Summary of the Margaret Bardon case¹

On 3 April 1869 at 3.15 am, Mrs Margaret Bardon, a 34 year-old woman and wife of John Bardon, a tanner, living in Dover Street in the inner Melbourne suburb of Richmond, died following childbirth. Mrs Bardon had given birth to five children previously and recovered well after each pregnancy, although one baby was stillborn. Her fourth and fifth children were delivered without the assistance of 'instruments' (obstetric forceps).

In the pregnancy that resulted in her death, Mrs Bardon's labour began on Tuesday 30 March in the evening. At 1 am on Wednesday 31 March, she asked her husband to summon the midwife engaged to attend her. The midwife, a local woman named Anne Patten, arrived at 2 am.² Around 8 or 9 am on Wednesday 31 March, Mrs Bardon was becoming increasingly distressed with pain and told her husband to go for a doctor. The midwife felt that this was not necessary. Anne Patten told Mr Bardon that his wife 'had no patience. [And that] The proper pains ... had not come on'.³ Some time later on Wednesday morning, Mrs Bardon in a loud voice told her husband to get a doctor, crying 'Look here, I am done for' and showed her husband her nightgown which was covered in a watery, dirty white substance.⁴

Responding to his wife's distress, Mr Bardon asked the midwife if there was any danger. Anne Patten answered that 'I don't think so - there might be danger' and then warned Mr Bardon that if he did go for a doctor, she would leave the premises before that doctor arrived.⁵ Mr Bardon went out to consult Dr Stillman, waiting a little time to see him. Stillman agreed to come, but said he had to go to the local dispensary first. Mr Bardon returned home to find the midwife gone. Mrs Bardon then urged her husband, 'For God's sake, go for him [the doctor] again'. Mr Bardon went out, meeting Dr Stillman on the hill in nearby Church Street, Richmond. Mr Bardon judged he had been away from the house for around forty-five minutes.

Dr Stillman arrived at the house at 11.10 am, finding Mrs Bardon to be 'in a greatly exhausted state, her countenance showing anxiety, the pulse around 120', all of which indicated that the labour was complicated and the woman was very ill.⁶ Based on his examination, Stillman concluded that the uterus (womb) had ruptured.⁷ Stillman's colleague, Dr Wilson, arrived to help at midday. Stillman called Dr Wilson aside to explain the case and 'said the patient had been previously under the care of a midwife'.⁸ Dr Wilson's physical examination confirmed that the uterus had ruptured. Mrs Bardon was given brandy and opium to support her while the doctors waited to see if her labour progressed. At 1.30 pm without any change, Dr Wilson began the difficult delivery of the deceased baby in the hope of saving the mother's life. Wilson told the inquest that extracting the baby took between an hour to an hour and a half because the infant's head was large and would not fit through the woman's pelvis. Mrs Bardon survived what was an extremely traumatic delivery. She showed some signs of rallying, but died around 60 hours following the extraction of the deceased baby, on Saturday 3 April at 3.15 am.

One might expect that, as death had occurred, whatever happened afterwards in a case such as this was irrelevant. However, care, preservation, and supervision of the body were of great importance in cases of maternal death because the body itself formed the evidence of what had occurred. Until a cause of death was established by anatomical investigation, each person who had attended a woman - midwife, nurse, neighbour, and/or doctor - was potentially open to charges of malpractice or negligence. It was the work of the coroner and the jury to establish who did what, when, why, and to judge their conduct. What happened after Mrs Bardon's death illustrates that this process was not as simple as might be imagined.