Introduction
The present Carmarthen Workhouse building and the one occupied by George Adams and master David John Rees was originally built in 1837, and was meant to serve twenty eight parishes within the County Borough of Carmarthen. 
The two stories that follow are excruciatingly sad as they show how intolerable the conditions were regarding those who fell ill in the early years of the Workhouse in 1846, through neglect and starvation, when up until then no inquests were ever held regarding the death of an inmate, and also fifty years later in 1896 when thirteen year old David John Rees died suddenly but could have been saved if more attention had been paid to his deteriorating health condition. The two newspaper reports give an amazing true and detailed insight into the conditions in the Workhouse and how it was run.
As I have mentioned in previous articles and reports, St David’s Cemetery was the burial place of most of those who resided at the Workhouse and by their very nature were simple burial services with little or no ceremony in unmarked multiple graves. Researching the following two stories only served to strengthen my resolve and determination to see the CROSS OF SOULS /Y GROES ENEIDIAU project come to fruition in February next year, if only to give due recognition to all of them, who through no fault of their own ended their days in an establishment that was meant to look after their health and educational needs and failed. As we approach Christmas this year, please spare a thought for all of them who had the misfortune to live there and to end their lives there and in particular George Adams and David Rees whose lives, though 50 years apart, were cut short by illness and neglect but will now be remembered once again. May they rest in peace.
As for George Adams, how could a successful silversmith and accountant/book-keeper end up a “Pauper Lunatic” in such terrible conditions all within the space of four years? It is impossible to comprehend and understand. In the 1841 Carmarthen Census he is listed as living in Priory Street as an accountant, presumably looking after the financial records of the Ivy Bush Hotel as stated in the Coroners report. Prior to that, as a successful silversmith, this was also mentioned by the Coroner. No records or documents exist to shed any further light on his sudden fall from grace. George Adams & David John Rees are but two entries in a burial register fifty years apart, but in reality they are far more than that. They represent a hugely important part of our social history in Victorian Carmarthen. Whatever the circumstances, the following Coroner’s Inquest Reports have been faithfully reproduced unedited and I have to admit in shedding one or two tears in the preparation of their stories. Finally, you will come across the name of a young man by the name of EVAN AYE, also an inmate of the Workhouse towards the end of the coroners report on George Adams who died a “short time previously” and to quote what was reported at the time of the inquest in connection with this young man…. “The Coroner said that it appeared to him that the workhouse authorities were anxious to withhold something from the public which they were afraid to have known” No official record exists of Evan Eye’s death in any available records and neither does his burial appear in any burial register, which makes the coroners remarks even more intriguing. What then happened to Evan Aye and his body? And what were the authorities hiding from the public, and why does no record exist of his death or burial? Also, what did the coroner know for him to make such a sweeping statement? Poor fellow, we shall never know the answer, or will we?
CARMARTHEN UNION WORKHOUSE – CORONER’S INQUEST.
The Welshman, page 2, 16th October 1846
On Monday evening last, an inquest was held in the Board Room of the Carmarthen Union Workhouse, before George Thomas, Esq., Coroner, and a respectable jury, upon view of the body of George Adams, a pauper lunatic, aged 52, whose death had taken place on the morning of that day. Deceased was formerly in a respectable station of life, having been a silversmith in an extensive way of business in this town, and at one period of his life he was book-keeper at the Ivy Bush Hotel. When residing in the town he was generally considered a quiet, inoffensive man. After the jury had been sworn, the Coroner addressed them briefly, and said that perhaps they would think there was some novelty in their being required to assemble in the Union Workhouse to inquire into the death of an inmate, and he wished therefore to state that although he had been in office two years yet he had never had intimation given him of the death of any individual in that workhouse. There had been cases in which he had heard of deaths after the bodies had been buried, and on which he certainly should have deemed it necessary to hold inquests had he received intimation of the decease of the parties. He however, happened to be accidentally at the Workhouse that morning, and was informed of the death of George Adams, which had just at that time taken place, and he immediately summoned a jury to enquire into the cause of death. His principal reason for enquiring into the cause of the death of a pauper inmate of the Workhouse, was this:—Under an old statute of the reign of Edward the First, whenever a death took place in prison, it was made imperative to hold an inquest on the body, because the law said that when a person was under restraint and not able to follow the inclination of his own will, it was but right and proper that the cause of death should be ascertained, in order that the public should be satisfied that death was not caused by reason of the hardships put upon the parties so confined. At the time this statute was enacted, there was no Poor Law, (the first Poor Law having been enacted in the reign of Elizabeth) so that there could, therefore, have been no Workhouse, and paupers could not have been under the same restraint as they are now. The old statute was undoubtedly confined to prison duress, but the jury would at once see that the reason for holding an inquest was as cogent where the party was confined though not in a prison. In either case the parties were not free agents, and were placed under the surveillance of others. It was therefore necessary to inquire whether the individual died naturally, and whether he was or was not treated properly. In this case no one assumed that the deceased was not properly treated, but he wished it to go forth to the public that it was necessary to hold inquests in Workhouses as well as elsewhere and perhaps more so, because of the restraint placed upon the inmates. He had that day taken the precaution to desire the Registrar not to register any death occurring in that Workhouse without first communicating with him on the subject. The jury then proceeded to view the body, which lay in the dead house of the Workhouse. The deceased appeared to be in rather an emaciated condition, but there was no mark to show that his death was the result of violence. On the return of the jury to the Board room, the Coroner called Henry Winchcombe, who in answer to the questions of the Coroner deposed as follows: – “I have discharged the duties of master of this Workhouse for more than 12 months. When I entered upon the duties Adams was an inmate of the House and has continued so until the present time. He was about 52 years of age when he died. When first I came to the Workhouse his health was very bad and he has been sickly ever since. He was a complete lunatic and unable to help himself. He was not at all violent and I never put him under any restraint. He would occasionally upset a ladder we have in the house and try to carry it on his shoulders, when both he and the ladder would fall to the ground. He once tried to make his escape through the front door, but was brought back again. He would often pile up the tubs that are in the male paupers’ yard, and endeavor to get to the top of the roof, in order as he said to make his escape. On different occasions he tried to get on the roof of the place where he is now lying, and if a person was to get up there, and was sensible enough, he might go along the roof to the outer wall and jump down into Mr. Norton’s field. He never attempted to injure himself or anyone else. I concluded he was a lunatic from the filthy state in which he kept himself, and the various tricks he played, which no sensible person would think of attempting. The men who attended the sick ward washed and dressed him because he was unable to do anything for himself. His clothes were always changed once a day and sometimes twice, and he was well washed every day. I never found vermin about him. His diet was what is usually given to sick paupers. For breakfast half a pound of wheaten bread with butter on it, and a pint of tea with sugar in it, but no milk. I don’t know whether he took all his meals or not. This breakfast was given at 8 o’clock, and at quarter past 12 he had for dinner half a pound of the best wheaten bread and three and a half ounces of beef. His tea, at six o’clock, was the same as his breakfast. If sick people wish it, they can have gruel for their meals instead of the usual food. Deceased generally chose the usual allowance. There were no other meals in each day and we generally shut the paupers up about 9 at night. He had a bed to himself in the sick pauper’s ward. Five men slept in the same room with him, four of them being sick paupers and the other was a pauper who slept in the room to take care of them. About a week or nine days ago deceased became confined to his bed. He complained of his stomach and his head. His appetite was not so good then. Sometimes during the last week he wished for gruel instead of tea. He never expressed a wish for anything that he did not get. During the last week 2 men and sometimes 3 attended him. There was always some one within hearing of him. I saw him once or twice a day and sometimes oftener. He has been under medical treatment ever since I have been here. The medical officer attends the sick ward almost every day. Our boy brought some medicine from Mr. William’s more than once a week. My wife looks at the directions on the label of the medicine, and tells the boy who brings it to inform the men who attend the sick paupers who it is for and when they are to give it. I never saw it administered myself, but I do not thing it likely that the medicine can ever go down the wrong throat. The attendants cannot read or write. Deceased has not taken medicine all the time I have been here, but has been in the sick ward. The medical officer has seen him almost every day. There is no book in the house stating when and what medicine was given. Deceased had gruel and wine in it several times this last week. He had 2 ounces of wine twice a day in gruel. This was sent up to the attendants, who were told to give it to him. They are not paid attendants but merely paupers. I do not know anything of the tastes of paupers, although I have been master of the Workhouse. I do not know whether they would prefer gruel with wine in it to tea without milk. We have no security that the sick man received the gruel or that the other paupers did not drink it. W. Owens had charge of the sick ward last week. I have not seen deceased at his meals this last week. I sometimes prepared the gruel and wine and sometimes my wife did so. My wife has the care of the wine and before she gives it she has an order from Mr. Williams, the medical officer. Mr. Williams makes an entry in his visiting book and on the day that wine was ordered for the deceased I forwarded the book to Mr. Phillips, Clerk to the Guardians, who sent me up a bottle of port wine. I did not taste it. It is kept in the pantry and is locked up by my wife. It was not labelled port wine.”
Mr. Phillips here remarked that as the wine was obtained from Mr. Webb, a respectable wine merchant that ought to be a guarantee of its genuineness. The Coroner said that he did not doubt its genuineness, but thought there ought to be some distinctive mark upon it, because there might happen to be a bottle of catchup by the side of the bottle of wine the contents of which might by accident be put in the gruel while the wine might by accident be used by the master.
Mr. Winchcombe re-examined:—
“I know the parishes of the two attendants but have no means of ascertaining their character. It is not my business. Owens has been in the workhouse more than 12 months, and Wm. Davies, the other attendant, about 2 months. A juror asked if a pauper named Wm. Thomas, a very honest and intelligent man, attended the sick. Mr. Winchcombe:—No, he does not, I find him useful in other parts of the House. The men are paid nothing whatever for attending the sick paupers. I select the men to attend upon the sick. The sick ward is open to 10 or 12 male paupers. There is nothing to prevent any of those from taking the sick man’s medicine or gruel, but I am of opinion that the two men who attend the sick would not allow any one to take it. Whether the sick man got his wine, his medicine, or his food depended upon the conduct of the attendants, but I went sometimes to see whether Adams had taken all his food and found that frequently he had not. It was then left there to be given him from time to time as he could eat it. I have seen Adams every day during the last week and several times in each day. The meals are sent up when the meals are sent into the Hall to the other paupers and I cannot attend to both at once. The two men who attended him and also the medical officer I believe were with him when he died. I have not seen him alive today. He died about 9 o’clock. The Board sat at 10. He died before the Board had assembled. I believe he did but really cannot say when he died. I heard in the House that he died before the Board met. I am not the master now, but merely fill the office temporarily until another person is appointed. I ceased to be master about 4 months ago. I was removed from my office by a letter from the Poor Law Commissioners. I was requested by the Guardians to remain until a certain time had expired and that request was renewed at the expiration of that time. I am now left from hour to hour and minute to minute to suit the pleasure of the Guardians. The joint salary of myself and my wife is £60 a year. There has been no fresh agreement as to salary since my dismissal.”
In answer to a juror – “We allowed fire and candles all night in the sick ward.” The last money I received on account of salary was about 10 months ago. I have made applications for payment of my salary. I still continue here because I cannot get my salary paid up so as to allow me to go away. My books have been examined for the last 3 quarters, but I have only been paid up to Christmas last. A juror wished to know how it was that in the printed quarterly abstracts the salary of master and matron appeared as if paid, when Mr. Winchcombe swore positively he was not paid. Mr. Winchcombe – “I cannot get a shilling. I would leave here directly if I could get payment. I have written to the Commissioners to that effect. I asked for a settlement of my accounts and payment of what was due when I opened the Commissioner’s letter containing my dismissal, but Mr. Stacey, (Vice Chairman of the Board) told me he did not read the letter as an immediate dismissal. I am not desirous of continuing here as master”. The Coroner here said that his motive for questioning Mr. Winchcombe respecting his salary was to show that the guardians were wrong in detaining him and continuing him as master against his will, and also in withholding his salary, and thus withdrawing all stimulus for him to act rightly. Mr. Winchcombe: “I consider that all my responsibility as master of this workhouse ceased when I received the Commissioner’s letter of dismissal, and I do not hold myself responsible for anything that occurs in the workhouse. I have stated this to the Board, but Mr. Stacey told me he did not view the letter in that light. The Coroner said this appeared to be a species of imprisonment of Mr. Winchcombe, and if by any possibility he were to die it would raise a doubt in his (the Coroner’s) mind as to whether an inquest ought not to be held upon him, since he was clearly under restraint. A juror observed that in the medical officer’s visiting book there was a remark that deceased had ulcers on his back; he wanted to know how the deceased’s back could become ulcerated when he had only been in bed nine days. Mr. Winchcombe said that deceased had ulcers about him for some time past, but they were not of any consequence. He was quite helpless and sometimes fell out of the bed. The skin was off his back. The doctor was aware of it. There was no discharge from the ulcers. I only attended to his cleanliness, and left the rest to the medical officer. Deceased’s back was washed with warm water and black soap, and properly dried. He had a clean bed and clean bedding. We changed the bed clothes when requisite. At the request of Mr. Phillips, Clerk to the Guardians, the Coroner asked Mr. Winchcombe if he was offered his salary up to the time his accounts were audited. After a rather rambling statement, Mr. Winchcombe positively denied that he was ever offered his salary up to the time to which his accounts had been audited, and declared he had not been paid since Christmas last. Mr. John Williams, surgeon, was next examined: – he said:—“I am the medical officer for, this Workhouse, and have been so for 1 year and 8 months. Deceased has occasionally been under my treatment since he has been in the house. His last illness commenced on Saturday week, but I visited him every day previously. He had vomiting and purging with a little fever, being the symptoms of English cholera. I gave him medicine on that day. I saw one pill administered. One was to be taken every four hours, I had brought them up in my pocket, having heard that he was vomiting and purging. My orders are to take any medicine that I may have occasion to give to paupers to Mr. Winchcombe, and tell him to take it to the sick ward. I gave them on this occasion to an intelligent man named White, and desired him to give them every four hours. I had written on the box “One of these pills to be taken every four hours, George Adams.” White can read and write. I saw the deceased on Sunday, the next day. I have seen him every day since except Friday when I was from home, and Mr. Rowlands, surgeon, saw him for me. Deceased was considerably better on Sunday. I stopped the pills because relaxation of the bowels had ceased that morning. I saw him on Monday and he was rather worse. He had no purging, but his back was very much excoriated, more so than on Saturday when I last saw it. I ordered it to be well washed and wiped, and kept perfectly dry. It has been excoriated for some time; in fact great decomposition had taken place in his back. He had no symptoms of English cholera after Monday. On that day I ordered him 4 ounces of wine daily when I found that the skin was losing its vitality and sloughing, knowing that he required more generous treatment. He was gradually sinking on Tuesday, and his back got gradually worse. The wound is as large as both the palms of my hands, at the lower part of the spine or back. I did not give him any medicine after Sunday night as it would only have disordered his stomach. I relied on the wine. I ordered a bread and water poultice to be applied to his back on Tuesday, which was done. His back is now partially ulcerated. The cause of death was a broken down constitution and a loss of vitality in the skin. His constitution had been broken up for some time. He had had incontinence of urine for some years, and as he lay so much in bed decomposition had taken place in his back in consequence of the pressure. I communicated with Mrs. Winchcombe daily. I could never find Mr. Winchcombe. I do not know where he keeps himself. I have a book at home in which I keep a register of the treatment of sick paupers, which the auditor inspects. There is no book kept in the Workhouse in which the treatment of the medical officer is entered, nor is any account taken of the medicine given. There is a book in which I make entries of visits to patients. I am sorry to say that I do not every day enter my visits, because I cannot always find the book, it being with the master. I generally entered a number of days together. Deceased was a harmless lunatic. The porter’s book shows when I visit the house, and forms a check upon my book. My book ought to be in the Hall in order that I may enter each visit, but it never is. I depended more upon Mrs. Winchcombe to attend to the sick paupers than any body else. I could not depend upon the master. I always gave instructions to the matron, and asked her to be kind enough to explain to the attendants how and when the medicine was to be administered. I saw the deceased take the wine and gruel yesterday, and the matron told me he had it every day. There are at present one lunatic, and three idiots in the house. A juror:—“do you include Mr. Winchcombe among the idiots”. Mr. Williams “No, but he is partially idiotic”. In answer to the same juror, Mr. Williams said that he considered the two men who were in the habit of attending the sick ward to be decidedly unfit to attend such a man as George Adams. A juror here remarked that if the sick paupers could thus attend upon each other, surely the healthy paupers could do so, and thus the salaries of officials would be saved altogether. The Coroner said that there ought to be paid nurses to attend to the sick. Mr. Williams re-examined:—“Adams died at half past 11; I was feeling his pulse at the time. There were maggots in his back when I saw him on Monday. The Coroner asked if Mrs. Winchcombe ever attended to the sick men’s’ ward. Mr. Winchcombe said she did not, as she was not allowed in the male paupers ward. Mr. Williams said he was sorry to contradict Mr. Winchcombe, but he had met Mrs. Winchcombe in the sick men’s’ ward. Mrs. Winchcombe afterwards protested she had never been in the sick men’s’ ward since her sojourn in the workhouse.
The Coroner said that he had heard that in the case of a poor idiot named Evan Aye, who died a short time ago, an inquest ought to have been held. Inspector Young stated that on one occasion when he entered the room where Evan Aye was sleeping, the stench was so intolerable that he was compelled to make a precipitate retreat. The Coroner said that it appeared to him that the workhouse authorities were anxious to withhold something from the public which they were afraid to have known. However he really hoped that in all cases in future, intimation would be given to him in order that he might exercise his discretion as to whether an inquest was requisite or not. The room was then cleared, and after a short time the jury returned as their verdict that the deceased died a” Natural Death.” The following observations were appended to their verdict, “and the jury express their regret at the inefficient attendance upon the deceased during his last illness, and at the want of care bestowed upon sick paupers in general in the Union Workhouse” The inquest then terminated.
DAVID JOHN REES 1833-1846
Sudden Death at the Carmarthen Workhouse. Inquest and Verdict.
An inquest was held by Mr Thomas Walters, the borough coroner, at the Union Workhouse, Carmarthen, on one of the inmates, David John Rees, a boy 13 years of age, son of Cornelius Rees, a labourer. Thomas Williams said I am 14 years of age in August next. I am an inmate of the Union Workhouse. I have been in here six years. I knew the deceased since he came in here some four years ago. He and I attended school together. We slept in the same room and in the company of seven other boys. We had a bed each. I was the eldest boy there. My bed was about two yards away from the deceased. Deceased used to be ill at times and complained of his head.
He was then in the day-room with the other boys. He went to bed about 7 p.m. The other boys went to bed at 8 p.m. I went to bed about 10 p.m. I was with the trainer until that time. The deceased complained to the trainer and me about five o’clock as to being unwell. The nurse gave him an aperient dose about six o’clock. Her name is Miss Burnhill. He sat down until he went to bed. I did not tell the master about his illness or anybody else. I am sure the deceased was asleep when I went to bed. He was groaning about half past ten and continued doing so until 4-45 a.m. I did not sleep the whole night. I told the other boys that I could not sleep with the row he made all night. I am a very bad sleeper and have been awake other nights. I got up about five o’clock to look at David John. He was frothing. I asked him if he would stop making that row. He was making the same row then that he had made all night. I went to call Miss Rees, the trainer. I did this because William Bentland told me that he was frothing at the mouth. There was no light in the room, but Bentland rose up the blinds. The trainer slept in an adjoining room about 10 yards away. Deceased had not been taken like this before. He drank his milk at supper, but left his bread. When the trainer came she sent us for the nurse— Miss Burnhill. She came at once; the trainer was there with the light. I was told by the nurse when she came that David John Rees was dead. I am not requested to do anything when something goes wrong at night. Hannah Burnhill said I am the nurse at this institution. I have been such for 18 years. Deceased had been in pretty good health during the whole time he has been there. The last witness asked me last night for a dose of aperient medicine for the deceased. He told me that the latter was complaining of headache. I gave him about a tablespoonful of Epsom salts. I think he was not very bad, otherwise the trainer would have told me. It is her duty to attend to the children. I did not hear anything more until 5 o’clock this morning. I was then called and found David John Rees dead. Mary Ann Rees said I am the industrial trainer at this institution. The children are under my care day and night whilst inside the establishment. The boys’ dormitory adjoins my bedroom. There is a passage and two doors between them. I can hear from my bedroom if there is any noise in the dormitory. I did not hear any noise last night. Deceased went to bed at my request at 7.10 p.m. I saw him again at 8 p.m. He was then no better. I looked in at 10 o’clock. He was then asleep. I then went to bed, and heard no more of it until Thomas Williams called me about 5 o’clock in the morning. The reason I concluded him to be asleep was that he did not reply to the boy Williams when the latter spoke to him. I did not go into the room at 10 o’clock. It is a mistake if I said so. Dr Lewis Hughes spoke to being sent for that morning. The boy was dead when he arrived. There was nothing to show the cause of death. A post-mortem examination might reveal the cause of death. Deceased had been fairly well during the whole of his time in the workhouse. The Coroner adjourned the enquiry in order that a post-mortem examination might be made. The adjourned enquiry was held at the Guildhall on Monday. William Bentland said I am 12 years of age, and have been two years and a half in the Union. I was 12 years of age in March last. I knew David John Rees. I saw him on Thursday afternoon in the yard. He was playing with me and the other boys. There are eight of us. This was about 5 o’clock. We afterwards went into the day-room. We sat down there and read a book. David John Rees was playing with a little boy. The little boy had a doll, and David John Rees was putting a handkerchief round it to make it dance. I went out for a bit. When I came again David John Rees was sitting on the fender by the fire. Afterwards I was called in to my supper. We have supper about 6 o’clock. Nurse sent for some medicine for David John Rees because he was bad. After we had been jumping, I asked him if he was cold. I asked him that because he was white, and his hands were blue. He said he was bad. I had never seen him like that. He took his supper. He took the medicine after supper. He was then white. The trainer asked him if he would like to go to bed. I next saw him at 8 o’clock. The trainer asked him if he was better, and he said no. We had a light. The gas was half-turned on. The trainer then put the gas out, and we went to sleep. I awoke about a quarter to five. I know that, because soon after the market clock struck five. I thought that David John Rees was choking because of the noise he was making. His brother, Henry Rees, went up to him and shook his head. He did not answer, and Tom Edwards, Tom Williams, and I went to call the trainer. There was no light at the time. Sometimes the trainer comes to see us after we go to bed. The trainer came when we called. Thomas Edwards (13) gave similar evidence. Dr R. G. Price said I made a post- mortem examination of the deceased. The cause of death was an abscess on the brain, in connection with middle-ear disease. He had chronic inflammation of the ear. There are usually outward symptoms of that disease, but there are cases of sudden death resulting from it. The cause of death is quite consistent with the symptoms described by the witness. I should consider them dangerous symptoms in a child. They were not of such a character as to impress an ordinary mind with the necessity of obtaining medical assistance. The” medical mind” is different from the ordinary mind.” Something might have been done years ago when the disease started, but nothing latterly”. There was probably then a running from the ear and nothing was thought of it. Such things develop into brain disease. He could not have been in good health for some time previously. He would not necessarily be in bad health. Mr Edwin Price, master of the house, was then called to define the duties of Miss Rees, the trainer. He did not consider it her duty to go round the dormitories at night except if there was something wrong. The Coroner, in his summing up, said that no blame could possibly be attached to anyone for the death.
Under the circumstances it could never have been foreseen nor prevented. It might be well, however, for the trainer to take a look round before going to bed. The Jury returned a verdict in accordance with the medical evidence. They added no rider.
Supplement to the Carmarthen Weekly Reporter January 10th 1896