Section 2 of Findings and Recommendations Following Enquiries into Allegations Concerning the Care of Elderly Patients in Certain Hospitals

Members of the Committee

  • Chairman : Mr. Brian Gibbens, Q.C.
  • Medical Member : Dr. A. N. Exton-Smith, M.D., F.R.C.P., Consultant Physician, University College Hospital, London.
  • Nurse Member: Miss L. de la Court, M.B.E., lately Matron of the Queen Alexandra Hospital, Cosham, Portsmouth.
  • Lay Member: Colonel J. W. Weld, O.B.E., T.D., Wessex Regional Hospital Board.
  • Secretary : Mr. J. Mullins, M.A., F.H.A., Secretary, Nuffield Orthopaedic Centre, Oxford.

To: E. W. Towler, Esq., Chairman, United Oxford Hospitals, Radcliffe Infirmary, Oxford.

Sir,

Introduction

1.In accordance with the directions contained in the Minister of Health’s letter dated 27th July, 1967, addressed to you, we were appointed by the United Oxford Hospitals Board of Governors to be a Committee of Inquiry to investigate certain allegations in the book entitled “Sans Everything’ edited by Mrs. Barbara Robb and published by Thomas Nelson and Sons Limited in 1967. Mr. J. Mullins, M.A., F.H.A., Secretary of the Nuffield Hospital Management Committee, Oxford, was appointed Secretary of the Committee.

2.Our terms of reference were:

(i) To investigate, so far as available evidence permits, the allegations in pages 27-37 (inclusive) of the book “Sans Everything” in relation to Cowley Road Hospital,

(ii) To examine the situation in the wards in the hospital at the present time; and

(iii) To make recommendations.The legal representative of the authors of the said allegations expressed satisfaction with these terms.

3. The commencement of our Inquiry was delayed by the fact that, as we understand it, correspondence took place between the Minister of Health and Mrs. Barbara Robb and her Solicitors as to whether or not the identity not only of the authors of the passages in the book relating to Cowley Road Hospital, but of the hospital itself, should be kept confidential; the authors were unwilling to give evidence without an assurance that their identities would not be revealed. Eventually, we opened the Inquiry on 21st December at the Cowley Road Hospital and heard evidence on the 21st, 22nd and 29th days of December, 1967, and 12th January, 1968. A shorthand note was taken of the proceedings.

4.We have now completed our Inquiry and have the honour to submit our Report.

5.The book “Sans Everything” contains two chapters which refer to Cowley Road Hospital entitled “They Would Rather Be Dead”, by Nurse Emily Swinburne, S.E.N. (on page 27), and “They Cannot Defend Themselves”, by Auxiliary Nurse Louisa Fenton (beginning on page 31). The names of the two authors are nommes de plume and, before they gave evidence to us, our Chairman undertook that their true names would be kept secret to our Committee.

History of Cowley Road Hospital

6.Cowley Road Hospital was opened in 1865 as “a workhouse of a size sufficient to hold 330 persons, men, women and children, properly classified”. The building cost £7,000 and was administered by the Poor Law Board. By the Local Government Act of 1929 the hospital was transferred from the Guardians of the Poor Law to the Oxford County Borough Council as the Local Public Assistance Authority and was used, together with the Headington Workhouse, by the Public Assistance Committee in discharging their duties for the proper care and maintenance of all persons requiring relief in a Poor Law Institution. In 1939 the Hospital was included in the Ministry of Health’s Emergency Medical Services Scheme and a unit was developed for evacuees and local maternity cases.

7.When the Hospital was handed over to the United Oxford Hospitals on 5th July, 1948, on the commencement of the National Health Service, it comprised four main buildings used for the accommodation of patients and three buildings used for staff purposes. We have been told that at that time the buildings and the hospital services were in a deplorable condition. There were no nursing facilities in any of the Wards and one single-storey block at the rear of the hospital was in such a bad state that it was eventually demolished.

8.In 1950, a Clinical Director of the Hospital was appointed and instituted a new programme of progressive patient-care for the class of patients known up to that date as “chronic sick”. Apart from instituting his own regime of medical care, he was instrumental, with the active co-operation of the Board of the United Oxford Hospitals, in greatly improving the standard of the buildings and of the nursing and medical amenities in the Hospital. The four front wards known as A, B, C and D, were included in a programme of upgrading including the provision of piped oxygen, piped suction, etc., and were reopened in 1961. A specially designed building, known as ” The Day Hospital” was erected and opened in 1958, the cost having been met by monies provided by the Nuffield Provincial Hospital Trust. And in the same year another unit of 40 beds, known as Hurdis House, was built with the assistance of a grant from the National Corporation for the Care of Old People, who administered that unit until 1st November, 1967. It is now under the administrative control of the Board of Governors. In 1963 work was started on a building at the rear of the Hospital, designed for use as a Hostel for 40 patients ; when completed in early 1965 it was decided to use this building as a rehabilitation unit, minimal care unit and a day hospital unit for 12 to 15 patients. The following is a record of the expenditure on Cowley Road Hospital since 1949: —

Capital Maintenance Furniture
£ £ £
to 31/3/49 2644 2229 1782
31/3/50 48613 7612 333
31/3/51 9455 2096
31/3/52 8086 1216
31/3/53 5156 766
31/3/54 4536 1653
31/3/55 11662 5144 859
31/3/56 21174 4627
31/3/57 7345 4712 1109
31/3/58 7201 5005 1174
31/3/59 4520 5312 862
31/3/60 24341 8573 329
31/3/61 19818 5737 335
31/3/62 8281 5117 415
31/3/63 34769 3051 298
31/3/64 37516 7785 1310
31/3/65 25801 16000 3717
31/3/66 4199 13263 2739
31/3/67 1564 12730 2059
Total 259448 134129 24132

The Medical Regime and Staff Situation

9. The improvement of medical services has been remarkable. In 1948, when the Hospital was taken over by the National Health Service, there was only one general practitioner in attendance, and that on a part-time basis three times a week; there are now two eminent consultants and ten doctors on the permanent whole-time staff. There has, however, been a constant shortage of adequate nursing staff which is, of course, understandable par­ticularly in geriatric nursing because it is a form of nursing which is without glamour and which does not appeal to the ordinary young woman who enters the profession. It is a form of nursing that requires a sense of vocation more, perhaps, than any other branch of that profession. It has been inevitable that a considerable number of auxiliary and part-time nurses have had to be employed, which of itself, creates particular problems for the trained staff in supervising and communicating with them. However, the Board of Governors recognised the need to recruit more trained nursing staff for this hospital and allocated twelve trained agency nurses out of a total allocation of fourteen for the whole of the Oxford United Hospitals. Moreover, in 1957, a pupil nurse training school was introduced into the Cowley Road Hospital unit which proved very successful and up to three or four years ago, provided something like 35-40 pupil nurses in training, so that it seemed possible that with this additional strength the nursing problem might be solved. When, in 1964, the General Nursing Council decided that Pupil Nurse Training should be based on a general hospital, in the interest of a more comprehensive training, fewer pupils were seconded to the hospital for geriatric experience. Negotiations are now proceeding between the Clinical Director and the other authorities concerned in the hope that the better nursing standards for the long-stay patient which have been achieved would justify the reintroduction of pupil nurses to this geriatric unit.

10.The Clinical Director, with the assistance of a geriatric physician, has instituted a regime for the treatment of geriatric patients which is to a large extent revolutionary. He is one of the pioneers in geriatric medicine, in which perhaps the main advance in modern times is the realisation of the possibilities of the active treatment of old people instead of merely caring for the chronic sick. It was outlined in a lecture given by him, a copy of which was published in the Nursing Mirror on 31st July and 7th August, 1964, and entitled “Treatment and Nursing of the Geriatric Patient” and may be summarised as follows: It is a system of progressive patient care involving the admission of patients to two acute wards for assessment and initial treatment. There are three zones for intensive care, intermediate care and minimal care. In addition, after their acute illness has been treated, patients are transferred to a new block for intensive rehabilitation. In the rehabilitation block they are divided into a quick stream and a slow stream. The results of this regime of treatment have been remarkably successful, as shown by the following figures: in 1950 there were 268 in-patients in the Hospital of whom 221 had been permanently “bedfast” for more than one year, but in 1966 of 212 patients only one had been permanently “bedfast” for more than one year. In 1950 the average length of stay of a patient in hospital was 290 days, but in 1966 it was only 35 days.

11.The difference between the Clinical Director’s approach and the former one of merely custodial care of the chronic sick can, for patients suffering from a stroke, make all the difference between a useful life of activity and one of bedfast invalidism. It also enables far more patients to be treated in the available hospital beds. Nevertheless, the crux of the problem may well be that the effects of the modem policy on geriatric nursing have not been fully assessed. Although there has been an addition to the nursing establishment, this has not been .adequate to meet the nursing needs of the large number of patients being treated. Theoretically the policy of early ambulation and active rehabilitation should lessen the burden on the nurses, since it allows the physiotherapists to take over and play an active role, but in practice the burden appears to be greater, in all probability due to the larger numbers of seriously ill patients who are admitted to the geriatric department. The nursing needs of the many acutely ill patients in the admission wards which we visited were very great.Instead of having this unit full of irremediable cases, as it was in 1949 and 1950, there are 100 “acute beds” out of 212, and with progressive patient-care, one quickstream rehabilitation ward of 40 beds, one slowstream rehabilitation ward of 32 beds, and one permanent care unit (for long-stay patients) of 35 beds. The Clinical Director also makes use of Hurdis House and the day patient unit to ease the demand for beds. (The Hospital serves a population of over 400,000 people; there are seven geriatric beds per 1,000 population aged 65 and over in this area, compared with the Ministry of Health’s recommendation of ten per 1,000.) The Clinical Director says he restricts the admission of patients to the numbers with which the available nursing strength can cope. It is to be noted that not only does Nurse Swinburne approve of the Clinical Director’s regime (she spoke to us of “the marvellous diagnosis that always took place”) but that there are no complaints at all against that side of the treatment of patients. It must, however, be realised that owing to the rather novel and bold method of treatment of old people, with a view to their rehabilitation, the untrained layman or auxiliary nurse may well form the false impression that the patients are treated harshly (e.g., the comment on page 29 of the book “physiotherapy which seemed to most of (the patients a mysterious and unwelcome discipline”). The gravamen of the complaints contained in “Sans Everything” is about the nursing of patients in the Hospital.

144.Before the new regime the nursing was, as we have said, for custodial care, and very little in-service training or instruction was given to nursing auxiliaries. Later in the 1950s some in-service training was undertaken, but owing to staff problems, was scant and intermittent. The Clinical Director, himself, when asked, said that the medical staff had assisted with a few lectures only, and that owing to pressure of work the Senior Registrars were not able to give any substantial assistance. In recent years, however, particularly since the appointment of the present Deputy Matron, in-service training has been much more active and constant, and we feel that her task would be greatly assisted if the medical Registrars would take part in the training of nursing staff.

“Sans Everything”

15.Under the first part of our Terms of Reference we are required to investigate and report our findings in regard to allegations made in the above-mentioned two chapters of the book “Sans Everything”. The allegations in those two chapters are numerous and somewhat lacking in precision but we were assisted by the fact that Miss Fenton in her evidence spoke of particular cases, which, she maintained, were examples of the complaints made by her in her chapter of the book. The allegations may fairly be characterised as (i) complaints of unsympathetic, unkind, and even “brutal”, treatment of patients especially by auxiliary nurses and young male nursing orderlies, (ii) complaints of lack of proper organisation of the nursing care and lack of supervision by the trained nurses of the work of auxiliaries and orderlies, (iii) complaints of failure to give proper training to auxiliary nurses, (iv) allegations of unhygienic practices and conditions which “have been habitual in the wards for so long that it is now almost impossible for a nurse to do the routine work in a normally clean way”.

16.In judging the evidence about these allegations we bore in mind the testimony that since 1951 the Cowley Road Hospital had been immensely improved in every way and even since 1960 there has been steady improvement. But probably its former reputation as a workhouse still lingers on. In view of this, and in view of the periods of service of Mrs. Swinburne and Miss Fenton, it seemed proper to concentrate on evidence relating to the period from 1960 to the present time, which was really the only evidence offered to us by them.

17.Anyone approaching an investigation into allegations of misconduct or negligence by nurses towards senile patients must realise that geriatric nursing demands of the nurse the highest qualities of dedication and an inexhaustible patience in the face of constant irritations due to irrational behaviour by those who are mentally confused and feeble. It would not be surprising to find that there have been .occasions when, for a moment at least, exasperation overcame the self-control of the most devoted nurse; but, nonetheless, where we find there has been any maltreatment, we shall not fail to say so. The investigators are also faced with the difficulty of having to assess the genuineness of complaints made by elderly patient who are often confused and suffer from delusions.

General

18.It is most unfortunate that none of the witnesses who now criticise the state of affairs in Cowley Road Hospital and the conduct of the staff complained about the things they disapproved of at the time when they could have been observed and investigated. Mrs. Swinburne said there was no reason for anyone to fear doing so, since “everybody was very civil and courteous during the whole of my training”. The obvious reason was, we think, an innate reluctance to criticise superior authority or to “tell tales” against fellow auxiliary staff. Nevertheless, the result has not only made it very difficult to determine the truth of the allegations (many nurses and patients having left the hospital in the meantime) but creates a risk of injustice to the staff referred to. We have no doubt that a reasonably presented complaint to the Hospital Board or to the Matron would have been carefully examined.

19.However, Miss Fenton did eventually complain to the Administrator of the United Oxford Hospitals Board, in late 1964 (see page 37 of the book). She says that he was sympathetic, but seemed overworked, and he told her to “keep on reporting to the Matron”. The Administrator, on the other hand, said Miss Fenton was nervous and hysterical,” quite obsessional about smells and incontinence; she painted an almost Crimean picture of conditions in Cowley Road, so that, if I had not known Cowley Road, it would have been horrifying”. Moreover, Miss Fenton refused to allow him to mention her name to the Matron lest she be victimised, which made the problem very difficult for him. As she seemed incoherent, he suggested she should write down her complaints and show that to Matron.

20.On 28th January 1965 Miss Fenton had another interview with the Administrator, this time bringing with her notes which were substantially the draft of her chapter ” They Cannot Defend Themselves”. He declared: “Frankly, I did not believe them in the form she was discussing them. I know Cowley Road very well; I had my own relations in there in fact, and I am frequently in and out . . . and it just was not a picture of the hospital as I knew it”. However, Miss Fenton, and her notes, were referred to Matron, who also did not accept the truth of what was said about her hospital.

21.Matron took no action upon the complaints put forward by Miss Fenton, principally because she did not believe them and also because, being a kindly and gentle person, she did not wish needlessly to upset her staff by seeming to entertain unjust reflections upon their professional competence. But she said in evidence that, as she went round the wards day by day, she kept special observation, with those complaints in mind, and saw nothing to justify them or to cause her disquiet.

22.Then in January 1967 Miss Fenton communicated with her Member of Parliament, who sent the complaint to the Clinical Director, whereupon the Hospitals Board began an inquiry which was suspended upon the publication of “Sans Everything” and the setting up of this Committee of Inquiry.

23.With the benefit of “hindsight”, we think the Matron’s judgment was wrong, for the best of motives, in failing to make a more strict examination of the complaints. It would have been so easy for her to have confirmed her disbelief of the allegations by simply asking Miss Fenton to go with her to the wards (or to summon her to the ward) and there to point out evidences of the matters referred to in her complaint.

CONCLUSIONS

24. (a) We have come to the conclusion that the allegations of Mrs. Swinburne and Miss Fenton, in so far as they are allegations of general or frequent unkindnesses, ill-treatment, cruelty and disrespect, have not been established; indeed, we have no doubt upon the evidence which we accept that they have been disproved. Nor have we any doubt that the trained staff, from the Matron down to the Sisters and Staff Nurses on the wards, would not tolerate the conduct complained of if they became aware of it.

(b) But the trained staff cannot know of every incident which occurs on their wards, and we believe that there may have been comparatively rare occasions when an auxiliary nurse, and sometimes a pupil nurse or male orderly, has spoken crossly, rudely or improperly to a recalcitrant or annoying patient. In view of the evidence of two other witnesses, and since we do not entirely reject the evidence of Mrs. Swinburne and Miss Fenton, we think that on rare occasions an untrained nurse has used vulgar language in the presence of a patient, though not by way of abuse, and has spoken carelessly in the hearing of a patient of the latter’s short expectation of life. We cannot identify these occasions, but we believe the offences were committed by unsuitable people who have necessarily been employed in order to meet the demands for staff (“even a pair of hands is valuable”) and, as the Clinical Director commented, “if you are employing people of low intellect, of lower ability to adjust to stress and strain, they are more likely to be exasperated”. The witnesses named above are not accustomed to use vulgar language; for some of the auxiliary staff it may have been normal speech.

(c).Similarly, we have come to the conclusion that there have been few occasions when patients have been treated roughly, but on only two occasions has this been done deliberately and in each instance the offending nursing auxiliary or orderly was immediately dismissed. Much of the roughness was attributable to the fact that some nurses are more vigorous than others, some of it was due to lack of skill in lifting patients and some to the feeling of harassment in overworked nurses. Save in the two instances mentioned, such roughness in handling or in speech as may have occurred was not deliberately intended to hurt the patient, and was not more than might well have occurred in the patient’s own home for the same reasons.

(d).We are satisfied that no other act of physical assault has been established.

(e).We accept the evidence, which was almost unanimous that the occasional misconduct which has been proved was due to either (i) lack of adequate supervision, particularly on night duty, owing to shortage of staff,(ii) lack of training and day-to-day instruction of the auxiliary nurses arising from the fact that some do not go to seek directions when they come on duty, as they ought, and (iii) the unsuitability of individual nurses, under stress and strain, did not manifest itself until he or she had been taken into service on the wards.

(f) We accept that in years past there have been occasions when fouled linen has not been properly disposed of, causing offensive smells and that nursing auxiliaries have been guilty of undesirable practices, such as using the same water to wash more than one patient. Most of these things happened on night duty when (until a Deputy Matron was appointed in October 1965) the staff was not as well trained or supervised as the day staff. These practices were, of course, also attributable, in part, to the lack of facilities which were being improved as fast as practicable year by year. The standard of the night staff has now been raised and such complaints ought not to arise again.

(g) We found no evidence of anything which called for disciplinary actioni against anyone.

Present situation

Present Staff Situation

25. The recruitment of nurses and auxiliaries to geriatric nursing continues to be, and will probably always be, a difficult problem, for the reasons we have indicated at the beginning of this Report, and it is very difficult to provide a large hospital such as Cowley Road, with 212 beds, with adequate staff unless it has a nurse training school. But we are satisfied from the Matron’s and Deputy Matron’s evidence that, despite the difficulty of finding recruits, the selection of auxiliary nurses is being carried out very carefully, in order to ensure, so far as possible, that only the right type of person, temperamentally and as regards intelligence, is selected. Student Nurses and Pupil Nurses are also being seconded to the hospital as part of their training, to study the special field of geriatric nursing. From the state­ment of the staff situation as it is at present, it will be seen that the number of auxiliaries is slightly above the establishment figure, but we would point out the more auxiliaries there are, the more trained nurses are required for supervision in this type of geriatric unit, and the employment of a large part-time staff adds greatly to the amount of supervision by the trained staff.

In-Service Training of Nursing Auxiliaries

26. Within the last two years, in-service training of nursing auxiliaries has been improved and is now taking place regularly. We think it is adequate, provided the present pattern is maintained.

Equipment

27. Considerable progress has been made in organising a supply service at the Hospital, which is said to work in a “conveyor belt” system, feeding supplies to each ward twice a day throughout the week. Those parts of the supply service which are the direct responsibility of the Supplies Liaison Officer are much further ahead in giving the nursing staff complete freedom from requisitioning or supervising supplies, thus providing efficient services to the wards. These services include the provision of sterile dressings, instruments and equipment.

Structural Considerations

28. We noted no matters for criticism in this connection. On questioning the Clinical Director, he informed us that he considered that the Board of Governors had provided all the facilities he wanted, and the upgrading of accommodation was carried out without undue delay. Two wards at the back of the hospital which lack some facilities at present will no doubt shortly be improved, and in our view the accommodation is of a satisfactory (in parts, a high) standard, entirely suited to the nursing of geriatric patients.

Medical Policy

29. We have pointed out the difference between the Clinical Director’s treatment of the aged and the old approach to the problem which can, for many make all the difference between a useful life of activity and one of bed-ridden invalidism. That policy is now recognised in the profession as being not only to the ultimate benefit of many patients, but it also enables far more patients to be treated in the available hospital beds. We have heard criticism which seems to suggest that everything would be all right if one went back to the former policy of treatment. Reports of surveys (e.g. by Sir Arthur Thomson in his Lumleian Lectures, Royal College of Physicians, 1949) describe graphically the results of such methods, which really amount to medical neglect, and we would be opposed to such a reversal of policy.

General Opinion of the Hospital as a Whole Now

30. In our opinion Cowley Road Hospital is an excellent geriatric unit, and we are satisfied that the charges brought against it and its staff in “Sans Everything” cannot in any way be substantiated today. We are confident that there is no cause whatever for public disquiet in any respect in the nursing or medical treatment received by patients in this hospital.

Recommendations

Nursing Staff

31.—(i) There should be post-graduate training for all nurses in the hospital in this special field of medicine.

(ii) The assistance of the medical staff should be sought in the programmes for the training of nurses.

(iii) Good senior trained nurse support should be given in the practical supervision on the wards.

(iv) Consideration should also be given to the question of adequate communication with and information to nurses at all levels, so that particu­larly the nursing auxiliaries may know more about the problems of the patients they deal with, and we would suggest that one method of improving the situation in this respect is that there should be staff meetings including nurses at all levels.

(v) It is obviously very difficult to ensure that part-time nurses, who come on duty at several different times of the day, will be fully informed of the changes in patients’ conditions and needs, and we would, therefore, recommend that it should be the rule that on reporting for duty every nurse should sign a book which should be kept immediately beside the Kardex file and the notice board on which notices relating to the patients are exhibited, and that she should be told to read them.

Equipment

(vi) The disposal and cleansing of fouled linen should not be the task of the nursing staff within the ward area, but other arrangements should be made for its disposal. The fouled linen washing machine in the acute Ward A should therefore, we consider, be removed.

(vii) We think it would be an advantage that the Tannoy system should be replaced, as it is rather disturbing to staff and patients alike.

(viii) The pattern of commode that is combined with a bedpan is capable of more hygienic emptying than the “deep pans” pattern, which can only be emptied in an open hopper, and we would hope that as replacements take place these would be introduced.

(ix) Though much of the hospital is well-curtained to protect the privacy of patients using the commode, more adequate arrangements should be made for screening patients when using the commode, particularly when several are doing so at once; e.g. extra screens should be provided.

(x) We understand there is now a satisfactory method of marking dentures with the patient’s name, and we recommend that this should be investigated and if suitable adopted as soon as possible. (The Ministry of Health recommends the use of marking ink supplied by C. M. W. Laboratory, Blackpool.) Likewise, we think that better provision should be made for identifying the brushes and combs and toilet equipment belonging privately to the patients, so as to prevent loss.

32.We wish to express our thanks to you, Sir, and your staff of the Cowley Road Hospital, for kindly arranging for our accommodation at the hospital. We wish also to express our very warm thanks to Mr. J. Mullins, our secretary, for the efficient, tactful and prompt assistance which he has given us throughout the inquiry; his help has been invaluable.

We are, Sir,

Your obedient servants,

Brian Gibbens, Chairman

A. N. Exton-Smith.

L. de la Court.

J. W. Weld.

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