Monday, 2 September 2019

Who’s to Blame?: Inquests into Convict Deaths in Mountjoy, c.1868-1900

In this blog post, Annika Liger, a graduate of UCD's MA in History of Welfare & Medicine in Society, reveals anxieties around the medical care of prisoners in the late nineteenth century by examining newspaper coverage of inquests into convict deaths in Mountjoy prison.

“Death of a Convict in Mountjoy Prison”, Evening Telegraph
(1 October 1895). Newspaper image © The British Library Board
All rights reserved. With thanks to the British Newspaper Archive.
Following a convict’s death, nationalist journalist Alexander Sullivan wrote to the city coroner saying, ‘you cannot be unaware that Mountjoy prison lies under public suspicion as to the medical treatment of prisoners’.1 This ‘suspicion’ surrounding Mountjoy greatly influenced the inquests into convict deaths in the late 1800s. These hearings, which were widely covered in newspaper reports, reflected the public’s interest in Mountjoy and the circumstances surrounding prisoner deaths. While many of the hearings resulted in a simple death by natural causes verdict, the courses of the inquests reveal deep reservations concerning Mountjoy’s medical care. When the juries decided that someone was to blame for a prisoner’s death, it then prompted the question of who was more at fault—the prison medical officer (PMO) or the prison system?  


In late 1800s Ireland, when someone died an investigation into their death was carried out at the coroner’s discretion. Generally, inquests only happened in cases of suspicious or unusual deaths, and the last attending medical practitioner, or any other local medical professional, was consulted. The medical community in general took these inquests quite seriously, and the ‘Principal Laws’ that governed United Kingdom medical professionals included a section on proper inquest conduct. These rules emphasized that medical officials giving evidence should be honest and accurate as their testimony was usually very influential.2

For general medical practitioners, these inquests could be stressful affairs. Depending on the outcome, the inquest could either enhance their professional reputation or destroy it. The same held true for PMOs, who had the added weight of also being responsible for protecting the prison’s reputation.3 Prior to 1877, prisoner death inquests were only called if the coroner felt one was necessary. In 1877, with the passing of the General Prison (Ireland) Act, inquests became mandatory in the event of a prisoner’s death. As a result, the number of inquests increased and PMOs ended up in front of a jury more frequently defending themselves and the prison. 

The PMOs

For information on prisoner death inquests, I mainly looked at Irish newspaper articles concerning the Dublin convict prison Mountjoy and two PMOs that worked there in the late 1800s: Dr James William Young and Dr Patrick O’Keefe. Young served at Mountjoy as a PMO from 1867-83. O’Keefe succeeded Young as head PMO at Mountjoy and served there from 1883-c.1907. Both Young and O’Keefe were highly educated individuals with multiple medical degrees who made careers out of working for the Irish prison system as medical officers.4 As PMOs, Young and O’Keefe were in charge of the general health of prisoners. They assigned diets, determined whether or not prisoners were suited for punishment or labor, and treated inmates’ specific aliments, among other duties.

Newspaper reports of the coroner’s inquests reveal that while Young and O’Keefe faced scrutiny in these hearings, Mountjoy itself received the majority of the blame in prisoner deaths. Coroner’s inquests in the late 1800s largely ended up being arenas where juries, coroners, and even the PMOs themselves, questioned and critiqued the Irish penal system’s care of prisoners in Mountjoy. 

Death by Natural Causes

In a few cases where Young and O’Keefe testified, the jury found no reason to blame either of the PMOs or the prison. They simply concluded that the prisoner had died of natural causes, as was the case when prisoner Patrick Naughton died in 1886.5 Likewise, when in 1893, Thomas Pembroke fell ill and died in prison, after testimony from multiple doctors, including O’Keefe, the jury decided that Pembroke was treated adequately and no one was at fault for his death.6

In other cases, ultimately both the prison and PMOs were cleared of blame, but during the trial there were debates over the various parties’ culpability. This is perhaps due to the general sense of skepticism when it came to Mountjoy that Sullivan mentioned in his letter at the beginning of this post. We can see evidence that others shared Sullivan’s concern over Mountjoy through the kinds of questions juries asked of the defendants, which often demanded that the PMOs explain in detail the care provided to the deceased. Some of the newspapers also reported that the juries were critical of the PMOs going into the inquests. After the death of a prisoner in 1868, for example, the jury was reportedly suspicious of Young from the outset. However, in this case they ultimately decided that he was not to blame.7

The testimonies that Young, O’Keefe, and other prison officials provided also suggest they were well aware of the public’s suspicion surrounding Mountjoy and tried to assuage any such fears. In 1883, during the inquest into Michael Watters’ death, Young, O’Keefe, and Kelly, another medical practitioner, all agreed that ‘death was not attributable to punishment or any form of ill-treatment’, thus contesting the notion that the prison’s disciplinary methods could be responsible for Watters’ death.8 In an 1886 case, the jury found that James Davies’ died of natural causes after a very laudatory testimony from the city coroner concerning the treatment of prisoners in Mountjoy. The coroner was adamant that Davies did not die as a result of neglect, saying that once a prisoner became ill ‘all his crimes appeared to be forgotten by the prison officials, who did everything for his comfort … they always have the best medical treatment’.9 Given the suspicion surrounding Mountjoy at the time, this praise was quite possibly an active attempt to combat the concern over inadequate prisoner care.

PMO Blamed for Convict Death

Unfortunately for the PMOs and Mountjoy, juries did not always decide that death was simply due to natural causes. When the juries found someone at fault, it placed the PMOs and the prison in a very critical spotlight and left juries, commissioners, and journalists debating which party was more to blame  the PMO or the prison. In particular, Young faced two noteworthy inquests, one in 1868 over Matthew Lynagh and the other in 1870, concerning Johanna Hayes. Both of these cases were suspicious enough to prompt inquests in a time before inquests were mandatory. Additionally, both cases were widely covered in newspapers across Ireland.

During Lynagh’s inquest, Young explained that he was treating Lynagh, but thought he was improving. As a result, Young initially declined to send Lynagh to the prison hospital. Ultimately, the jury blamed Young for Lynagh’s death, arguing that Lynagh should have been sent to the hospital much sooner. They also specifically called out Young, saying he ‘might be more attentive to extern patients’.10

Or Was the Prison Really at Fault?

While the jury in the Lynagh case firmly held that Young was to blame, the nationalist newspaper The Nation and the official Commissioners’ Report presented slightly different takes on Lynagh’s death. Both addressed the jury’s critique of Young, but argued that Lynagh’s death was not actually Young’s fault. One month after the inquest, the Commissioners released their report exonerating Young. They recognised the jury’s verdict, but said that Lynagh’s death was inevitable and ‘that the man was not neglected during his illness by Dr Young or the other officers of the prison’.11 Notably, while defending Young, they also declined to assign any blame to the prison system.

In 1871, The Nation published a scathing review of Mountjoy prison and mentioned the Lynagh case from 1868. The writer primarily saw Young as an agentless cog in a machine, thereby absolving him of blame. They claimed that the Lynagh inquest ‘resulted in a verdict censuring the Medical Officer; a clear injustice towards him, inasmuch as he probably did his duty as far as he could [sic] under the altered systems’.12 The article continued and reiterated this point suggesting that some vague prison bureaucracy prevented Young from providing more treatment to Lynagh. Unlike the Commissioner’s report which absolved Young but did not blame the prison system, The Nation blatantly held the prison at fault for Lynagh’s death.

Conclusions like this that pardoned the PMO while simultaneously condemning the prison system were not uncommon. In an 1895 inquest over Christopher Connor’s death the coroner told the jury that ‘the evidence showed that no blame attached to Dr. O’Keefe or the governor ... they did all that the rules permitted for the man ... the rules as the nursing of sick persons in [Mountjoy] were simply abominable’.13 The jury agreed with the coroner and their verdict called out the prison’s nursing system while also clearly stating that O’Keefe was not at all responsible for Connor’s death.

The Complicated Case of Johanna Hayes

In 1870, Young was dragged back into the spotlight with the death of Johanna Hayes in Mountjoy Female prison. During the hearing, Young reportedly testified that after entering the prison Hayes’ health began declining, and he recommended that she be released from prison with respect to her failing health. However, this recommendation was not heeded, and Hayes remained in prison where she died. In contrast to the Lynagh case, here the jury lauded Young for his attempts to aid Hayes and get her released. Interestingly, the jury did not directly blame the prison system, despite the penal system’s denial of Hayes’ release on medical grounds. The jury did note, however, that Hayes died as a result of her being in prison.14 This conclusion suggests the jury found the prison partly to blame, but not wholly at fault as it had not actively contributed to Hayes’ death.

While this trial ended relatively well for Young and the prison, not everyone agreed with the jury’s take on the events. Like the jury, Sullivan, the aforementioned nationalist journalist, did not blame Young, although he was skeptical of him. Rather, Sullivan railed against the Irish penal system in a letter to the city coroner, which was eventually published in the newspaper The Warder. In this letter, Sullivan addressed his preference for Young’s predecessor, Dr Macdonnell, and basically called Young a government lackey. He also commented on the testimonies presented in the Hayes trial. In particular, Sullivan disliked the reliance on Young’s deposition, saying the jury held ‘a suspiciously laudatory protestation’ of Young, and that it was ‘very likely all true; but methought the jury did protest too much’.15

Sullivan’s issue with the jury’s praise was further illuminated during a libel trial that resulted from the publication of this letter. During that libel trial, Mr Butt, speaking for defendant Sullivan, argued that the jury’s praise was for the benefit of Young and the prison system:

Then came the [Hayes] inquest, when Dr. Younge [sic] whitewashed off the black cloud of censure passed on him at the first inquest [Lynagh’s case in 1868] … was it very strange if Mr. Sullivan should say this was an attempt to prop up a new system, in which Dr. Younge [sic] was to be praised for his exertions?16 

While Sullivan did take some shots at Young with his suggestions that he was a government stooge, he ultimately did not think Young was to blame, even if the jury’s praise in the Hayes inquest was suspicious. Instead, Sullivan complained about the penal system and how it affected prisoner health. While not directly stating that Mountjoy was responsible for prisoner deaths, Sullivan certainly found the inquests, and their non-critical outcomes, to be dubious, thinly-veiled attempts to protect the prison’s reputation following convict deaths.

In House Complaints

Critiques of the prison system were not unusual in inquests, and as we have already seen there was an established suspicion surrounding prisoner deaths and the prison system’s level of blame. Prison outsiders, such as juries, coroners, and journalists like Sullivan, used these inquests to question the prison system. Likewise, prison insiders also utilized inquests to critique the prison, and Young and O’Keefe occasionally provided testimonies that called out the prison’s operation and treatment of prisoners.

O’Keefe, albeit somewhat begrudgingly, spoke out against the prison system in his testimony during the 1895 inquest into Christopher Connor’s death. The jury began the inquest highly suspicious of the prison, with O’Keefe, the prison governor, and the penal system all being called into question. One of the coroner’s and jury’s main problems was that Connor’s family and friends had not been alerted to his illness, a matter one juror reportedly called ‘monstrous’.17 O’Keefe explained that no one was contacted because he did not believe that Connor’s condition was as serious as it ended up being. He also emphasized that the governor notified families, not the PMO, so he was not technically to blame for the lack of contact.

The other issue highlighted in the newspaper coverage was the implementation, or lack thereof, of night nursing in Mountjoy. The coroner implied that Connor would have been better cared for had there been a better nursing system in place. When the coroner asked O’Keefe for his take on the system of night nursing, O’Keefe initially refused to give an opinion. After the coroner pressed, O’Keefe relented replying ‘Well, I think it might be improved’.18

Following the death of a convict in 1878, Young testified that he had done what he could for the patient in the prison cells, but chose not to send the prisoner to the hospital. This decision was vastly unpopular with the jury who heavily questioned Young’s decision. Young claimed that the convict was not sent to the hospital because of ‘the small hospital accommodation and heat of the weather … the accommodation [in hospital] was insufficient’.19 Using the public forum of the inquest, Young aired his complaint about the prison hospital and argued its inadequacy directly contributed to the convict’s death.

While both Young and O’Keefe clearly critiqued Mountjoy and the ways in which the prison was run, these criticisms were not perhaps without ulterior motive. Going into these inquests, the juries were already suspicious of Young and O’Keefe and the care they provided. As a result, it is possible that O’Keefe and Young highlighted the poor night nursing and hospital accommodations respectively as a way to transfer the blame from them to the prison at large. In both of these cases as well, neither O’Keefe nor Young were found at fault for the prisoner’s death.


Coroner’s inquests into prisoner deaths were weighty affairs for the PMOs and Irish prison system. While in most cases the juries and coroners agreed that death was by natural causes, there was still an underlying suspicion concerning the prison officials and the prison. When the inquests found that the convicts’ deaths were preventable, it resulted in a debate over which party, the PMO or the prison, bore the brunt of the blame. In the end, while the juries were skeptical of the PMOs, it was the prison that was blamed most often for deaths in Mountjoy in the late 1800s. 

Annika Liger

Annika Liger completed her MA on History of Welfare & Medicine in Society at the UCD Centre for the History of Medicine in Ireland in 2018/2019.


Research completed in collaboration with Harriet Wheelock, Keeper of Collections, Royal College of Physicians of Ireland Archive Collections.

1. “Assize intelligence” The Warder 1 April 1871.
2. “Duty of medical men as witnesses”, United Kingdom Register 1889, pp. 18-9. Royal College of Physicians Ireland (RCPI) Archives.
3. Michael J Clark, “General practice and coroners’ practice: Medico-legal work and the Irish medical profession, c. 1830-c.1890” in Cultures of Care in Irish Medical History 1750-1970 eds. Catherine Cox and Maria Luddy (New York, 2010), p. 40, 50.
4. Biographical information was gathered from papers, medical registers, and the Kirkpatrick Index all held in the RCPI archive.
5. “The death of a convict” The Daily Express 18 September 1886
6. “Death of a convict”, Evening Herald 9 January 1893
7. “Mountjoy prison”, Nenagh Guardian 21 March 1868
8. “Death of a convict” The Daily Express 25 October 1883
9. “Death of a convict” The Daily Express 11 March 1886
10. “Coroner’s inquest on the body of a convict” Saunders’s Newsletter 15 February 1868
11. Report of the Commissioners appointed by Lord Lieutenant to inquire into circumstances concerning death of convict M. Lynagh in Mountjoy Prison, H.C. 1867-1868.  p. 4
12. “Secrets of the prison-house” The Nation 15 April 1871
13. “Death of a convict in Mountjoy prison: Extraordinary condition of things: Strong condemnation by the coroner and jury” Evening Telegraph 1 October 1895.
14. “Inquest at Mountjoy prison” Irish Times12 January 1870
15. “Assize intelligence” The Warder 1 April 1871
16. “Assize intelligence” The Warder 1 April 1871
17. “Death of a convict in Mountjoy prison: Extraordinary condition of things: Strong condemnation by the coroner and jury” Evening Telegraph 1 October 1895.
18. Ibid
19. “The sudden death in a convict prison” The Northern Whig 27 July 1878