Conclusions and Recommendations
Allegations made by XY
483. In respect of the five particular cases of ill-treatment originally alleged by XY we find as follows: —
(a) The young epileptic patient Lovelace (on Ward 23) probably was teased and assaulted by a member of the nursing staff on two occasions within a short space of time. But, in view of the confused state of the evidence, Nursing Assistant ” Q” should be acquitted of the charge that he was the person responsible for this incident. For the same reason we cannot feel satisfied that the incident was reported to the Chief Male Nurse and ignored by him in the manner alleged (Paragraphs 104 to 108).
(b) The middle-aged patient Housman (on Ward 21) was on one occasion handled with undue roughness by Charge Nurse “M” and Staff Nurse “N” and mismanaged so as to be wounded in the scalp. The wound was sutured by Charge Nurse “M” and the patient treated with paraldehyde without any medical supervision and was not seen by a doctor until the following day. This incident was caused not by malice but by the acceptance of old-fashioned, unduly rough and undesirably low standards of nursing care; and of a system whereby members of the nursing staff were permitted to suture wounds and administer drugs without any or sufficient reference to or supervision by medical staff (Paragraphs 89 to 96).
(c)The elderly patient Addison (on Ward 17A) was struck in the face on at least one occasion in course of an unduly clumsy and rough attempt to control his movements. The incident was caused by lack of skill and some lack of sympathy in handling a difficult patient and probably not by malice. We were unable to identify with certainty the male nurse responsible for this incident (Paragraphs 30 to 37).
(d) The young epileptic patient Masefield (on Ward 23) who had aggravating and difficult habits, was slapped on the face on more than one occasion by Charge Nurse “A” and Staff Nurse “R”. This conduct was not caused by malice but was due to the acceptance of old-fashioned and unsophisticated techniques for controlling a difficult patient (Paragraphs 109 to 113).
(e) We were unable to pursue the allegation that Charge Nurse “A” used a hose on certain naked patients in a yard. XY did not claim to have been an eye witness of this incident; and the witness to whom he attributes the story was unwilling to give evidence before us.
484. In respect of XY’s additional allegation of specific ill-treatment we find as follows: —The difficult, elderly patient Byron (on Ward 17A), was secluded for unduly long periods in a bolted room and there was complete laxity in reporting the periods for which he was secluded. He was treated with some lack of sympathy by Charge Nurse “G” (Paragraphs 38 to 43).
485. In respect of XY’s more general allegations of ill-treatment we find as follows:
(a) In the absence of any corroboration for XY’s allegation, we feel obliged to accept Charge Nurse “A’s” denial of the suggestion that he uses a thick stick to threaten patients (Paragraph 101).
(b) The patient Jonson (on Ward 23), a potentially useful person but with a known capacity for impulsive violence, was permitted to exercise too much authority over other patients and did, on occasions, slap them about the head. This situation was allowed to arise because of the persistence of some aspects of the concept of custodial care (Paragraphs 114 to 117).
486. In respect of XY’s allegations of pilfering by members of the nursing staff we find as follows:
(a) Many members of the staff who took their meals on the wards made use for this purpose of food originally supplied and intended for patients (Paragraph 307).
(b) A significant proportion of the fruit (and probably also cheese,butter and confectionery) supplied to the wards was there consumed by members of the nursing staff (Paragraph 307).
(c) Uncertain quantities of the same kind of foodstuffs were probably removed from the hospital from time to time by members of the nursing staff (Paragraphs 308 to 309).
(d) There was an inadequate system for the control of meat supplies, the “provision” of which to the nursing staff was on an excessive scale (Paragraph 311).
(e) It was not established to our satisfaction that pilfering extended to clothing or other items, whether supplied by patients’ relatives or by the hospital (Paragraphs 312 to 313).
487. XY withdrew his allegation that the Physician Superintendent “did not care ” but his similar allegation against the JHMO was substantially justified (Paragraphs 373 to 378).
488. XY was in error in attributing most of the incidents of ill-treatment of which he complained to wilful or malicious misconduct. Most (but not all) were due to the persistence of nursing methods which were old-fashioned, untutored, rough and, on some occasions, lacking in sympathy.
489. Generally, the situation at Ely has proved to be sufficiently disturbing to make XY’s concern well justified. It is a matter of speculation how long that situation, would have persisted had it not been for XY’s communication to the News of the World.
Allegations made by witnesses named by XY
490. One witness, Mrs. “I”, who was still on the staff at Ely, did not support XY in any respect. A second witness, “P”, corroborated XY’s allegations about pilfering, when he was interviewed at the Welsh Board of Health in August, 1967, but declined to give evidence to us (Paragraph 308).
491. XY’s third witness, “B”, was not willing to give evidence to us until after he had been dismissed from the staff at Ely at the end of January, 1968. His evidence dealt with different matters from those raised by XY. In respect of “B’s” allegations we find as follows: —
(a)Night Charge Nurse “U”, on two separate occasions, treated patients with a degree of violence that was unprovoked and unjustifiable (Paragraphs 184 to 190).
(b) Night Charge Nurse “U” told “B” that if “B” reported these incidents, then “U” would see to it that “B” did not last long on night duty” at Ely, (Paragraphs 187 and 189).
(c) In consequence of these, and other incidents, “U” made an unfounded charge against “B” which was accepted by a disciplinary sub-committee of the HMC and led to “B’s” dismissal from the staff at Ely in January, 1968. This plain case of victimisation has caused us grave concern. (“B” was reinstated in the hospital service—not at Ely—after we had recommended to the RHB that they should hear his appeal against dismissal). (Paragraphs 191 to 225).
Allegations made by other witnesses
492.Evidence from other witnesses, lay and professional, has helped us to arrive at a number of our general conclusions. It has also raised three specific matters that are sufficiently important to call for separate consideration.
493. A qualified, conscientious and competent nurse “T”, who made, in January, 1964, a complaint that Night Charge Nurse “U” had ill-treated a patient (which complaint was held “not proven “), had his terms of duty altered so that he was left with no practical alternative to resignation from his post at Ely. We regard this as symptomatic of a situation in which members of the nursing staff who were genuinely concerned about conditions at Ely must have come to feel that it was almost more than their professional life was worth for them to voice any feelings of concern (Paragraphs 166 to 175).
494 When relatives were visiting the patient Dryden (Ward 17A) in the late summer of 1966, a female nurse complied with a request for Dryden’s dentures to be fitted by endeavouring to fit a set from a bowl in which a number of unidentified dentures were kept together. The nurse probably also tried to fit Dryden with a set of dentures removed from the mouth of a sleeping patient, after “rinsing them under a tap”. (Paragraphs 49 to 54.)
495.The toenails of the patient Newbolt (Ward 23) were, on one occasion in the autumn of 1967, cut clumsily and with inadvertent cruelty, so as to expose the flesh of the toes and cause him pain. This incident is also indicative of lax and uninstructed standards of nursing (Paragraphs 131 to 134).
Children’s Villa 2
496. This was the only other ward that we considered apart from the four male wards referred to by XY. Our attention was directed to it by complaints from four parents whose boys had been accommodated there at various times between 1961 and 1966. In respect of these allegations we find that at all material times (up to and including the time of our own visits to this ward):
(a) Conditions in this ward give cause for grave concern (Paragraph 161). This ward, which was constructed to an untried design and opened in 1958, is so designed that the ameliorative measures suggested will scarcely be sufficient to mitigate its inherent and substantial deficiencies. The ward was designed for 50 patients and is at present occupied by that number. In our view the ward is not sufficient to accommodate more than 30 patients. Even this number exceeds the maximum of 20 now recommended for this type of unit (Paragraph 156).
(c) The furnishing and recreational equipment of this ward scarcely exceeds the bare necessities and is seriously deficient (Paragraph 157).
(d) Too little activity or occupation is organised for the children in this ward (Paragraph 158).
(e) The staff establishment of this ward is half the minimum desirable; and the present nursing staff, including the Charge Nurse, have not had any other experience of or instruction in the care of sub-normal children (Paragraphs 159 to 160).
(f) The regrettable conditions in this ward are the consequences not of shortcomings on the part of individual nurses, but of inadequate management and leadership (Paragraph 155).
Nursing standards on the male wards
497. Lax and old-fashioned standards of nursing, reminiscent in too many ways of the old era of custodial care, have been accepted. The nursing establishment, and its organisation, has not been kept in line with changing requirements. Virtually no attention has been given to the training of nurses, either on recruitment or in service. The responsibilities of nursing staff, particularly the Senior Nursing Officers, have not been redefined to keep them up to date (Paragraph 271).
498. The foregoing general conclusion is amplified throughout Chapter VI, where we draw attention to the following particular matters:
(a) An unduly casual attitude towards sudden death (Paragraphs 73 to 83).
(b) The lack of any habit training for incontinent patients (Paragraph233
(c) The inappropriate role assigned to patients on the ward (Paragraph 234).
(d) Inadequate systems for the reporting of incidents and the hand over of nursing responsibility (Paragraphs 237 to 239).
Complaints and discipline among nursing staff
499. Both ‘T” and “B”, qualified nurses, who had made well intentioned complaints and were themselves innocent of any offence were, in different ways, obliged to leave the hospital service (Chapter V and Paragraph 295).
500 An atmosphere had plainly come to exist at Ely in which such well-intentioned members of the nursing staff (including XY) had been persuaded that it was useless, if not hazardous, to complain (Paragraph 295).
501. Responsibility for this state of affairs must be shared between :
(a) The Chief Male Nurse and Night Charge Nurse “U” and, to a much lesser extent, other senior members of the nursing staff (Paragraphs 298 to 299).
(b) A structure of nursing administration which has resulted in the virtual isolation of the male nursing side at Ely in a close-knit and inward-looking community (Paragraph 300).
(c) Insufficient awareness on the part if the HMC, its senior officers and the Physician Superintendent of their responsibility for the quality of nursing care and discipline (Paragraphs 301 and 389).
(d) Shortcomings in the methods prevailing in the hospital service for dealing with complaints against members of the hospital staff (Paragraphs 468 to 480).
Administrative matters
502. Inadequate provision has been made, until some of the shortcomings came to light for a variety of reasons during 1967, for:
(a)Food and diet control (Paragraphs 305 to 314).
(b) Provision of individual clothing for patients (Paragraphs 315 to 317).
(c) Provision of an adequate level of pocket money for patients (Paragraphs 318 to 323).
(d) The laundering of linen, particularly foul linen, from the wards (Paragraphs 324 to 333).
503. Deficiencies in the foregoing respects, as well as in respect of standards of medical and nursing care (and training) have persisted notwithstanding the distribution by the Ministry, over a number of years, of numerous circulars and instructions suggesting ways in which higher standards could, and should, be attained.
Quality of medical care
504. All the male wards are seriously overcrowded. The buildings are very old and ill designed. Even after making allowance for these grave handicaps, and notwithstanding certain improvements in recent years, the standards of amenity attained fall short of what should nowadays be expected of accommodation provided by a public authority (Paragraphs 337 to 344).
505. Patients of widely differing ages and disabilities (ranging from severely sub-normal to psycho-geriatric) have had to be accommodated in the same wards, without any real separation of types (Paragraph 345).
506.There is substantial room for improvement in the co-ordination of services with local authorities (Paragraphs 349 to 351).
507.Insufficient consideration has been given to the need to provide special accommodation and instruction for nursing staff in order to secure the proper care of violent patients (Paragraphs 353 to 354).
508. The existing facilities for occupational and industrial therapy and for recreation of patients are seriously inadequate. Quite apart from these deficiencies, too little has been done to secure the occupation and training of patients under existing circumstances (Paragraphs 355 to 359).
509. No special accommodation or facilities are available for the reception of patients who require short-term care (Paragraph 361).
510. There has been a lack of energy and sophistication in medical care and record-keeping especially on the male side at Ely and the standard has fallen short of what could reasonably have been expected (Paragraphs 362 to 368).
511. Responsibility for this state of affairs must be shared between :
(d) The Physician Superintendent (Paragraphs 387 to 390)
(b)The JHMO (Paragraphs 373 to 377)
(c)The HMC and its officers (Chapter XI)
(d)The RHB (Paragraph 464)
(e) Various aspects of the system within which they have had to work (Chapter XII).
512. The Physician Superintendent did too little to improve the low standards of medical care on the male side. These standards are at least in part due to shortcomings on the part of the JHMO, for whose supervision the Physician Superintendent was responsible (Paragraph 389).
The HMC
565. Ely has not enjoyed the advantage of any identifiable “champions” nor any pressure group to argue its case within a Group administrative structure; nor has it derived any advantage from its association, in the same Group for 20 years, with a mental illness hospital of high repute.
566. The HMC and its officers and advisers must accept the principal responsibility for the shortcomings identified: an ineffective system of administration; the effective isolation of Ely from the mainstream of progress and the absence of any well-informed stimulation towards an improvement of standards.
More general matters
567.The present tri-partite administrative structure of the NHS has failed, so far as Ely is concerned, to produce a sufficiently integrated service and pattern of care for the mentally sub-normal. The concept of community care has been insufficiently developed (Paragraphs 456 to 459).
568.The RHB and its officers have not accepted any responsibility for the inspection or supervision of standards at Ely and have done little to make the HMC aware of what needed to be done to bring the hospital up to the standards aimed at by the Minister. Nor has the hospital been subject to any other system of inspection that would have helped to achieve that end (Paragraphs 460 to 467).
569.The RHB has not used the powers which it undoubtedly possesses to bring about any improvement in the standards which have prevailed at Ely (Paragraph 464).
570.The system for the investigation by the HMC of complaints and incidents affecting the hospital has not proved capable of reconciling the diverse objectives that have to be achieved. XY not unreasonably felt that he had to take his complaint outside “the system” (Paragraph 471).
571.We have felt hampered in our own Inquiry by an ambiguity of our role and purpose. It has been difficult within the procedure prescribed to combine our investigatory role with the desire to prevent injustice to particular individuals (Paragraphs 473 to 479).
RECOMMENDATIONS
572.The real relief for Ely’s worst shortcomings is to be found in the complete reconstruction of the hospital. But the pursuit of this objective cannot justify any lack of energy in securing the many improvements that are practicable and essential within the existing buildings.
573.The relief of over-crowding in the existing wards is urgently necessary. This may be made possible by prompt and effective use of the accommodation that should become available on the acquisition of the adjacent Ely Children’s Homes.
574.The nursing establishment requires immediate review so as, if possible, to double that now specified for the children’s villas and attain the stated objective of a 1 to 3 nurse-patient ratio on the male wards.
575.The necessary increase in establishment will have to be matched by corresponding efforts to recruit the necessary extra staff.
576.These over-riding objectives, along with others indicated below, can only be achieved if substantially increased financial resources are made available. The prospect of a continuing shortage of funds cannot, however, justify any continuing failure to implement many of our other recommendations.
Nursing care and administration
525. The senior nursing structure, within the group as well as within the hospital, needs to be reviewed in light of the recommendations of the Salmon Committee, so as to reduce the present isolation of the male nursing side at Ely and to ensure that it is, if possible, brought under the charge of someone with the outstanding talents that will be needed to raise the morale and standards of performance and discipline on the male nursing side.
526. The role and status of the senior nursing officer(s) need to be clearly defined in a form of standing orders so that the appropriate senior nursing officer is indisputably responsible for and in charge of nursing discipline and in a position to press for and secure the necessary improvements in standards.
527. More effective supervision is required on the nursing side and consideration should be given to the strengthening of nursing administration by the appointment of sufficient nursing officers who are free of responsibility for a ward.
528. The nursing staff and their representative bodies should be accorded a higher status, and encouraged to take a more active role in the affairs of the hospital. Consideration should be given to the holding of regular meetings of senior nursing staff and to the establishment of a joint consultative committee.
577.Vigorous action is necessary to introduce a system of induction and in-service training for the nursing assistants. Trained staff should be encouraged to participate in post-training courses and conferences in order to acquaint them with the work of comparable institutions, so as to secure an all-round improvement in the standards of nursing care. This is particularly necessary for the staff of units such as Villa 2.
578.Further domestic assistants should be appointed.
579.The part played by patients in the work of the wards should be reviewed in light of modern concepts.
580.Nursing duty rosters should be reviewed so as to ensure sufficient time for responsibilities to be handed over.
581.An effective system needs to be introduced for the proper reporting of incidents that occur and complaints which are made at ward level. The pages of all ward report books should be numbered consecutively.
582.Methods of dealing with incontinence should be reviewed and habit training should be much more widely attempted.
583.There should be more effective medical control of the administration of drugs and suturing of wounds by members of the nursing staff. Considerable improvement is needed in the provision of tooth brushes and the care of dentures.
584.Any necessary seclusion of patients must be duly reported and under taken only under medical supervision. Any room that is used for such seclusion (and, in particular, that in Ward 17A) must be provided with a lock and not a bolt.
Administrative matters
585.Nurses must not be permitted to take meals on the ward. Special accommodation should be provided where those who bring their own food in the hospital can eat.
586.A better system of diet and food control is needed, particularly to prevent misuse of stores that have to be despatched to the wards. The recommendations made recently by Ministry Catering Officers should be implemented.
587.Pocket money for patients should be assessed by reference to more liberal standards and rewards for work must be regarded as payable even to those who have their own resources.
588.Reorganisation of laundry arrangements, in accordance with proposals recently outlined by the Hospital Secretary, should go ahead with all possible speed.
Medical care and amenities
542. The standard of furnishing and amenity in the wards needs to be substantially improved. Every patient should have a locker of his own. Patients can thus be enabled to have clothing that will be and remain their own.
589.Special accommodation should, if possible, be set aside for violent patients and all members of the nursing staff should receive guidance in their care and management.
590.Unless and until it becomes possible to separate patients of different types, the intake of psycho-geriatric patients should be reduced and cease as soon as possible.
591.The projected adolescent unit should, if possible, be accorded higher priority.
592.Greater efforts should be made to reduce and prevent overcrowding by more frequent discharge of patients to local authority hostel accommodation, more of which is urgently needed in the area.
593.Consideration should be given to the provision of special accommodation for short-term admissions. This is particularly desirable for children of the kind now admitted to Villa 2. Some overnight accommodation for parents should be provided.
594.The facilities for occupational therapy and training will remain seriously deficient until the opening of the unit now being planned. Vigorous efforts are urgently necessary to provide more activity and occupation for patients of all kinds in the meantime. These should be made the specific responsibility of a senior nursing officer. And the help of voluntary organisations should be enlisted in this task.
595.Cases of sudden death within the hospital should be more thoroughly investigated.
596.The standard of medical record-keeping needs to be sharply improved.
597.The medical staff must set themselves higher standards of clinical care so that the hospital will be able, within the group structure, to provide an effective specialist service in subnormality.
598.The duties and responsibilities of the Physician Superintendent should be reviewed and redefined, especially those concerning nursing matters.
599.The medical work at Ely should be linked up more closely with the paediatric, child psychiatric and adult psychiatric services for the area, and the medical establishment at Ely should be decided with regard to the staffing of these services as a whole. There is an immediate need for some increase in the medical establishment at Ely.
HMC
554. The HMC’s organisation and administration needs to be critically reviewed and overhauled. The steps recently taken should be carried through to an effective conclusion, with particular emphasis on the following matters:
(a) Clear division of function and responsibility between the HMC and its officers.
(b) The development of greater awareness on the part of the HMC and its officers of their responsibility for standards within the hospital.
(c)The need for a committee and sub-committee structure which will enable some members of the HMC to play the part of well-informed and enthusiastic champions of Ely, with an awareness of its special responsibility for the care of the sub-normal.
(d) A more frequent, purposeful and systematic pattern of rota visiting.
(e) More prompt and systematic response to Ministry Circulars and reports and proposals from within and outside the hospital so that they can be translated into effective action.
(f) A pattern of organisation within the Group that will enable Ely to derive greater advantage from its long-standing association with a mental illness hospital of repute.
555. A determined effort needs to be made to associate the work of Ely with the surrounding community so as to secure a more effective pattern of community care and greater participation by voluntary organisations in the work of the hospital.
556. Every effort should be made to establish a League of Friends for Ely.
557. The prospective booklet about Ely, for the guidance of patients, relatives and others, needs to be prepared to a high standard and as soon as possible.
558. Serious consideration should be given by the HMC to the commencement of disciplinary proceedings against Night Charge Nurse “U” in respect of the matters disclosed in Chapter V of this Report.
559. The RHB should give consideration to :
(a) The organisation of a course or conferences to ensure that HMC members have more specialized knowledge of the needs of the mentally sub-normal and that full account is taken of Ministry and other guidance on the subject.
(b) Extension of their list of organisations to be consulted when making appointments to the HMC, so as to include educational and voluntary organisations associated with the field of retardation, with a view to introducing different kinds of expertise.
(c) A deliberate attempt to recruit to the HMC a number of younger members, who have the required knowledge, are less burdened with other public responsibilities and who, with the right guidance, could do much to promote a more modern approach.
General matters
560. There is a clear need for closer and more effective co-operation between the three branches of the present NHS administrative structure if Ely is to be enabled to play a proper role within the concept of community care. A final solution of the difficulties will only be found within a new and more closely integrated administrative structure.
561. There is a clear need for some system of inspection of a hospital like Ely, which will ensure that those responsible for its management are made aware of what needs to be done to bring it up to the desired standards. Only in this way can the Minister be assured that the gap between aspiration and performance will not become or remain too wide.
562. The RHB should make more vigorous use of its power to bring about an improvement in the standards hitherto obtained at Ely and (so far as possible within the existing system) to improve co-ordination with local authorities.
563. The existing systems and recommended procedures for the investigation of complaints affecting the hospital service, including the establishment and procedure of Committees of Inquiry such as our own could well be reconsidered. It may be doubted whether any system that does not assure, in the last resort, the existence of a truly independent investigating body can be relied upon to reconcile all the conflicting objectives.
564 If it is considered that the task of inspecting hospitals like Ely should be entrusted to an independent inspectorate there is much to be said for giving to the same body the investigatory function which we have had to perform. Consideration should also be given to the establishment of an independent body that could, in the last resort, undertake consideration of complaints and disciplinary matters which had not been satisfactorily handled in some other way.
565. We wish to express our thanks to the RHB and HMC and to the members of their staff, including those at Ely Hospital, for the kindness and courtesy with which they helped us in our work. We were also greatly assisted at every stage of our proceedings by the legal and other representatives who appeared before us and are much indebted for their help. Finally, we wish to record our very real gratitude to our Secretary for the energy, tact and efficiency .with which he has served us throughout our work. Without his invaluable assistance our task would have proved beyond our capacity.