authorities who were generally reassuring about Robert’s physical condition, whilst confirming that he remained extremely mentally unwell. William, in fact, made the long expensive journey to visit Robert in September 1876 but there are no details of the visit in the records and he did not visit again.
Edwards’ clinical course continued over the next couple of years with his changeable mental state and his fluctuating physical condition. He remained in the infirmary ward. On 13 July 1879 he developed pneumonia and his brother was informed that he was seriously ill; he died two days later. The Broadmoor Superintendent, David Nicholson, wrote to William on the 16th of July informing him of his brother’s death and inviting him to the funeral. William replied that he could not afford the time or expense of the journey but expressed sincere gratitude for the care and attention his brother had received. An inquest on the 17th of July gave the cause of death as inflammation of the lungs and Edwards was buried in the grounds of the hospital.
Image of the Men's Day Room from Illustrated London News p 209 August 24 1867 courtesy of the British Newspaper Archive
For further information from the article see the foot of this page.
What was Roberts Edwards’ condition?
The evidence of Robert Edwards’ history after the tragedy in the Norfolk and Norwich Hospital clearly points to a severe and chronic psychiatric disorder. Although the Broadmoor notes lack detail, they do identify his experience of paranoid delusions; such as his food being poisoned by doctors, and that his sister had been murdered. His mood appeared to fluctuate between deep depression and apathy, and agitation and restlessness. There is no evidence of any violent behaviour after his transfer to Broadmoor. There is no absolute indication of a diagnosis but we suggest that a mood disorder, varying between severe depression and a more excitable, manic state, is most likely. He was in poor shape physically, clearly suffering from a chronic gastro-intestinal condition which is, in our opinion, impossible to diagnose in retrospect.
Given the fact that he was suffering from both physical and psychiatric conditions, the vital question is, was it correct to admit him to the Norfolk and Norwich Hospital or should he have been referred to the Norwich County Asylum? Edwards’ father James and the other witnesses to the inquest who had seen him at home in the weeks before his admission, are clear that for at least several months his mental health had given cause for concern. In the previous week he had required restraint, apparently to stop him harming himself. He had confessed to having no control over himself, asking for his razor to be hidden, presumably because he had suicidal impulses. Although there are indications from witnesses that he had been unwell for a long time, it seems apparent that his disturbed behaviour was recent and his father and others were sometimes frightened of him. At that point it does seem clear that, taking his condition as a whole, it was not safe to admit him to a general hospital without considering his mental state – his suicide risk especially.
Having said that, the accurate prediction of dangerousness in people with no history of violence has always been notoriously extremely difficult. There is nothing in the written accounts which could have foretold his dreadful homicidal attack. Indeed, it is difficult to understand why it occurred at all, as sudden homicidal attacks are not common in severely depressed people. Edwards did not lash out indiscriminately at people around him but moved a fair distance through the hospital without a weapon and only armed himself once in the children’s ward, hinting at an impulsive drive possibly underpinned by a false belief concerning the boys. This may have been that they were either the cause of, or the victims of, an impending catastrophe. Such a delusion is typical in very severe depressive states.
Was anyone to blame?
If, as seems likely, an error was made in Edwards’ admission, can we understand how this came about and who might have been responsible? Those involved are the doctors Morton, the Rev Gunton, Dr Little and Dr Bateman. Dr Bateman had no real opportunity to disagree with the recommendation for admission since he saw Edwards only once on the Saturday morning when he was calm and rational.
It is unfortunate that the only doctors with any prior knowledge of Edwards, Dr Morton Senior and his son, would not or could not respond to James’ request to visit his son. Had they done so they may have come to a different conclusion about his condition and made a different referral. This leaves Gunton and Little, the first was a reluctant witness to the inquest, whilst the second was not called, a strange omission under the circumstances. At the end of the inquest, the jury severely criticised Gunton for making the recommendation for admission since ‘he must have known his antecedents’ and expressed, in the strongest terms, their disapproval of the conduct of Little.
Gunton had, by his own admission, known the Edwards family for thirty years and had visited Robert, as he would any sick member of the parish, frequently. He gave evidence that he visited eight times from the end of October until the day before the admission to hospital. Gunton testified that he had never had any suspicion that Edwards might be insane, and described him as always calm in mind but sometimes restless in body. This is in marked contrast to the view of his curate, Richard Wright, who was in no doubt that Edwards was insane and getting worse when he saw him during the six or seven months of his curacy. When he tried to raise this with his vicar, he felt Gunton dismissed his opinion without further thought. Wright did not raise it again and knew nothing about Edwards’ admission to hospital until after the event. Richard Wright had met Dr Morton junior at Edwards’ house about two months before and they agreed on their opinion that he was insane. Morton said that he would visit the next day with his father to examine him properly. This did not happen. It seems that these two junior men had a better grasp of the situation than their seniors but neither was able to persuade the latter to their opinion.
Although Little did not appear at any of the investigations, he was quick to defend himself vigorously in public in a letter to the Norfolk News of 4 January 1876 reprinted in the Norwich Mercury the following Saturday. This letter was swiftly followed by one from Richard Wright written on behalf of James Edwards, refuting many of the points raised by Little. Little denied that James Edwards had ever raised the question of his son’s insanity whereas James asserts that he said, ‘my son is a crazy man’ and that he expected that Little would send him to the asylum. Other details in the letters, such as medication and relevant dates, do imply that Little was trying to cast doubt on the truthfulness of James Edwards’ testimony which had been given under oath.
Looking back on the evidence we have, it seems to us that the most reasonable explanation of what occurred during the critical week before Edwards’ admission was as James asserted. That is, that Little did expect to meet Roe and Gunton at the house on Saturday 4 December as he had asked James to arrange. James said that he expected the purpose of this meeting was to sign the certificate for Roberts’ removal to the asylum. In fact, for whatever reason, neither man kept the appointment and Little examined Robert alone. Faced with a patient who was clearly physically ill but who at the time was in one of his calm moments, the simplest option for Little was to arrange for his admission to hospital, which could be achieved by writing a recommendation to Gunton, thus ending his involvement in the case, and this he seems to have done. It appears that rather than go to the trouble of re-arranging a joint meeting, when he would have had to visit again and go through the rather more bureaucratic procedure for asylum admission which required an application, with medical evidence to the JP for pauper patients, Little took the easier option.
According to James, the note to Gunton was written on that day and delivered by him. Non-emergency admission to the Norfolk and Norwich Hospital was on Saturday morning which explains the delay of a week. During the waiting period Little was called again to see Robert and according to him it was on this second visit that he wrote the note to Gunton.
It was only after Little was blamed for the unforeseeable tragedy in the hospital that he felt the need to justify his actions. Whether his denial of the history given by James was due to poor memory or deliberate cover-up, is impossible to know, although one can draw one’s own conclusions. What is certain is that had James’ anxieties been taken seriously and Robert had gone to the asylum the boys would not have died.
What were the repercussions of this case for the Norfolk and Norwich Hospital?
The Board of Management of the hospital generally met each week on Saturday but gathered on the Thursday after the killings in an emergency session. The details of the attacks were related to the members who decided that no blame could be attached to the hospital for what had occurred. They recommended that the admission forms should be changed to ensure that the exclusion criteria, which included insanity, were printed on the form which should be signed by the referring governor and examining doctor. They also suggested improving security at night by having an alarm system for the doctors, locking the doors between the male and female wards, and increasing the night nursing staff. They particularly praised the courageous actions of Dr Baumgartner and the Matron and nursing staff. Finally, the meeting agreed to pay the funeral costs of the three dead boys, recorded after a subsequent meeting at £13 11s.
And for the rest?
John Gunton continued as a governor of the hospital and remained vicar of Marsham until 1888 and died two years later. Frederick Little too had a long working life, continuing in practice in Aylsham until his death in 1927. The doctors Morton also remained in practice in Aylsham, the son succeeding his father in due course. Frederic Bateman became one of the most eminent Norfolk physicians, noted particularly for his expertise in diseases of the nervous system; he was knighted in 1892 and died in 1904.
John Baumgartner, the only one to leave Norfolk, moved to his wife’s native Newcastle to practice in 1881 where he remained for the rest of his working life. He died in Kendall, in the Lake District in 1920. Edward Lubbock, the boy who Baumgartner saved, lived until he was 75, dying in 1947. These portraits of Dr Baumgartner and his wife Augusta have been very kindly supplied by Christopher Vane Percy who is a Baumgartner descendant and today lives at Island Hall which was the family seat of the Baumgartners:
Images from Illustrated London News pages 208- 209 August 24 1867 courtesy of the British Newspaper Archive