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A coronial inquiry into the death of 9 year-old George Everett Jones and the management of the Swan Boys' Orphanage, opened in Perth on 2 June 1911 with a viewing of the boy's body in the Children's Hospital. The inquest was continued in the Coroner's Court from 7 June and concluded on 13 July 1911. George, who was not an orphan, had died in the Perth Children's Hospital in the presence of his mother on 31 May 1911, allegedly as a result of inhumane treatment at the orphanage. According to the Sunday Times (16 July 1911, p.13), the inquiry examined 60-70 witnesses, and sat for 15 days over a six week period.
The inquiry took evidence from other boys resident at the Swan Boys' Orphanage. It was reported at the time that these boys were transferred to from the Swan Boys' Orphanage to the Government Receiving Depot at Subiaco for the duration of the inquiry.
The inquiry heard that boys at the orphanage were underfed, ill-clothed and ill-treated. Eleven boys aged 9-14 years appeared as witnesses and gave examples of: boys being caned for bed-wetting; being made to work at the orphanage in the kitchen, wait upon staff in the dining room, cutting the hair of smaller boys and dressing each other's sores. The boys also gave evidence of orphanage practices such as: washing heads with phenyl to rid them of vermin; hunger, and being refused food as a disciplinary measure; maggoty meat; being hit on the head and scratched by staff; canings and beatings by male staff and beatings by the matron, including hitting boys' sores; boys being afraid to complain; and the dead child being made to walk to school during his illness, and being beaten and further hurt by the matron, as well as having his illness generally neglected.
On 13 July 1911, the jury found that George died from toxaemia with his death accelerated by 'gross negligence and want of attention by the matron'. In relation to the matron, Mrs Coates, it was reported that the jury found her to be 'a person so callous in her disposition that she was totally unfit to havethe care of children, more particularly of those deprived of parental affection and care'.
On 15 July the jury delivered its findings about the administration of the orphanage. The Western Mail (22 July 1911, p.45) reported that jury found the boys were 'suitably clad' but did not receive sufficient meat and bread, and that their food lacked variety. The Anglican Orphanages Committee was 'lax' in its oversight of operations at the orphanage, and the manager did not properly control or supervise staff, which had led to an unjustified and 'indiscriminate use of the cane and corporal punishment'. Certain staff were found to be 'unfitted' for their duties or scope of responsibility and three male staff were found to have ill-treated the boys at the orphanage.
The jury considered evidence that a member of the Orphanages Committee, Mr Bethell, supplied goods to the orphanage without having gone through a tendering process. The jury found this practice to be 'questionable'.
The jury also commented on a previous inquiry that had been conducted by Mr FD North, from the Colonial Secretary's Department. That inquiry was found to have been 'perfunctory' - a judgement that was later disputed by Mr North.
The Public Charities and State Children Department was found to have neglected its responsibility for oversight of the orphanage and the jury recommended that an inspector be appointed 'for the exclusive purpose of paying surprise visits from time to time to all charitable institutions under the control of the State' The jury also recommended that regular medical, dental and eyesight inspections for all children in charitable institutions.
The response of the Colonial Secretary, who was the Minister responsible for the Public Charities and State Children Department, was reported in the Western Mail (p.20) on 22 July 1911. He said that the three inspectors employed by the Department were fully occupied 'visiting boarded-out children, maternity cases, andcharity cases generally' and that the inspection of institutions had been the sole responsibility of the Secretary of the department but would, from the beginning of the 1911-12 financial year be assigned to an officer engaged especially for that task. The inspector would visit not only the children in institutions, but also those children 'apprenticed out' from them (in other words, children placed at service, generally on farms or in domestic labour but sometimes including placement with tradespeople). To ensure that state grants of monies achieved 'full value', the Public Service Commissioner would appoint an auditor to 'periodically investigate' the accounts of charitable institutions. The medical inspection of children in institutions had been enabled under the Health Act 1911 and the appointment of two doctors and nurses had been approved by Cabinet. These personnel would also conduct medical examinations of all schoolchildren. The Colonial Secretary said that the charitable institutions were well served by various Perth doctors who charged only a 'nominal' amount whenever they were called upon to treat the children. In the metropolitan area, arrangements with the Dental Association had been made 'some time ago' to examine the teeth of all children free of charge, with the Government providing a subsidy for the treatment of children whose parents could not afford to pay.
The Colonial Secretary also stated that henceforth all managers of institutions would be required to live on the premises and oversee the day-to-day operations of the institution. He upheld Rev. Burton's commitment to the children at the three institutions for which he was manager (Swan Boys' Orphanage, Redhill and the Swan Native and Half-caste Mission). The Colonial Secretary also praised the Anglican Orphanages Committee for their 'care and welfare' towards the boys in their institutions.
