Age: 8 weeks
Date: 7 Dec 1955
Place: 153 Woad Farm Road, Boston
Rosemary Bentley died on Wednesday 7 December 1955.
She had died from neglect. However, the Coroner's jury said that they did not feel that it was a case of manslaughter.
It was heard that Rosemary Bentley had had a curable disease but that her mother had not taken her to see a doctor.
After the jury had returned their verdict that Rosemary Bentley's death was due to gross neglect, the Coroner asked them, 'Let us get this quite clear. Do you find there is a case of manslaughter?', to which the foreman of the jury explained that they had had difficulty in find an alternative word for gross. The Coroner then asked them whether they found that the neglect did not amount to manslaughter and the foreman said, 'Yes'.
The Coroner then said that he entirely agreed with what he thought was a very proper verdict.
The Coroner then went on to say that he hoped that it would be borne in mind not only by Rosemary Bentley's mother, but by all mothers, that hte Health Service was provided for everybody at the national expense and that it was the duty of mothers to take advantage of the facilities offered.
The Coroner then explained the law relating to murder, manslaughter and infanticide, saying, 'You may think that the mother is of such low mental intelligence that her failure was a failure to appreciate her obligations, and not a failure to carry them out'.
The mothers doctor said that on 7 October 1955 he went to 153 Woad Farm Road and found her in labour. He said that she was taken to hospital and that Rosemary Bentley was then born in the early hours. He said that he next received a telephone call from another doctor on 7 October 1955 and that when he went to 153 Woad Farm Road he found Rosemary Bentley was dead.
He said that at no time between 8 October and 7 December 1955 did he see Rosemary Bentley.
The doctor noted that it was a duty imposed upon parents by the National Health Service that babies should be brought to be seen by a doctor at the age of six weeks and that if that was not done, that it was the practice to send a letter of reminder to the parents after eight weeks.
The doctor said that the illness that Rosemary Bentley had, had not been apparent when she was born, but said Rosemary Bentley must have been ill for some time before her death and that her mother must have been aware that her condition had been getting worse, adding that he had no doubt that Rosemary Bentley's mother had fed her.
The pathologist that carried out Rosemary Bentley's post mortem said that when he examined her on 7 December 1955 he found that she was small and underweight and described her as a 'wasted' baby, noting that there was still evidence of vomiting with a considerable about of vomit still in Rosemary Bentley's mouth.
The pathologist said that Rosemary Bentley's stomach had a condition by which the lower end was so thickened as to cause an obstruction to the passage of food and that that condition caused vomiting and the loss not only of food, but of some of the chemical constituents of hte body. He said that Rosemary Bentley's stomach was grossly extended with semi-solid food and that there was a small haemorrhage in the left kidney. He further noted that all the tissues in her body were shrunken and dry.
The pathologist said that Rosemary Bentley's cause of death was dehydration due to her stomach complaint. He said that her condition was self-curable if left long enough but that if allowed to gone on for between five and eight weeks that her condition might well have required urgent treatment. He noted also that the condition might not appear until about the second week and that even then it might not have been obvious, and added that if Rosemary Bentley had had a cold that that might also have masked the symptoms, which were a failure to thrive.
Rosemary Bentley's mother, who was 30-years-old, said that she had four children, two of whom, a boy born in 1948 and a girl born in 1954 were still living, and noted that Rosemary Bentley had been born in Boston General Hospital after an operation.
After being warned by the Coroner that she didn't have to answer any questions that might incriminate her she went on to say that Rosemary Bentley at first seemed contented with her food but that about a week before her death she had a cold and went off it, and that after the cold she seemed all right again.
However, she said that on 5 December 1955 that Rosemary Bentley went off her food again altogether and was the same the following day. She said that during 6 December 1955 Rosemary Bentley was spoon fed in the afternoon after which she slept until about 10pm when she was fed again. She said that Rosemary Bentley had been vomiting during the day but did not vomit after her night time feed.
She said that on 7 December 1955 she looked at Rosemary Bentley twice in the morning and saw that she seemed to be sleeping peacefully but that when she went back after a while to look at her she noticed that her breathing appeared laboured and so she telephoned the doctor. However, she said that by the time the doctor arrived Rosemary Bentley was dead.
Rosemary Bentley's mother went on to say that she thought that it was the mother that was supposed to visit the doctor after six weeks and noted that she never took Rosemary Bentley to a doctor or a clinic. She noted that she had not received any welfare food at all.
She said that Rosemary Bentley had been about 8lb at birth and that she had been in hospital for 14 days.
The lodger who lived at 153 Woad Farm Road said that when Rosemary Bentley's mother called the doctor that he had gone upstairs to look at Rosemary Bentley and said that at that time she had been breathing very slightly. However, he said that when he again went to look at Rosemary Bentley just before the doctor arrived he found that she was dead. He added that he didn't touch her at all.
A consultant obstetrician at Boston General Hospital said that he had carried out a caesarean operation on Rosemary Bentley's mother when she gave birth and that her progress in hospital after that was normal. He said that on 1 December 1955 Rosemary Bentley went to see him for a post-natal examination and that he found that her health was reasonably normal.
The consultant obstetrician added that there was no sign in Rosemary Bentley whilst she was in the hospital of the disease from which she died and nor was there any vomiting whilst she was there.
A health visitor who lived in Fishtoft Road in Fishtoft said that she had visited Rosemary Bentley's mother several times since June or July when she moved to the area and that on 24 October 1955 she saw Rosemary Bentley at 153 Woad Farm Road at which time she seemed to be healthy and well cared for. She said that she made some subsequent visits but didn't find Rosemary Bentley's mother in.
She noted that on one occasion she saw Rosemary Bentley's mother in Emery Lane with Rosemary Bentley and noted that Rosemary Bentley didn't look so well. She said that she had to remark on the way that Rosemary Bentley was being fed, noting that she was lying flat in her pram with half-a-bottle of food.
The health visitor noted that the child welfare services held three sessions a week in Boston and that Rosemary Bentley's mother had attended 52 times in the past with her previous child.
When the police presented photographs of Rosemary Bentley's dead body, the Coroner said, 'We need not dwell unduly on these rather dreadful photographs'. The police noted that Rosemary Bentley's mother had not mentioned to anyone that Rosemary Bentley was ill until the day she died.
The inquest lasted two hours.
see Boston Guardian - Wednesday 11 January 1956, p5
see Boston Guardian - Wednesday 14 December 1955