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} experience this would incite him to fur ther violence . For some time
Hall had been worried by the use of handcuffs, which had always been
under the
charge of the underkeeper, and had directed that they should
never be used without immedi ately telling him.
However, as the two
attendants did not conceal the fact that Hi ckman died in handcuffs, which
they could easily have done, as sudden death was common to the patients ,
he was convinced that they were guilty only of a bad error of judgment and
not of any intentional and unnecessary cru elty .
Neverth eless, he
reported the incident immdiately to the Coroner and an
inquest was held.
Hall 's conscientious effort to follow the correct procedure
unfortunately did not produce the results he expected.
To his great
astonishment, the jury, with one exception (the Coroner 's District
Constable) , was composed of the convict officers of the station, including
the man whom he had suspended at Ross and others with whom he had
conflicted. The finding of the jury was ''died by the visitation of God11,
but it was accompanied by a rider which Hall considered unj ustly reflected
upon the management of the asylum rather than on its provisions, and found
the attendants .
guilty of intentional cruelty rather than of ignorance.
Although he tho.ught the verdict wrong and unj ust, Hall, nevertheless,
forwarded it by the first post to the Principal Medical Officer, enclos ing
fu ll details and his own comments, especially emphasizing his
opinion that
restraint in the treatment of lunacy should only be used to prevent
patients from inj uring thems elves or others, and that the utmost kindness
and strictest justice, allied with firmness, were essential to their
treatment .
Hall was completely unprepared for what fol lowed . Denison
directed the setting-up of a Board of Enquiry compr ised of James Smith ,
the Vis iting Magistrat at the Coal Mines and Saltwater River , and
Dr Galbraith, a staff surgeon, to enquire into and report on the
circumstances surrounding Hickman's death and on certain charges made
against Hall as to the general management of the asylum .
Th.e Board began its enquiry at Saltwater River on February 4,
1853.
Hall objected both to its constitution and procedur e;
although
Galbraith admitted to his inexperience in such matters, he was, none-theless,
most offensive in his statements , especially about handcuffs .
Smith was the Visiting Magistrate at the asylum and already biased.
Contrary to the attendants ' original statement , the Board found that
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Hi ckman was not acting violently when handcuffed;
also , that his death,