Report of the Committee of Inquiry into Allegations of Ill – Treatment of Patients and other irregularities at the Ely Hospital, Cardiff.

Presented to Parliament by the Secretary of State of the Department of Health and Social Security

by Command of Her Majesty

March 1969

Cmnd 3975

I: INTRODUCTION

1. In July, 1967, the News of the World forwarded to the Minister of Health (We refer to the Minister of Health throughout this report as “the Minister”) a statement by a man we shall call XY, containing allegations of various forms of misconduct on the part of members of the staff at the Ely Hospital, Cowbridge Road, Cardiff. (We refer to the hospital throughout this report as “Ely”). XY’s statement was subsequently published (without disclosure of the identity of the hospital or any of the staff concerned) in the News of the World for Sunday, 20th August, 1967.

2. XY had been employed as a Nursing Assistant at Ely from 26th September, 1966, until 24th September, 1967. The full text of his original statement is set out in the Appendix to this Report. The allegations made, which all referred to the male wards at Ely, fell under the following general headings:

  •  Cruel ill-treatment of four particular patients by six named members of the staff;
  • Generally inhumane and threatening behaviour towards patients by one of the staff members already referred to;
  •  Pilfering of food, clothing and other items belonging to the hospital or the patients;
  •  Indifference on the part of the Chief Male Nurse to complaints that were made to him;
  • Lack of care by the Physician Superintendent and one other member of the medical staff.

3. Acting on the instructions of the Minister, the Welsh Hospital Board (We refer to the Welsh Hospital Board throughout this report as ” the RHB “) accordingly constituted us a Committee of Inquiry consisting of:

Mr. Geoffrey Howe, Q.C. (Chairman).

Miss Hilda L. Adams, S.R.N., Retired Nursing Officer, South Western Regional Hospital Board.

Mrs. Jean Cole, Member of the Birmingham Regional Hospital Board.

Professor D. Russell Davis, M.D., M.A., M.B., B. Chir., F.R.C.P., D.P.M., Professor of Mental Health, Bristol University.

with Mr. G. Eaton Jenkins, M.B.E., F.C.C.S., Assistant Secretary of the Welsh Hospital Board, as Secretary of the Committee.

4. The Committee’s terms of reference were as follows:

  1.  To investigate the allegations made by XY in a statement to the News of the World about ill-treatment of patients and pilfering by members of the staff at the Ely Hospital, Cowbridge Road, Cardiff;
  2.  To examine the situation in the wards in the hospital at the present time; and
  3.  To make recommendations.

5. Guidance as to the general procedure to be followed by the Committee was given by the Minister along the following lines:

(a) The Inquiry was to be conducted in private, with evidence being given in confidence, except in cases where witnesses wished to make serious allegations against named individuals, in which circumstances they had to be prepared to give evidence in the presence of the persons accused, who were to have opportunities to question the evidence;

(b) The Committee was to have so power to summon witnesses, to take evidence on oath or to make any recommendations in respect of the award of costs;

The Chairman of the Committee was to decide whether any persons should be represented before the Committee, legally or otherwise;

The Committee’s investigation was to include:

(i) Inspection of the accommodation and equipment in the parts of the hospital concerned;

(ii) Interviews with all members of the staff who worked in the relevant parts of the hospital during the relevant period, includ­ing, so far as possible, those who were no longer employed at the hospital;

(iii) Interviews with persons who were patients in the relevant wards during the relevant period.

6. The Committee, before it commenced its work, requested the appointment of a solicitor to assist in identifying relevant witnesses, obtaining an outline of the evidence which they might be able to give and (subject to the directions of the Chairman of the Committee) presenting such evidence to the Inquiry. This request was made because it seemed probable that the procedure of inter­viewing witnesses in a partially haphazard sequence without any idea of what they were likely to say was likely to make the Inquiry disorderly, incomplete and, in appearance at least, less than fair. The Committee’s request for such assistance was not granted. In consequence, and notwithstanding the manful assistance of the Committee’s Secretary in a host of roles (from enquiry agent and unofficial process server to chauffeur of elusive witnesses), the risks which the Committee had in mind in making the request were far from being eliminated.

7. Subject to the guidance already referred to the Committee was left to evolve its own method of work, along the following lines:

(a) A public announcement was made of the appointment of the Committee, identifying the hospital whose affairs were being investigated, accompanied by an invitation to any person—whether a past or present member of the hospital staff, a past or present patient or a friend or relative of any such patient—who had any information which might be relevant to the subject matter of the Inquiry, to communicate with the Secretary of the Committee. This announcement, which the Committee regarded as essential to the preservation of public confidence in the thoroughness of the Committee’s investigations, proved to be invaluable. Without it there is no doubt that some of the most important witnesses would never have been identified.

(b) Letters were sent to 44 members of the staff still in post at the hospital and to 19 former staff members. The replies to these letters give some indication of the evidence likely to be available from this source.

(c) Letters were sent to 254 relatives and/or friends of patients in the relevant wards, inviting evidence from such people. Of these letters 22 were returned undelivered by the Post Office. The replies which were received were placed together with other letters received as a result of the Press announcement of the Inquiry and analysed, in general terms, as follows:

Ward In favour of Hospital Critical of Hospital
17A 18 4
17B 22 2
21 35 3
23 27 5
Female Wards and Children’s Villas 11 1
Patients discharged, died or unidentified 2 4
Anonymous - 1
115 20

(b) Attempts were made (with reasonable success) to secure the attend­ance of all witnesses whose evidence appeared to be relevant and who were willing to come; we tried to include all those named by XY as well as almost all members of the staff in the relevant wards (subject to our own judgment of the possible irrelevance of some of their evidence). Many of the patients referred to were seen; but because of the severe disabilities of most of them, little assistance was derived from this source. The clinical notes of any material patient, ward report books and any other relevant records were made available and examined.

8. We met for the purpose of hearing evidence on a total of 15 days as follows:

Monday, 4th December, to Friday, 8th December, 1967: Monday, 12th February, to Friday, 16th February, 1968: Monday, 19th February, to Friday, 23rd February, 1968:

and during this period sat for 104 3/4 hours. We met on four other days for the purpose of considering this Report. The Committee as a whole visited all the relevant parts of the hospital; and individual members of the Committee (particularly its medical and nursing members) made a number of other inspections of the wards and other parts of the hospital in pursuit of particular information. The proceedings were recorded by Messrs. W. B. Gurney & Sons, London, Shorthand Writers, and the transcript of evidence ran to 1,029 pages (that is to say more than half a million words). Three barristers, one solicitor and two trade union officials were permitted to appear before the Committee, as representatives of various members of the medical, nursing and administrative staff of the hospital and of the Cardiff North and District Hospital Management Committee. 52 witnesses gave evidence to the Committee. Any such witnesses who seemed likely to give evidence which bore upon the allegations made against particular people or authorities were permitted to do so in the presence of the representatives, whose attendance virtually throughout the Inquiry was of the greatest assistance to the Committee. All witnesses whose confidential views seemed likely to assist us were, in addition, interviewed in private and in the absence of the representatives.

9. We experienced considerable difficulty as a result of the partially blindfolded way in which the Inquiry had to be conducted. Without any knowledge of the matters about which any particular witness was likely to speak our investi­gation necessarily had an incoherent and disorganised quality. Much time was wasted with some of the earlier witnesses in pursuing points which were very largely disposed of without doubt by later witnesses (of whose evidence we were necessarily unaware until such .later witnesses had come to give their evidence). Fresh points were raised by later witnesses which ought, ideally, to have been investigated with those who had already given evidence; not all such points were pursued, since if they had been the Inquiry threatened to become circular if not immortal. Most, if not all, of these difficulties could have been avoided if a solicitor had been available, as requested by the Committee, to conduct a preliminary investigation of the possible evidence. In the absence of such a solicitor to present the evidence to the Inquiry, the Chairman of the Committee had necessarily to cross-examine some of the witnesses—often upon the basis of premises which later turned out to be false, and thus in a manner which must at times have appeared unfair.

10. Notwithstanding the difficulties to which we have referred, we have endeavoured, with reasonable confidence, to arrive at conclusions of fact upon the matters raised by our terms of reference and to make recommendations accordingly.

11.The scheme of our Report is along the following general lines. We begin by considering the particular complaints made, by reference to each of the wards concerned, starting from the allegations made by XY and incorporating such other allegations as came to our notice. We then consider what our findings on these complaints imply about standards of nursing, nursing discipline and leadership, administrative and medical matters—including the quality of medical and administrative leadership, We conclude by considering the role of the Hospital Management Committee (including that of its predecessor, the Whitchurch and Ely Hospital Management Committee) and some aspects of the administrative structure within which they have had to work. Finally we summarise our conclusions and recommendations.

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