Part 3 of Findings and Recommendations Following Enquiries into Allegations Concerning the Care of Elderly Patients in Certain Hospitals

1. On 31st August, 1967, at the request of the Minister of Health the North West Metropolitan Regional Hospital Board appointed an independent Committee of Enquiry into allegations concerning Friern Hospital. The Committee was composed as follows :—

  • Legal Chairman: D. G. A. Lowe, Q.C.
  • Nursing Member: Dame Muriel Powell, D.B.E., S.R.N., S.C.M., R.N.T.
  • Medical Member: A. B. Munro, M.D., Ph.D., M.R.C.P.E., D.P.M.
  • Lay Member: Mrs. I. Graham Bryce, M.A.

2. The terms of reference of the Committee were as follows :—

(a)To investigate, as far as available evidence permits, the allegations starting on pages 15, 58, 65 and 71 of the book “Sans Everything ” in relation to conditions at Friern Hospital;

(b)to examine the situation in geriatric wards of the Hospital at the present time ;

(c)to make recommendations.

FINDINGS ON THE ALLEGATIONS IN THE SECTIONS OF THE BOOK ” SANS EVERYTHING ” STARTING ON PAGES 15, 58, 65 AND 71 IN RELATION TO CONDITIONS AT FRIERN HOSPITAL

3.Mrs. Barbara Robb has admitted to the Minister that the allegations starting on these pages in the book relate to Friern; and the last of the four sections appeared under her name. The task of investigating the allegations was rendered more difficult owing to the refusal of Mrs. Robb or her friends to give any further information, or to support their allegations by giving evidence before the Committee, and the same difficulty arose over the similar refusal of the contributors of the first three sections.

4.The Committee were further hampered in their task because every person criticised was given a pseudonym, as were the alleged victim of ill-treatment (a Miss Wills) and her relations in the section written by Mrs. Robb herself. In the course of the enquiry, however, the Committee were able to ascertain in many cases the identity of the alleged culprits and also of “Miss Wills” and her relatives ; and the Committee were thus able to interview most of such persons, as well as other members of the Hospital staff who were or might be able to deal with the allegations. Moreover some of the complaints about the hospital buildings or other general matters were susceptible of examination by the Committee on the spot.

5.Another important factor affecting the investigation arose out of the lapse of time since the majority of the alleged matters of complaint arose or occurred, namely the first half of 1965 or earlier. The Committee do not know why publication of the book did not take place until almost two years later, in the late spring of 1967 ; although this delay permitted the inclusion of the section beginning on page 58 which the Committee were able to discover related to an event in August, 1966. In assessing the value of the evidence given to them the Committee have naturally borne in mind the effect on people’s memory of such a time-lag.

6.The allegations starting on page 15 are made by an anonymous contributor describing himself (at page 13) as ACMN Michael Osbaldeston RMN. This man’s identity was almost certainly established. He never worked in the ward but was appointed specifically for a new job which may have been difficult, involving the organisation of entertainment and occupation for the patients ; and this man did complain to the Chairman of lack of cooperation by doctors and nurses, despite the efforts of the Management Committee to secure it. Nonetheless the Committee do not regard his criticisms in the article as justified, partly because he ignored a direct invitation to be interviewed and partly because he has been guilty of such distortion of fact, amounting to downright untruth, that little or no credence can be given to what he writes.

7.The author comments on the lack of entertainment for middle-aged schizophrenic patients and of occupation for many of the elderly. It is impossible to judge two or more years after the event whether this comment is justified, first because there is certainly some entertainment now and no evidence that it did not exist in or before 1965, secondly because there was occupational therapy available at that time, although perhaps less than desirable, and thirdly because so many of these older patients desire nothing more than just to sit or loaf around owing to their mental condition. They may appear to be bored and dejected: in fact they are often incapable of animation.

8.The criticism of the quality of the hospital clothing is not fully justified in view of the fact that in so many cases it is constantly soiled and damaged. It is rightly stated that for an outing the patients have to be—and in fact were and are—suitably dressed ; but the Committee doubt if the extra work involved caused resentment among the staff, as this article seems to imply.

9.The next serious allegation, that the author was always told that if he let the patients out of the locked wards for the purpose of entertainment he would “lose the bloody lot”, is quite unsubstantiated and probably exaggerated ; but the Committee accept the possibility that on some occasion another male nurse may have used the alleged or a similar phrase. What is not brought out, as in common fairness it should have been, is the undoubted necessity to keep many, if not all, wards locked because of the propensity of many patients to wander and the clear risk of their being lost or even injured on the near-by highway. This is the true explanation of locked wards and not, as the author so unjustly alleges, that it was (or is) for the sisters’ convenience.

10.The Committee reject entirely the allegation that everything in Friern was arranged for the benefit of the staff and that this attitude probably stemmed from the top. Whereas some arrangements, such as duty hours, had and have to be made to meet the needs of the nursing staff and to some extent of their Union, the Committee are satisfied that the welfare of the patients was and is the prime consideration of all concerned, whether doctors, nurses, orderlies, or administrative staff.

11.The article next makes the false and really scandalous allegation that the Physician Superintendent was seldom in the hospital for more than one or two hours a day. The Committee interviewed this gentleman. He was a whole time consultant from October, 1956, to November, 1966; but although non-resident from 1959 onwards he informed the Committee, and they accept, that he attended the hospital daily from 9 a.m. to 5.30 p.m. except on Wednesday afternoons.

12.The author next criticises in quite general terms the matron and the eight or nine assistant matrons “whom she had chosen for the job”. The Committee are not prepared to accept from this anonymous author, whom they have been unable to interview, the somewhat wild allegations against the matron who retired in June, 1967, on attaining the minimum retiring age.

13.There follow some general criticisms of the nurses and doctors, of which the most serious are, first (by implication) that they are idle and secondly that the doctors seldom go into the wards. The Committee disbelieve these generalisations, which are not only unsupported by any evidence produced to them by or on behalf of the author, but are in flat contradiction of the evidence actually obtained and the Committee’s visual observation of conditions in the wards.

14.It may be that some of the staff appeared to regard the patients more as cogs in a machine than human beings: no one could expect every nurse to be a paragon of charitable conduct. The Committee do not accept, however, that “most” of the staff so regarded the patients and are sure that none of the senior staff did so.

15.The allegation of maltreatment by hitting and thereby bruising patients is easy to make, and difficult to disprove when no specific instances are given. The fact may be that apart from the need to restrain a violent or overactive patient, the bruises usually resulted from falls or bumping against furniture, as is only too apt to happen to elderly people. In any case the Committee think that if any ill-treatment by one of the staff were properly reported the matter would be promptly investigated and, if established, suitably punished —as indeed occurred in one instance of which the Committee were informed, the nurse being dismissed.

16.The allegations against Friern in this section of the book conclude with an account of an alleged interview with the Chairman of the Management Committee. The Committee have seen this gentleman, who cannot recall the interview although it may have taken place. If so and if this charge nurse had then complained or protested about maltreatment of patients, the Chairman feels sure that this would have been impressed on his memory and that he would have asked immediately for particulars and made inquiries. The Committee accept this evidence as they think that if the protest was made it would have been remembered, and—more important—would have resulted in action by the Chairman, who always investigated complaints brought to his notice.

17.The allegations starting on page 58 are made by an anonymous contributor describing herself as Elizabeth Tasburg (Psychiatric Social Worker) Her identity was easily established by one of the senior hospital medical officers, who recognised himself as the “Dr. Cure ” in the article and recalled the case of Miss Tasburg’s father, whose admission to treatment in and removal from Friern purported to be described in the article. The case notes of a patient were produced to the Committee; and the record corresponded so closely with the chronicle of alleged events that the Committee were satisfied that “Miss Tasburg” was in reality this patient’s daughter If further evidence were required it was provided by a charge nurse “Mr. Well” , who also recalled the case or recognised himself as the charge nurse “Mr. Well” in the article. Both “Dr. Cure” and charge nurse “Well” were interviewed. Regrettably Miss Tasburg refused, through solicitors, to attend the Committee.

18.”Mr. Cure” told the Committee that he had known Miss Tasburg for a long time and had been on good terms with her when she attended his “follow-up” clinics. She was an outside social worker and Dr. Cure talked with her as a fellow professional worker. He was much upset by the breach of confidence implicit in Miss Tasburg’s by no means accurate account of one of their private conversations in his consulting room; and the Committee are unanimous in agreeing that this lady has been guilty of a breach of professional etiquette.

19.Dr. Cure admitted that during one of their conversations he probably expressed a preference for treating psychotic—not “mad “—patients to seeing discharged patients in a follow-up clinic; and he also admitted that he probably described his technique in talking to non-psychotic patients as charlatanry. None of the Committee regard these remarks as impugning in any way the services actually rendered in the hospital by Dr. Cure during his 19 years there, during which he has looked after male and female patients in most types of wards.

20.The true facts concerning the admission and treatment of Mr. Tasburg were as follows—and they are very different from the incomplete and distorted version set out in the article. The discrepancies, distortions and omissions of vital facts may be due to the highly emotional state in which Miss Tasburg seems to have been, perhaps not surprisingly as her father had been admitted after two attempts at suicide and another attempt to strangle his wife, which had necessitated his daughter remaining at home as he was beyond his wife’s control.

21.Dr. Cure heard of the case from a mental welfare officer on the llth August, 1966; and Mr. Tasburg, aged 69, was admitted on Friday, 12th August, under an urgency order signed by his own doctor. The admitting doctor noted that he had been attending the National Hospital, Queen’s Square, and was said to be suffering from Huntington’s Chorea. He was mentally co-operative, but tearful and agitated. He had not been sleeping properly and had marked involuntary movements of the limbs. He was prescribed Largactil as a sedative and Chloral Hydrate at night if necessary. When seen next morning by Dr. Cure he was confused, agitated, deluded, miserable and very tearful. He was considerably retarded and constantly wanted to go home. In view of his suicidal and homicidal history this was thought to be inadvisable; and another independent doctor continued the compulsory order on the 15th August. When Miss Tasburg visited her father on Tuesday, 16th August she was dissatisfied and demanded that she should remove him. Dr. Cure explained in detail the dangers involved; but as Miss Tasburg assured him that she would take every precaution and ensure treat­ment for her father elsewhere, Dr. Cure agreed to discharge him to her care. Dr. Cure also gave Miss Tasburg a prescription for Largactil to tide her father over.

22.Charge Nurse “Well” was on duty when Mr. Tasburg was admitted, weeping and very depressed. On the following evening Miss Tasburg and her father were seen by “Mr. Well”, and he agreed that there was a conversation about clothing because it was his practice as a charge nurse of some six years standing, to request relatives to take home articles that the hospital would supply; and he had naturally been reluctant to allow Mr. Tasburg to keep a razor as he might still have suicidal tendencies. “Mr. Well” also agreed that the patient’s money (except loose change) had been handed in to the Admissions Office together with other articles, as was the prescribed procedure with which the Committee find no fault; and that Mr. Tasburg had wrapped the loose change in a handkerchief and put it under his pillow. Such an action was to be deprecated because of the risk of petty theft, but it was difficult to prevent; and the Committee think that on balance it was (and is) better to placate disturbed patients by allowing them to retain small sums or minor valuables than to upset them by requiring nightly or total surrender.

23.Mr. Well did not dispute the substance of his conversation with Miss Tasburg about medication although he denied saying that they had had to give Mr. Tasburg “a good dose”; and the medical records confirm that medication was given before Mr. Well went off duty and that none was given by the night nurse, who mistakenly therefore told Miss Tasburg on the telephone that her father had slept without medication. According to Mr. Well, Mr. Tasburg was very distressed and more depressed than anyone he had ever seen, which may explain his alleged remarks to and bearing towards his daughter, concerning which the Committee had no evidence; but the only ensuing conversation that Mr. Well recalled was a remark by Miss Tasburg that her father looked a little better and a reference by him to Mr. Tasburg’s belongings having been checked and to the loss of some silver (as mentioned above). Mr. Well denied having said either that “your father’s very confused” or that “it’s a form of insanity”; and the Committee accept his denial.

24.It is apparently correct that Miss Tasburg visited her father on the next afternoon, the Sunday; but as everything written by her about what happened that day relates either to her own observation or to her conversation with her father, and neither of them gave evidence, the Committee cannot accept any of her statements as proved. They suspect however that if Mr. Tasburg referred to nurses hitting patients on the head or to his having had no medicine he was suffering from delusions, partly because they have received no credible evidence throughout the enquiry that patients were hit on the head except perhaps accidentally in the course of restraining them, and partly because in fact Mr. Tasburg did receive medicine, as the case record shows.

25.Miss Tasburg next complains about the treatment of her father and herself when she returned at 7 p.m. on the Monday. The Committee are satisfied that Mr. Tasburg had put himself to bed and that in his disturbed state no reliance could have been put upon any uncorroborated statements that he may have made to his daughter. If, as she states, she was told by a nurse that she could not enter the ward, which was a men’s sleeping dormitory, this was perfectly proper as she should have realised. It was also proper to prohibit smoking in bed. Miss Tasburg admits that the medicine sheet was produced and shown to her by Dr. Cure; and the Committee are forced to the conclusion that Miss Tasburg was quite unable or unwilling to grasp or accept the real nature of her father’s illness, which (as she was informed) had led an independent doctor to put him on a detention order.

26.There is no doubt that when Miss Tasburg returned on the Tuesday morning (16th August) she was very angry because of this detention order and in effect refused to heed Dr. Cure’s explanation and warning about the risk if she took her father away. The Committee accept Dr. Cure’s evidence, including the explanation he gave Miss Tasburg for putting her father “in a ward for older men” as a precaution “because he might have been knocked about in a younger ward with acute schizophrenics and psychopaths”.

27.The Committee are satisfied that Miss Tasburg’s next assertions about failure to give medicine to her father and that nothing had been done about his depression are untrue ; and in fact he had improved somewhat by reason of the Largactil.

28.The Committee conclude that the allegations by Miss Tasburg are based on a gross distortion of many of the facts, a suppression of other facts, and a remarkable inability in a psychiatric worker to perceive or accept the truth. They dismiss her complaints.

29.The allegations starting on page 65 are said to appear under the author’s own name, Roger Moody. Were it not for Mrs. Robb’s admission that this article refers to Friern the Committee would have doubted the truth of this assertion because intensive enquiries have failed to trace any worker of this name, whether trainee or social or of any other kind, at the hospital and no one can remember him. But of course the name may be a pseudonym. In any event it has been impossible to interview him.

30.The author describes himself as trainee social worker in a mental hospital of more than 2,000 beds in the London area.

31.The article begins by describing the procedure generally adopted by an unnamed consultant psychiatrist in an unspecified ward and a particular interview with a female patient on some unknown date. Neither the Committee nor anyone on the staff of the hospital could identify this consultant psychiatrist: and in these circumstances, and in the absence of any assistance from Mr. Moody, the complaint cannot be investigated and must be dismissed.

32.The remainder of the article consists either of generalised assertions which are easy to make but almost impossible to disprove, or generalised criticism of the “geriatric ward in this hospital”. Again one does not know to which of the numerous geriatric wards the author is referring so that no investigation has been possible: and all the Committee can do, in the absence of any available evidence, is to record its condemnation of the tactics whereby, without a shred of evidence or attempt at proof, such generalised criticisms have been published about a hospital and its staff who in the circumstances cannot refute them save by a justifiably indignant denial of their validity.

33.The allegations actually commencing at page 69 are entitled “Diary of a Nobody” and purport to be written by Mrs. Barbara Robb. They relate admittedly to Friern Hospital, under the pseudonym “Cossett”, and in particular to a patient called “Miss Wills” and her relatives, and to various members of the medical and nursing staff, all of whom are disguised by pseudonyms. Mrs. Robb herself, and the five friends who are said to have visited Friern independently or to have accompanied her there at various times and to have witnessed some of the alleged matters of complaint, appear under their own names; and their qualifications are set out at the end of the “Diary” on page 112. As none of these ladies and gentlemen was willing to meet the Committee and seek to substantiate their respective allegations about the illness of the anonymous patient and the treatment provided for her, the Committee feel justified in commenting that none of them possesses a medical qualification.

34.The refusal of Mrs. Robb and her friends to co-operate with the Committee made it more difficult to investigate the allegations in the Diary. Fortunately the Committee were able in the course of their enquiry to dispel some of the aura of anonymity with which Mrs. Robb sought to cloak her charges; and although the Committee did not succeed in identifying every member of the staff referred to, they traced and managed to interview a sufficient number, including the majority of those most criticised, to be able to deal with most of the allegations and, as the Committee will presently show, to dispose of them as based sometimes on misquotation, misrepresentation and serious distortion of facts, and in other instances on almost wilful disregard of medical opinion. The Committee accept that for some obscure reason Mrs. Robb had a genuine desire to assist the anonymous patient who was virtually a stranger to her and that she is possessed of an almost fanatical zeal to further the interests of geriatric patients in mental hospitals; but the Committee deplore the flamboyant and exaggerated style in which she presents her case in the Diary, a case which—if it has substance—would be more impressive if stated factually and without adjectival adornment. The Committee do not wish to criticise anyone unheard; but they are bound to state that they are unprepared to accept any statement by Mrs. Robb that has not been admitted or corroborated either in evidence given or in documents placed before them. The Committee observed, of course, the assertion in the Preface of the Book, written by Mrs. Robb, that “her own story of Miss Wills is true down to the smallest detail:” but the evidence the Committee were able to obtain established the falsity of this unsubstantiated claim.

35.The identities of the patient called “Miss Wills” and of her two relatives, a sister and niece called “Mrs. and Miss Lovat”, were easily established; but as those relatives expressed a desire for their anonymity to be preserved the Committee refer to all these people by their pseudonyms. Before dealing with the allegations concerning Miss Wills and her relatives it is necessary to recite her history, and in particular her case record, which the Committee have examined.

36.Miss Wills was bom in 1891. She was employed as a clerk in the Civil Service but became psychotic and had to retire. Thereafter she had various jobs including that of a seamstress; and her hobby was making coloured tinfoil pictures of some merit called “collage”. She had a long history of mental illness commencing in 1928. She spent six years at Napsbury and a further period at Shenley; and in December 1941 she first entered Friern as a voluntary patient, leaving in August 1942. According to Mrs, Robb she met Miss Wills in 1943, and this may have been due to both being Roman Catholics. She lived alone in very poor circumstances; and in October 1963 she had become a patient in Hampstead General Hospital, suffering from chronic delusions. A request was made for her transfer to Friern ; and she was admitted to Villa 1 on the 4th November 1963, as an informal patient. She was then 72 years of age. The referring psychiatrist suggested that a brief period of in-patient treatment with modern drug therapy, or even a course of ECT, might be helpful. A course of ECT was in fact prescribed and Miss Wills signed the consent form; and six treatments were given altogether, the last being on the 2nd December 1963. Contrary to Mrs. Robb’s statement, Miss Wills expressed herself as feeling better and not ill after this course, which was not repeated because the doctor at Friem doubted whether it had really been beneficial although not detrimental, Thereafter drugs were administered; but during 1964 her condition generally deteriorated, she became doubly incontinent, and she continued to suffer from the delusions and hallucinations to which the psychiatrist at Hampstead had referred. In May 1964 Miss Wills was transferred to Ward E. 3 which is a geriatric ward with a small four-bedded annexe in which she slept; and she remained in that ward until she left on the 26th June, 1965.

37.Whilst in Villa 1—a geriatric admission ward—Miss Wills was in the care of a Consultant Psychiatrist, who has since left Friern; in ward E. 3 she was under another Consultant, whom the Committee interviewed. Miss Wills was also looked after by that Consultant’s Registrar; and on the 26th May, 1965, she was examined at the request of the Court of Protection by the Senior Hospital Medical Officer, who then recorded that Miss Wills was suffering from, inter alia, senile dementia. One month later this Medical Officer described her physical condition to the Official Solicitor as “frail and senile” and her mental condition as ” of severe senile dementia “, and said that ” her prospect of recovery was nil”. On the 25th June, 1965, the Consultant wrote to the doctor in charge of the “convent” (so described by Mrs. Robb) that Miss Wills “at present is not unduly worried by her delusions but presents mainly a geriatric nursing problem”, The Consultant stated the quantities of the two drugs she was receiving and added that “it is not thought advisable to attempt further therapy at present” for Miss Wills’ delusional state and that “she is of course suffering from schizophrenia”. The Consultant told the Committee, and they accept, that when she took charge of Miss Wills her physical state was so low that she did not treat her mental state but that of all her patients Miss Wills most needed to be in a psychiatric hospital.

38.It is against this background that the Committee have investigated the allegations in the “Dairy of a Nobody” about the treatment of Miss Wills ; but the Committee have also investigated the allegations of a general character.

39.For obvious reasons the Committee have been unable to check the accuracy of statements said to have been made by Miss Wills to Mrs. Robb or Mr. Buss, whether orally or by letter; nor do the Committee know how Miss Wills became acquainted with Mr. Buss. He seems, however, to have interested himself in the old lady, who for her part sometimes expressed her belief (when in Friern) that they were married. The Committee heard no evidence that (as alleged on page 69) Miss Wills asked for occupational therapy; but none was provided for the simple reason that she was unfit for it, as was shown by her inability to use paints when these were provided. It is true that shortly after admission to Friern she was given “electrical treatment” ; but untrue—according to the records—that it frightened or upset her. It is true that Mr. Buss visited her (though Mrs. Robb did not) when Miss Wills was in Villa 1 and they both did so later when she was in Ward E. 3; but the Committee doubt whether Mr. Buss was ever told or led to believe that a place was being sought for her in an old people’s home, as this would never have been suitable. The Committee have been unable to investigate the subsequent complaints on page 70 of which Mr. Buss might have given evidence, because the sister-in-charge who is criticised here and on subsequent pages appears to have left the Hospital and letters sent by recorded delivery have been returned. It is certainly possible that on some occasion Mr. Buss was told that Miss Wills’ spectacles were lost—there was evidence that in common with other senile patients she used to lose her personal belongings, or think that she had done so—and it is a fact that there were few lockers in the ward. This was due largely to lack of space and was remedied during Miss Wills’s stay, but as far as she was concerned the Committee had some evidence that the absence of a locker made no real difference to her.

40.In November 1964 Mr. Buss did see the Registrar, who denied to the Committee that he had said that Miss Wills was not a mental case who could be cared for in an old people’s home or by relatives or friends, as alleged on page 70. He did advise Mr. Buss to write to the Physician Superintendent; and the Committee have seen a letter, dated the 4th December, 1964, inquiring what steps Mr. Buss and other friends might take as they “would like to see her in a home rather than a mental hospital”. This letter was dealt with by the Social Worker responsible for Ward E. 3 (and other wards). This lady is allotted throughout the Diary the pseudonym Miss Cloake; but the Committee were able not only to identify but also to have a lengthy interview with this lady. The Committee believed her evidence; and except where she frankly agreed with some of the remarks attributed to her they accept her refutation of the unsupported allegations of Mr. Buss and Mrs. Robb, some of which—e.g. that she was lazy and dishonest—are as false as they are deplorable.

41.The Committee have seen the correspondence between Miss Cloake and Mr. Buss during December 1964. It is manifest that this lady made thorough inquiries of at least six homes suggested by Mrs. Robb (through Mr. Buss), but they were either unsuitable or had no vacancies ; and Mr. Buss wrote a warm letter of appreciation of her efforts. It is surprising that he should now state (at page 70) that prior to meeting Miss Cloake that lady had not visited Miss Wills for over six months, when in fact she had seen Miss Wills frequently ever since her admission. As for Miss Cloake’s alleged promise to find a place in a home, this related to a nursing home, which had been the topic of discussion when she met Mr. Buss on the 15th December, 1964.

42.The Committee cannot comment on the alleged remarks by the sister-in-charge to Mr. Buss at Christmas as there was no evidence from either of them.

43.It would appear that prior to her visit on the 21st January, 1965, Mrs. Robb had last seen Miss Wills shortly before her admission to Hospital in October 1963 ; and if so the description of her as then being “plump and upright” conflicts completely with her condition on entering Friern, when she was very frail and scarcely mobile, desiring only to sit about and be looked after. Her hair was probably cut by one of the two hairdressers who go regularly round the wards ; but Miss Cloake doubted if it could be described as “shorn”, and as for the alleged lack of teeth, this would not normally have been the case by day but they would have been removed at night. If the nurse told Mrs. Robb that Miss Wills was very confused this was medically accurate, whatever Mrs. Robbs may have thought; and if Miss Wills said that she had not been allowed to have her spectacles since coming into Ward E. 3 this was untrue, but she may have said this, in her confused state, perhaps as a result of her frequent loss of her spectacles. Of Mrs. Robb’s alleged conversations with Miss Wills, with the sister-in-charge, and with two nurses, no evidence was available as none of these persons could be identified. It would however be wrong to reject entirely Mrs. Robb’s general description of the other patients: most of them were very old and senile, and many were incontinent and required skilled nursing. Neither spectacles nor hearing aids, if totally absent as Mrs. Robb implies but the Committee do not accept, would have been of much use to most of them. It is quite possible that some patient fell out of her chair, a mishap that cannot always be avoided.

44.The Consultant’s Registrar identified himself as “Dr. Payne” referred to on pages 72, 73 and 75. He disputed the version of the telephone conversation on the 29th January given by Mr. Buss, and particularly that he said that Mr. Buss was “all mixed up”, or that he refused to answer the question whether an ordinary hospital would be more suitable for Miss Wills than an old people’s home. In the Registrar’s opinion Miss Wills was a psychiatric case and in the right hospital; and he regarded any application to admit Miss Wills to a general hospital as quite wrong.

45.The Committee received no evidence in support of the events alleged to have taken place on the 6th February ; but Miss Cloake denied having ever told Miss Wills that she had not enough money to pay the rent. Possibly the old lady was confused about the arrangements being made forher flat to be given up, to which on the 20th January, 1965, she had signed a consent, after discussion with the Registrar who witnessed it; and whereby she also authorised her niece to dispose of the contents.

46.The Committee have seen Mrs. Robb’s letter to “Dr. Payne” dated 15th February, inquiring into the nature of the treatment Miss Wills required and whether she needed hospital care, in which event she (Mrs. Robb) would ask a friend, the head of the local hospital, whether he could find room for her. By this time Mrs. Robb and to some extent her husband were arrogating to themselves the role of self-appointed guardians of Miss Wills, who, as an informal patient, was, of course, free to leave the Hospital at any time; and the Committee regard as totally unjustified the insinuations in the Diary that the hospital authorities or medical staff did their utmost to obstruct Miss Wills’ departure. The evidence received, both oral and documentary, refutes this unworthy suggestion.

47.The Committee had the same difficulty in investigating the allegations concerning the 17th February, viz. the failure of Mrs. Robb or Mr. Buss to substantiate them and the impossibility of identifying “Sister True”; but Miss Wills almost certainly would have walked with difficulty and Sister True possibly did say that she was very confused as this was the case. The Sister may also have mentioned thieving in the ward because the Committee heard evidence aliunde that this used to occur in many of the geriatric wards—a lamentable circumstance partly due to staff shortage and partly, the Committee suspect, to the not uncommon predatory proclivities of many elderly people. It may well be that on this occasion, as on the 24th February, most of the patients in Ward E.3 had gone to bed by 7 p.m.: owing to their age many would wish to do so. The Committee could not investigate the other allegations concerning the 24th February owing to lack of evidence.

48.The next allegations by Mr. Buss against Miss Cloake and Miss Lovat are an almost complete distortion of the facts. Had they been true it is difficult to understand why neither this gentleman nor Mrs. Robb made any complaint to the authorities: but the explanation is simple—they are basically false. The charge that Miss Cloake said that Miss Wills was “probably dying, which she thought the best thing” was cruel, wounding and false; although Miss Cloake admitted that she may have said that Miss Wills was not so well but that Mr. Buss need not worry as Miss Lovat was coming that night—a very different version, which the Committee believe. The further remarks attributed to Miss Cloake concerning Miss Lovat are a distortion of what she said ; but as they form the introduction to the subsequent charge of dishonesty the Committee must deal with them fully.

49.Miss Cloake, as the Social Worker, had dealt with the problem of paying the rent for Miss Wills’ flat (consisting of two rooms on a third floor and with no lavatory) shortly after her admission to Friern ; and Miss Wills signed an authority to that effect. In accordance with the practice this flat was kept on for a year: but when at the beginning of 1965 it was realised that Miss Wills could never return and the property was said to be deteriorating, steps were taken to surrender the tenancy and dispose of the contents of the flat. As already mentioned Miss Wills signed the requisite consent with the Registrar’s approval on the 20th January, 1965. Miss Lovat had nothing whatever to do with this; and her denial of this charge in the course of her evidence is amply corroborated. Subsequently, however, Miss Lovat accom­panied Miss Cloake, at the latter’s request, to the flat; and it was undoubtedly in a bad condition, as indeed it had been when Miss Cloake inspected it at the end of 1963. The furniture was virtually “junk” and quite unsaleable; and far from any money being paid for it a demand of £2 for its removal by a man with a junk yard was later made. The only articles salvaged were two paintings by Miss Lovat’s grandfather and three of Miss Wills’ own tinfoil pictures. There is thus no justification for the allegation of dishonesty, which appears to be bolstered up by the reference to Miss Lovat being an out-patient at Friern. This is not a fair reference to Miss Lovat, who has a responsible post with a nationalised industry but does occasionally spend a few days in the Hospital for treatment. So the Committee approached all her evidence with reserve; but they are satisfied with the truth of her account of the sale of her aunt’s possessions. The Committee would add that Miss Cloake agreed that she probably told Mr. Buss that Miss Wills was “better off at Cossett than anywhere and it would be a mistake to move her” and that it was a good thing that she should not return to her flat: and on the evidence the Committee would endorse these views.

50.Mrs. Robb next refers (page 75) to “Dr. Payne’s reply to her letter. Dr. Payne had first quite properly obtained Miss Wills’ permission to write about her, and he described her condition in more detail than Mrs. Robb’s quotation would suggest. Pursuant to Dr. Payne’s recommendation she wrote next to the Physician Superintendent, making no complaint about Miss Wills’ treatment, and after some delay the Consultant replied on the 16th March with a reminder that Miss Wills’ family would have to approve any arrangements for her transfer. This letter is in fact quoted on page 88 as emanating from “Dr. Aix”, but the quotation ends with an unfortunate inaccuracy and omission. The Consultant wrote: “if you and Miss Wills’ family have somewhere (not ‘ anything’) in mind which would suit the patient better and be willing to accept her I should be extremely interested to hear about it”. The Consultant never heard from Mrs. Robb again ; and she never met either Mrs. Robb or Mr. Buss, neither of whom ever asked to see her, which is somewhat extraordinary in view of their subsequent allegations about the condition and treatment of their protegee Miss Wills.

51.There follows a series of statements by Mrs. Robb about telephone calls to third parties which the Committee could not check ; but they would observe that contrary to Mrs. Robb’s allegations Miss Cloake had never promised orally, and certainly not in her letter of the 16th December, 1964, to Mr. Buss, to put Miss Wills’ name on any waiting lists or to hasten the alleged project of a place in an L.C.C. home. All that Miss Cloake had said, according to her evidence, was that she would try to get Miss Wills into a Catholic Nursing Home; but when she explained this to Mrs. Robb on the only occasion when these ladies actually met, namely the 9th March, 1965, Mrs. Robb would not listen to her and may even have shouted at her, for the Committee had other evidence of how unpleasant the behaviour of Mrs. Robb was towards the hospital staff.

52.The Committee were unable to identify the “fattish, middle-aged nurse ” who is alleged to have shouted at Mrs. Robb as she entered the Ward on the 6th March. The Committee were not impressed by a later reference to the unidentified Sister True being unable to look Mrs. Robb in the face, or the implication that in order to get out it was necessary to traverse a corridor nearly a quarter of a mile long. The Committee saw this undoubtedly long corridor: they also saw that there was no need to traverse it on leaving the ward.

53.Miss Cloake had no recollection of the alleged telephone conversation on the 8th March (page 78), but as a meeting took place with Mrs. Robb on the following evening some conversation probably occurred. The Committee are not prepared to assume, however, that Mrs. Robb’s version is accurate: indeed they do not believe that Miss Cloake referred to Miss Lovat as an out-patient or said that she “had sold her aunt up” or that she was so emphatic as to say that there was “absolutely no possibility of getting Miss Wills a place outside Cossett”.

54.The Committee had no direct evidence about the condition of Miss Wills when visited by Mr. Buss and Mrs. Robb on the night of the 8th March; but a witness who was appointed an Assistant Matron after twenty-four years at Friern identified herself as the “Sister Neville” referred to as being in charge on this and subsequent occasions. This Sister could not recall the precise occasion, but it is doubtful whether she said that Miss Wills “ought never to have come” in view of her evidence that she required a lot of nursing care and was incapable of reading or doing anything occupational; and indeed Sister Neville denied saying this. This Sister confirmed that Miss Wills was incontinent and at times very confused; that she needed much nursing care which a geriatric home might not be able to give her; and that she just sat about and had to be washed, dressed and lifted into bed.

55.The account of the meeting on the 9th March, 1965 (the only occasion on which Miss Cloake saw Mrs. Robb), is somewhat garbled. The meeting began, according to Miss Cloake, in a very different fashion. Upon opening the door Mrs. Robb said in the presence of Mr. Buss and Mrs. Neal: “There is nothing wrong with this woman that a fortnight’s help won’t put right. Why doesn’t she have a room to herself and her pictures with her?”; and the Committee are disposed to believe that something like this was said because it reflects the attitude of Mrs. Robb to the whole situation. Miss Cloake agreed that there had been some further discussion about Miss Wills’ flat and the disposal of the contents but denied having referred to either Mrs. or Miss Lovat’s being “often a patient at Cossett”, which in any event would have been untrue as regards Mrs. Lovat, who had been there once only, in 1962 for a nervous breakdown. She did not tell Mrs. Robb that “everything was sold”—the Committee have already set out the facts—but did try to explain the state of the flat and shocking condition of the contents, although Mrs. Robb was disinclined to listen; and she also tried to explain that she had told Miss Wills about these matters but owing to that lady’s confusion she had probably forgotten. Miss Cloake agreed that Mr. Buss complained that someone from the Hospital ought to have gone to clean up the flat and that it was absurd to have continued to pay the rent, ignoring the fact that such cleaning was not the province of the Hospital and that such payments of rent were in accordance with the practice; and she also agreed that she had referred to Mrs. or Miss Lovat tidying up, if Miss Wills had been well enough to return.

56.Miss Cloake could not recall asking if Mrs. Robb thought she had a place for Miss Wills and denied emphatically the alleged inquiry (on page 80) about the Court of Protection, although she had probably mentioned the expense of a nursing home and the fact that Miss Wills had a retirement pension only, though this was not £3 7s. 6d. a week as stated. Miss Cloake had no knowledge of a bank account or of a Post Office Book, but she did undertake to enquire about the latter as the Hospital would be holding it. The Committee are not prepared to accept in the absence of any corroboration that there was any further reference to a bank account, which in any event has no relevance to the treatment of Miss Wills either by the Hospital or by Miss Cloake; and although there may have been some reference to Miss Wills’ pictures the Committee are sceptical about their alleged value.

57.According to Miss Cloake the purported conversation about an L.C.C. home is muddled. She would never refer to an “L.C.C. home” and she certainly did not quote the rule requiring ability to wash and dress and climb stairs. Nor did she assure Mrs. Robb or her companions that she had put Miss Wills’ name on the L.C.C. list in 1963: admittedly she had not. Miss Cloake did not recall the alleged reference to shock therapy and E.C.T. treatment, although if Mrs. Robb had criticised this she (Miss Cloake) would probably have said something to the effect that the doctors and nurses were the best judges of the appropriate treatment—a statement, if made, with which the Committee would not cavil.

58.Miss Cloake may have said that Miss Wills’ sister and niece were sure it was best for her to stay at Cossett for that was their well justified belief; but she would not have said that these relatives could prevent Miss Wills spending or using her money as this was not the fact, as each of them told the Commmittee. Nor would she have referred to both having “got the same disease “.

59.The Committee had no evidence to support the allegations about communications with a Welfare Office or the Court of Protection on the 10th March 1965 but they have seen a medical report to that Court as mentioned above. They accept that on or about this date Mrs. Robb made a complaint to Sister Neville, about an orderly being rude, but neither that Sister nor anyone else could positively identify this “harsh-faced Irish orderly” who answered to the name of “Grace”, although one such person whom the Commmittee interviewed might have been “Grace” despite her denials of the conduct attributed to her at page 82 and subsequently. The Committee suspect that either this orderly, or another, was less kind than almost all the others who looked after Miss Wills but they do not accept as proved the unkindness alleged on page 98 over a chocolate biscuit.

60.The Committee had no evidence to support Mr. Buss’ allegations on pages 82 and 83 but did have general evidence which contradicted the suggestion that Miss Wills was ever “crushed” or “cowed”, although undoubtedly often confused and always frail. The subsequent allegations by Mrs. Robb about communications with the Welfare Offices were not substantiated and the Committee do not accept the apparent insinuations against Miss Cloake ; but Mrs. Robb is correct in saying that she spoke to “Mr. Good”, whom the Commmittee were able to interview. His evidence was illuminating. He told the Committee, and they accept, that he did see Miss Wills, unaccompanied; and he thought it not inappropriate for her to be in Friern; that she was hardly able to walk about; that if she were in a home she would need special attention; and that he thought Mrs. Robbs’ account of the telephone conversation as given on pages 84 and 85 was erroneous and did not make sense. Mr. Good also told the Committee that he had been an occasional visitor to the wards during the past six years, had seen doctors there at times, and had never witnessed any unkindness towards or ill-treatment of patients, who would have been quite able to complain to him of any case of being struck.

61.Miss Cloake denied that she “rang” Mrs. Robb on the llth March about an infirmary: and the Committee accept her denial of all the statements attributed to her in the last paragraph on page 83, and, where relevant, in the subsequent paragraphs on page 84.

62.Miss Cloake recalled a telephone conversation on the 12th March with Mr. Buss about Miss Wills’ music, which he wanted to buy back from the dealer, and the possibility that she had promised to ask Miss Lovat for his name and also that she had said that Miss Wills had said she did not know if she wished to leave Cossett; and she also told the Committee that she might have told Mr. Buss on the 13th March that Miss Lovat could not remember the name and address of the dealer. As for the opinion of Mr. Winder, mentioned on page 85, the Committee place no reliance on this in view of all the medical evidence ; but they would comment upon Mrs. Robb’s next observation, relating to Miss Wills being awakened and brought out of the dormitory, that if true it reflects no credit upon her and her friends if they caused this old lady to be awakened in order that they might see her.

63.The alleged telephone conversation with a Mr. Newall (page 85) was unsupported by evidence and the Committee cannot accept it; but it reveals further examples of Mrs. Robb’s unreliability. In reply to her “enquiring sweetly” about Mrs. Lovat she falsely attributed to Miss Cloake a statement that this lady was “always in and out”, and she also alleged against Miss Cloake, equally falsely and most uncharitably, that she “hardly ever sees Miss Wills”.

64.With the alleged visit of Lord and Lady Strabolgi to Cossett in the evening of the 13th March (page 86), and the subsequent statement attributed to some opticians, the Committee could not deal in the absence of any evidence. Equally they could not deal with the alleged visit on the 15th March by Mr. Buss and Mrs. Robb, where the Committee had the additional difficulty of being unable to ascertain the identity of the staff nurse. Nor could the Committee investigate the allegations concerning visits on the 16th and 17th March. The Committee have already dealt with “Dr. Aix’s” letter, received on the 18th March. ” Mr. Good” had no recollection of the telephone conversation on the 19th March, but agreed that it might have taken place. He would not, however, have commented on ” Dr. Aix’s” letter and indeed denied having done so ; nor did he recall any reference to Miss Wills’ next of kin.

65.The Committee could not deal with the alleged visit by Mrs. Robb on the 22nd March or the conditions in Miss Wills’ ward and of the patients in it which are described on page 89 as a “transformation”, because neither Mrs. Robb nor Miss Wills was available to give evidence. But as the footnote on this page records Mrs. Robb’s information from the Ministry that this was the occasion of ” one of the rare visits to the hospital of an inspector from the Ministry”, and insinuated that the “transformation” was effected for such inspector’s benefit, the Committee checked the accuracy of this alleged information. They ascertained that Mrs. Robb had again been guilty of serious inaccuracy if not deliberate misrepresentation, the true facts being as follows: —

66.The Ministry do not have ” inspectors ” and there is no trace in the records of any Ministry official visiting the Hospital either on the 22nd March or at any time about that date. There was in fact a meeting at Friern on the 13th April 1965, between officers from the Ministry and from the Regional Board, to discuss building planning; and the opportunity was taken to tour some of the wards. This was in no sense an official inspection but merely a tour out of interest; and the Hospital was simply used as a venue for the meeting. It cannot be established that any member of the staff of the Ministry made the alleged statement to Mrs. Robb about an inspector from the Ministry; and the Committee are frankly sceptical about Mrs. Robb’s statement.

67.The incidents on the 25th and 26th March related partly to the physical and mental condition of other patients and are not to be attributed to anything save their senility and liability to fall without any­one being to blame, and partly to Miss Wills’ alleged complaints against “Grace” for scolding her or “banging” other patients. As has been said, this orderly may have been impatient and even unkind at times; but the Committee are astonished that if Mrs. Robb or her friends had been really convinced that this orderly was cruel or seriously neglectful none of them reported her or sought an interview with anyone in authority.

68.The Diary next refers to a copy, “to date”, i.e. the end of March 1965, being sent by Lord Strabolgi to the Minister of Health together with other documents, including the “Comments” said to appear at pp111 ff. Naturally the Committee cannot comment on the actions of Lord Strabolgi or the Minister, save to deal with the ” Comments “, which—as printed—cannot be identical with the document sent to the Minister, because, for example, the article in “The Guardian was not published until twelve months later! Some of these “Comments” are quite unjustified and even false, e.g. the allegations that the treatment of Miss Wills with E.C.T. Appeared to have been to the grave detriment of her health, that the staff are of an inferior type, and that lockers, spectacles and hearing aids were not provided in Miss Wills’ ward. As for the allegations in Comment 7 to the effect that a lazy or dishonest social worker at Cossett could obtain the signature of a patient, in collusion with a “mentally unbalanced relative, to a paper allowing the disposal of that patient’s possessions without any­one questioning the operation” the Committee regard these as disgraceful for they are demonstrably false. Similar observations apply to the so-called Comment 8.

69.On page 92 Mrs. Robb purports to describe the condition of some other patients, and they may well have presented an unhappy picture; but evidently Mrs. Robb at this point and elsewhere in the Diary has quite failed to appreciate the mental condition of many senile patients, whether at Friern or elsewhere, who are frequently schizophrenic, deluded or what doctors would not inaptly describe as “vegetables”. This is a lamentable fact which it is essential to bear in mind when considering behaviour and also treatment.

70.Mrs. Robb proceeds to remark upon the absence or infrequency of visits by relatives. She is justified in this but it is not the fault of the Hospital. In so many cases, unfortunately, the really old have scarcely any relatives or friends surviving or their relatives simply will not bother with them, as the evidence established. The Committee cannot deal with the implied criticisms about a blind patient and a ” Mrs. Leicester” as neither could possibly be identified, but on one occasion two members of the Committee observed the great kindness and assistance being given to two blind female patients by another and younger patient not so afflicted.

71.The Committee did not consider it appropriate for them to check Mrs. Robb’s version of her communications with the Court of Protection. They have seen the report made on the 26th May, 1965 ; and it is significant that even Mrs. Robb (at page 96) has to record that the Official Solicitor reported that he “did not come to the conclusion that anybody had acted improperly”. This was on the 14th September, 1965 after inquiries under Rule 76 of the Court of Protection Rules 1960: and it might, one would have thought, have led at least to a deletion from the Book of Comment 7 at page 112.

72.The Committee need not comment further upon Miss Wills’ description of her furniture—which is unlikely to have been reliable—for they are satisfied by the evidence before them that it was in lamentable disrepair and the “Victorian upright piano” emitted virtually no sound. The quoted opinion of some Reverend Mother upon the sale is of no evidential value whatever. Nor is the account of some investigation by the police, the purpose of which is not clear.

73.On page 96 there is a reference to meeting Miss Lovat and the infrequency of her visits to her aunt; but whatever Miss Lovat may have said about the nursing staff or her mother’s visit to the Committee are satisfied that she (Miss Lovat) did visit her aunt quite frequently. As for the following allegation about the doors of the chapel always being locked, the Committee interviewed both the Catholic priest and the Church of England chaplain. The Roman Catholic chapel was and is open for services every Saturday and Sunday morning, and on some other occasions, but locked afterwards ; and the priest also explained that many of the staff and patients attend the local Catholic Church, which is always open. The chaplain told the Committee that he did normally keep the Church of England chapel locked because of petty thefts, minor damage and occasional misbehaviour. He has been the resident chaplain for almost ten years and constantly round the wards ; he would seem to be on good terms with the patients, particularly in the geriatric wards ; and he knew of no instances of ill-treatment save one, some years ago, which he reported and the offending nurse was dismissed. The Catholic priest could not recall Miss Wills, perhaps not surprisingly after 2 ½ years ; but the Committee are satisfied that he would have given her such spiritual help as he could, bearing in mind his regular visits to 3 or 4 wards each week and special visits on requests.

74.The Diary next refers to an interview between Mrs. Robb and a relatively senior official at the Ministry; and again the Committee are precluded from comment.

75.The Committee could not deal with the alleged meetings between Mrs. Robb and a “Mrs. Leicester” on the 30th May and Whit Sunday (6th June), respectively; and they have already indicated the improbability of “Grace” teasing patients with a biscuit on the latter occasion although she may have shouted at some patient, as Mr. Buss alleges. Nor could the Committee deal with the alleged meeting with two other old patients neither of whom could be identified; but it would seem most unlikely that “they” (presumably “Grace”) would make such a stupid remark as that electric shock treatment would do stomach injuries good, or that “Grace” would threaten to murder Miss Wills if she ate or drank.

76.There follows a repetition of the insinuation that Miss Wills had been dishonestly sold up and a description of the possible method (a “racket”). As Mrs. Robb and Mr. Buss here exonerate Miss Lovat the Committee wonder again at the persistence in the charge of collusion with Miss Cloake.

77.The Committee are not prepared to accept Mrs. Robb’s account of what Miss Wills may have said about “Grace’s orders” on the 13th June. Apart from denials by the nurse who may have been ” Grace” the Committee simply do not believe that any nurse or orderly would tell a patient to make a mess in her chair; and if Mrs. Robb had given any acceptable evidence about these alleged statements by Miss Wills the Committee would have attributed them to Miss Wills’ confused state.

78.Whether or not a priest had not visited Miss Wills “for a very long time” as alleged at page 100, the Committee were able to confirm with the “under-matron” there mentioned, who is now an Assistant Matron and was responsible for Miss Wills’ ward, that she gave Mrs. Robb the names of both Roman Catholic priests and assured her that Miss Wills would be taken down to services if she were well enough and that these gentlemen would be pleased to come and see Miss Wills at any time. This was the only occasion on which this matron who was in charge of the ward spoke to Mrs. Robb, and the Committee wonder why she never sought out the under-matron to complain about the alleged ill-treatment of Miss Wills. Significantly enough, the under-matron informed the Committee—and they accept—that Miss Wills was incontinent at times and very confused, though she had lucid intervals. She was not interested in reading even the newspapers and preferred to sit around.

79.Owing to the lack of any evidence the Committee cannot accept any of the allegations concerning the visit of Mr. and Mrs. Robb on Monday, 20th June, 1965, but if it be correct that the priest had been to see Miss Wills on the preceding Thursday, the matron had evidently kept her promise. Apart from this the Committee would be disposed to dismiss as nonsense —had any evidence been given—that a senile patient had been planted to listen-in. As regards the suggestion based on alleged statements by Miss Wills that nurses had said that they could not administer such simple remedies as ” aspirin” or “cough lozenges” without reference to a doctor, the Committee found no evidence that there was or is any undue delay in obtaining a doctor’s prescription for appropriate drugs.

80.The next section of the Diary purports to relate to “getting Miss Wills out of Cossett” and into a convent home. It proved practicable for the medical members of the Committee to visit this home, but unfortunately this was just a few days after the death of Miss Wills whom they had hoped to see. The Mother Superior, the Sister chiefly in charge of Miss Wills, and the general practitioner who attends the home were all interviewed; but as they all wish to remain anonymous neither their names nor that of the home are given here. It transpired that the picture of the home given by Mrs. Robb is not entirely accurate. It was and is a home for the care of the helpless, and in no sense designed for rehabilitation. The suggestion in the book that Miss Wills was suffering from only minor mental ailments and could respond to the change to this home by becoming more active is unrealistic, although she might receive more physical care because the home’s staffing resources were greater. The Committee will deal later with Miss Wills’ condition upon entering and while resident at this home.

81.The Committee had considerable difficulty in investigating the criticisms and complaints by Mrs. Robb concerning Miss Wills’ discharge or her transfer to the convent. The only doctor who was thought to be ” Dr. Giddie” satisfied the Committee that she was not that person. The sister-in-charge (“Sister Gay “) was identifiable only as the sister already mentioned who has left Friern, and letters addressed to her have been returned. “Dr. Faynt” could not be identified but fortunately “Dr. Aix” could, and was seen by the Committee. They could not positively identify the “man with iron-grey hair ” who is said (page 103) to have interviewed Miss Wills on the 24th June. It may have been the Senior Medical Officer, whose report to the Official Solicitor was made on that day; but this interview seems to have been perfectly proper and quite innocuous. Consequently the Committee were quite unable to investigate Mrs. Robb’s complaint, as they understand it, that at 7 p.m. she was unable to make arrangements with the doctors for Miss Wills’ transfer, presumably next day ; but in any event it seems unreasonable to criticise the Hospital on this score. The case was not urgent and it would have been more sensible to have made the appropriate appointment during the day, as apparently “Dr. Giddie” or her companion suggested. The Committee would add that none of the unidentified doctors in this section of the Diary could have been the Registrar as he was absent for three months after a motoring accident on the 1st June, 1965.

82.If “Dr. Herts” was one particular doctor whom the Committee saw, she recalled one telephone conversation with a lady who called herself Mrs. Robb and was rather unpleasant. This lady asked for an ambulance to take Miss Wills (with whom this doctor had nothing to do) to an Old Ladies’ Home, and wanted it that day; and this doctor told her that the Hospital had been unable to get one for that day, whereupon Mrs. Robb had said that she would arrange her own transport.

83.The complaint about the lack of an ambulance until Monday looms large in the Diary but is really a gross exaggeration. Upon learning that Mrs. Robb had found a place for Miss Wills in South London Miss Cloake went to see Miss Wills, who was anxious whether Miss Lovat would visit here there, and she also spoke to the Consultant, whose view was that Miss Wills might go for two weeks and then return if she was unhappy. (This was in fact the arrangement made with the convent.) Miss Cloake spoke also to Mrs. Lovat, who did not know what to do for the best; and it may well be that Miss Lovat expressed anxiety to Mrs. Robb about the place to which she was taking her aunt. Further in accordance with the hospital practice, in which the Committee find nothing to criticise, Miss Cloake twice requested an ambulance, but the Ambulance Control stated that this could not he provided until the Monday as the case was not an emergency or urgent; and when Miss Cloake so informed Mrs. Robb that lady shouted and so frightened her that she put down the telephone. The Committee repeat their opinion that Mrs. Robb was quite unreasonable in her demands and they see nothing to criticise in Friern in relation to Miss Wills’ transfer to the convent.

84.The Committee were quite unable to check or investigate the account of the departure of Miss Wills on the afternoon of the 26th June, 1965, with its facetious surmise that she might be “handed over in the nude”. It is probably correct, however, that in accordance with general routine, approximately two weeks’ supply of medication would be handed to Mrs. Robb, and undoubtedly correct that the Consultant provided a medical report for the doctor at the Convent and that another letter was sent indicating that a bed in Friern would be kept for two weeks.

85.With some of the remarks about “Miss Wills at the Convent” the Committee could not deal in the absence of Mrs. Robb and Mr. Buss, or the “Mrs. Lacey” referred to; but the information obtained by the medical members contradicted the impression created in this section of the Diary that Miss Wills’ “health took a marked turn for the better” (page 108). The Committee have no doubt that throughout her stay at the Convent Miss Wills was treated with the utmost kindness; but the evidence received from the doctor, Mother Superior and Sister in charge was to the effect that Miss Wills had been just capable of walking for a short period after admission, that she had then been confined to a chair and later to bed, and that from April, 1966, or earlier she had led a virtually “vegetable” existence. During the last few months of her life she had a series of mild strokes. She never read after admission nor did she ever attempt to paint; and she would generally be found—before becoming bedridden—slumped in her chair, apparently asleep. She was visited regularly by Mrs. Robb and her friends, and fairly regularly by her niece “Miss Lovat”, but not very often by “Mrs. Lovat”. Both Mrs. Robb and “Mrs. Lovat” attended the funeral, which was paid for out of the £50 or so in cash that Miss Wills possessed on admission.

86.The Diary concludes with some “Comments” to which the Committee have already made reference. They add some observations upon the generalisations. While not accepting that Miss Wills was in Friern merely because she was old, because in fact she was highly disturbed, the Committee agree that in principle, and if sufficient funds could be made available and further building were practicable, it would be desirable to separate the merely elderly patients (of whom there were and are very few in Friern) from the mentally sick patients, preferably by lodging them in old people’s homes. Responsibility for achieving this end must rest, the Committee believe, with the Ministries concerned and Local Authorities; and also to a considerable extent with the community who must provide the means by financial contribution and by voluntary help as visitors, especially to relatives. In relation to Friern, whilst more visitors would be welcome they simply do not come.

87.The Committee have disposed of the suggestion that ECT was administered to Miss Wills to the detriment of her health; but they must state that the impression given that ECT was employed almost indiscriminately is quite wrong. A schedule was produced by one of the Medical Officers showing the number of patients given this treatment in 1965, and upon how many occasions in each case. During 1965 just over 7 per cent, of the patients in Friern received this treatment, and of these patients 19 only were over 65 years old. In the Committee’s opinion the administration of this treatment was neither indiscriminate nor excessive.

88.The Committee have dealt with the alleged failure to provide Miss Wills with a locker or spectacles; but they wish to add in relation to the general allegation in Comment number 8 that although in 1965 there may have been a shortage of lockers owing to lack of space through too many beds, this has since been remedied; and they reject the charge of failure to provide spectacles or deaf-aids generally (or in Ward NNE in particular). The evidence before the Committee refuted this allegation inasmuch as those patients who needed or desired such articles were supplied with them.

89.The Committee have disposed of the false and reckless allegations in the two final Comments and need not repeat their findings.

90.In conclusion the Committee would say that in the light of the evidence available and their own investigations and inquiries they are satisfied that none of the allegations of cruelty towards or ill-treatment of Miss Wills in particular or of other unidentified patients in general is justified; that the charges of laziness and dishonesty against the Social Worker “Miss Cloake” are false and scandalous; and that far from Miss Wills being a patient who ought not to have been in Friern but was wrongfully prevented from leaving she was in the most appropriate place, and of course permitted to leave whenever her self-appointed guardians found alternative suitable accommodation.

FINDINGS ON EXAMINATION OF THE SITUATION IN THE GERIATRIC WARDS OF FRIERN HOSPITAL AT THE PRESENT TIME

91.In order to examine the situation in the geriatric wards the Committee conducted a large number of interviews and paid several visits to Friern Hospital, where they inspected particularly the wards wherein geriatric patients resided and interviewed approximately one patient in ten, selected at random, among those who had been in those wards in 1965. They obtained also a considerable amount of documentary and oral data, statistical and factual, about conditions in the Hospital. The persons interviewed, besides patients, were all such persons as might be identifiable under pseudonym in the book “Sans Everything “, such members of the Hospital staff who responded to an invitation from the Committee and whom the Committee thought might assist the Enquiry, and such other consultants and members of the staff as the Committee thought might help them, together with—naturally—the Chairman and Secretary of the Management Committee and the Chairman and Secretary of the Regional Hospital Board.

92.Throughout their Report referring to geriatric patients and geriatric wards the Committee have in mind and under consideration chiefly those elderly patients who are chronically mentally disturbed, although the degree and type of disturbance may vary from time to time.

93.Friern Hospital was built in 1849/50 as a lunatic asylum; and this accounts for its rather inconvenient size and depressing external appearance, whilst still permitting separation of the male and female sections. It is situated in spacious grounds which are doubtless pleasant in summer or good weather; but it has another drawback as regards such patients as are apt to wander that it is within 100 yards of a main road and omnibus route. For this reason the Committee understand why the much criticised practice of “locking in” is frequently adopted ; but they think a greater degree of supervision (which might require more staff) could reduce this necessity. It is also obvious that without rebuilding many of the disadvantages consequent upon the gradual change of use to a geriatric as well as psychiatric hospital cannot be overcome—for example, very high windows to many of the single cubicles. On the other hand the Committee are satisfied that much “up grading ” of the wards has been done during recent years so that some of the female day wards are bright and cheerful, although those of the men are much less so; but some of the female dormitories were in very poor condition. The Committee think that attention is still needed to the provision of warmth in the toilets and certainly to an increase in their size and number and also in that of the bathrooms.

94.The Hospital is on the outskirts of North London in a suburban area comprising some 600,000 inhabitants from among whom the majority of the patients come. Out of just over 2,100 patients in the Hospital, 35 per cent, are over the age of 65, of whom 536 were women and 202 were men in 1966, and in the same year 292 geriatric patients were admitted, many suffering from senile dementia, others from serious or mild depression. Most of the geriatric women patients are nursed in 12 out of the 24 female wards. These 24 wards have a total staff on each day shift of about 80, including sisters,all grades of nurses and students, and ward orderlies. The majority of the elderly men are nursed in 4 out of the 16 male wards, whose nursing staff fluctuates between about 38 to 60. The total nursing staff for the whole Hospital in November 1967 was only 429, including nursing administrators.

95.The medical staff consists of six consultant psychiatrists of whom Dr. Bradley alone is full-time at this Hospital, and ward doctors of whom there are three senior Hospital Medical Officers, one senior Hospital Dental Officer, eight registrars, three part-time registrars, three senior house officers and one medical assistant, who visit the wards daily and deal with medical or dietary problems. Other consultants visit weekly or when additionally required, and they include two ophthalmic surgeons; and there are also a full-time physiotherapist and a full-time remedial gymnast. Occupational and industrial therapy are encouraged but are, the Committee think, inadequately used for reasons stated later.

96.Endeavours are made to promote social life and to provide social services, including dances, film shows, whist drives and outdoor games, and every ward is provided with television and radio sets. The wards consist of dormitories and day recreation rooms, but there are some small annexes to the large dormitories consisting of rooms for, say, four patients or one patient only: and whereas some of the large day rooms on the female side are cheerful, warm and comfortably furnished, the smaller ones (chiefly on account of size) are cold and less attractive. On the male side the dormitories and cubicle rooms are warm but tend to be gloomy and less agreeably furnished, and they are grossly overcrowded.

97.There is a resident Church of England Chaplain and there are visiting Roman Catholic, Free Church and Jewish Chaplains, all of whom conduct weekly services and visit the wards regularly.

98.Visitors are permitted daily in the evening and on Thursday and Sunday afternoons, or at any time if a patient’s health demands or would benefit by more frequent visits. Only about 30 per cent, of the female geriatric patients and some 40 per cent, of the males are visited regularly, which may be due to lack of friends or relatives in old age or to sheer neglect once responsibility for care and maintenance has been successfully transferred to a public service provided at virtually no cost to patient or relatives. Without wishing to appear complacent or to ignore shortcomings in the service the Committee do feel that carping criticisms of an over­burdened staff performing duties—often most unpleasant—which relatives are either unable or unwilling to undertake come ill from such persons; but the Committee have studied anxiously all allegations of ill-treatment or neglect to see whether they are justified and if so what remedial or preventive action should be recommended.

99.The nursing staff in the judgement of the Committee, in a Hospital of this mixed character, is gravely inadequate in number, particularly as most wards are overcrowded. Even more serious is the lack of domestic help, which results in nurses and even sisters being obliged to do domestic chores instead of their proper work.

100.The administrative staff of the Hospital, consisting of some 37 or 38 persons, seems to be adequate. There was no serious criticism of the catering arrangements, though the Committee considered that some adjustment of the time of delivery and service of the evening meal time is desirable. Generally speaking the laundry arrangements seemed satisfactory.

101.In reviewing the present situation the Committee have been constantly conscious of certain other grave problems which under present national conditions may be insoluble. The Committee refer particularly to lack of finance; grave shortage of staff, especially nursing and domestic staff; and antiquated buildings.

Numbers and types of patient

102.As already indicated 738 of the patients are over 65, and 18 per cent, of all admissions are over that age. In the course of each year many of these patients will either be discharged or die in the hospital, so that there is a steady flow of incoming patients, roughly in the proportion of 1 male to 3 female, which is slightly less than the overall proportion, indicated by the fact that of the 738 geriatric patients in November 1967, 202 were men and 536 were women. Most of the “permanent” patients suffer from some chronic schizophrenic illness.

103.Many patients are admitted because of senile dementia and will never leave. Others enter because of depressive illness, and after treatment they may become fit for discharge. Yet others may be suffering from transient confusional states or be only mildly depressed or demented, and they may recover. It does not always follow, however, that patients fit for discharge will leave. Relatives may be unable or unwilling to resume responsibility; or in the case of old people formerly living alone a return to solitude may lead to relapse. Moreover some patients become so acclimatised that it would be unkind to discharge them.

104.This situation is not satisfactory. It involves overcrowding and possibly prevents necessitous cases being admitted, though the Committee were not told of specific instances. That many wards were overcrowded was obvious, and admitted by the medical staff ; and the remedy is for strong action to be taken to obtain or establish more hostels and Old People’s homes and to induce the appropriate Local Authorities to fulfil their obligations, including the provision of domiciliary services. The evidence revealed a lamentable lack in the area of such hostels and homes and of fulfilment of such obligations.

Admission Policy and its Effects

105.The admission policy is determined by individual consultants, but in practice admissions follow upon (a) discussion with the general practitioner or mental health social worker concerned, (b) interview at a hospital outpatient clinic and (c) reference by the police under section 136 of the Mental Health Act, 1959. Patients over 65 suffering from “pure” psychiatric disorders such as depression are admitted without question; but those who are confused or senile are selected with a view to arranging that as soon as possible those requiring intensive (sic.) nursing shall be dealt with through the local authority or in geriatric wards of general hospitals. In practice this can be arranged only rarely, partly because of the failure of local authorities to provide suitable accommodation and partly because general hospitals are unwilling or unable to take in long term patients. In the result Friem is overburdened with patients who ought not to be there, certainly whilst there is no proper segregation of the purely senile and geriatric types.

106.One of the most serious defects arises out of “night” admissions, i.e. after 10 p.m. The night duty doctor, whether consultant or senior hospital medical officer, would do his or her best to control these admissions, the number of which might be about 10 males but fewer females a month, by telephoning the medical officer referring the patient; but the evidence the Committee heard suggested that such officers were not always as candid as they ought to be with the result that patients might be admitted without real justification. General hospitals will at times state that they have no available beds when in fact they have; and general practitioners will send for admission patients of whom it is said that they are “ill and confused” when in fact they are suffering from some physical illness such as pneumonia and ought to be sent direct to a general hospital, to which Friern usually has to transfer them. These practices are to be condemned, not only because of the imposition upon Friern of unsuitable patients, but also because they disrupt the admission wards and besides disturbing patients therein have been known to result in one or more such patients being bundled out of bed and transferred to another ward. The remedy for the shortage of beds in the admission wards should be supplied when the two new admission wards are functioning later this year; but the remedy for the improper requests for admission lies almost entirely outside Friern.

107.The practice under (c) in paragraph 105, is also undesirable—and causes complaints by the nursing staff—because a patient brought along by the police under Section 136 is often simply drunk or may have been refused admission at a general hospital; and unless such patients fall within section 29 of the Act the Committee think that admission ought to be refused in the majority of such cases.

Treatment

108.A striking feature of the treatment of geriatric patients is the present rather haphazard situation whereby many of those whose mental illness has progressed to the point where their principal needs are for care of senility and incontinence are in wards containing either a number of patients who also require specifically psychiatric treatment or (in some instances) patients who are suffering from “pure” psychiatric disorders.

109.There was a fair measure of agreement among the medical and nursing staff whom the Committee interviewed that this arrangement is not in the best interests of the patients. It is unsatisfactory, indeed wrong, for patients who require mainly physical nursing to share wards with others whose needs are predominantly for psychiatric treatment and supervision, despite attempts, as the Committee understand, to sub-divide the wards. The experiment of “mixed” wards—i.e. of male and female patients—by day, which is planned, is to be commended.

110.The treatment of patients in the geriatric or predominantly geriatric wards is inevitably bound up with the problems of finance and adequate staff. In general terms, however, the Committee have concluded that a nursing staff gravely inadequate in numbers has been and is doing its utmost to serve the geriatric patients in their care. Instances of unkindness or intolerance consisting in shouting and pushing are rare and are usually the result of long hours and overstrain, but also of the inevitable employment of foreign staff and the consequent language difficulties. Of deliberate cruelty, however, the Committee found no reliable evidence whatever. More­over the Committee think that despite some well-justified criticism of lack of communication between the lower and higher hierarchies in the staff no complaint of cruelty or even real unkindness would fail to be received and acted upon by those in authority, whether senior charge nurses or matrons, members of the Management Committee or the Chairman.

111.What has been said about the care and devotion of the nursing staff applies equally to the medical staff, concerning whom the Committee heard no real criticism save that communication with the nursing staff needs improvement—but steps are being taken to achieve this—and that more time might be devoted by the medical staff to training student nurses. At present far too many students leave, even before completing their training.

Therapy—Occupational and Recreational

112.The Committee heard a considerable amount of evidence about the provision of occupational and industrial therapy for geriatric patients. After allowing for the recognised fact that the more senile patients are often incapable, or not desirous, of much or any form of recreation or mental activity there was a predominant opinion expressed to the Committee that there is inadequate provision of occupational or diversionary therapy and—to a lesser extent—of industrial therapy: and the Committee endorse this opinion, whilst acknowledging the difficulty of obtaining more qualified practitioners, partly, but not solely, on the score of finance. It is important to intensify the efforts of voluntary helpers, whether relatives, social workers or simple visitors; and in this connection the Committee were glad to learn of the recently formed League of Friends, numbering over 300. The Committee were also pleased to learn of the valuable services rendered in many ways for a number of years by the Women’s Royal Voluntary Service. In particular their staffing of the patients’ library has contributed to an important amenity. The Committee noted, however, that the library was housed in accommodation which was too small and poorly decorated. There was a paucity of modern and suitable books and apparently no close link with the local public library. The Committee therefore considered that the appointment of a trained librarian might be of assistance.

Clothing

113.Much of the clothing worn by patients in the geriatric wards is of poor quality and appearance. Better clothing for some of the chronically sick and incontinent patients might be too expensive because of the risk of damage and need for frequent replacement; but the Committee see no reason why the majority of the geriatric patients should not be supplied with better clothes, and it should be superfluous to stress the psychological advantages to be derived by a patient who thereby retains more of his or her sense of pride and dignity as a human being.

State of the Wards

114.Much of what the Committee are about to state about the problem of staff shortages and the material conditions of the geriatric wards applies to the whole hospital; and if steps are going to be taken to improve conditions at Friern for the geriatric patients they must also be taken in relation to the other patients. Otherwise there will never be the requisite revivified life at Friern that in the Committee’s judgement is essential.

115.The Committee would stress the value of “up-grading” the wards, including of course the recreation or day rooms, and ensuring that the new reception centre is cheerful and properly manned. Moreover the provision of adequate domestic staff—which is woefully lacking—should release nurses and even sisters from doing purely domestic work so that they may attempt more personal relationships with their patients. Another improvement would be to extend the ” official” visiting hours and a second improvement to render life more home-like for the geriatric patients might be to adjust the time of the evening meal which in many wards was served much too early.

116.One of the principal adverse features of the conditions in the wards arises out of the proportion of incontinent—and often doubly incontinent—patients. Most of these patients cannot help themselves ; but their plight —and that of their companions and even more that of the nursing staff— would be alleviated if the fundamental problem of staff shortage could be solved, as it should be. It is little short of scandalous that at night one nurse should be expected—indeed obliged—to deal with over 20 such in­continent patients, which often involves changing clothing and bed-linen and lifting and washing patients. The Committee consider that there ought to be more modern sanitary equipment, including sani-chairs, commodes and extractor fans ; and that there ought to be more lavatories and that they should be warm.

117.The wards are too large and overcrowded and would be more attractive to patients if greater use was made of simple partitioning or curtains. An energetic investigation of this whole problem should be undertaken, and although sub-division of the larger wards may necessitate more nurses this need should be faced and met. Wards containing nearly 50 patients are quite wrong; yet the numbers in the male geriatric wards varied between 39 and 49, and in the female wards the numbers varied between 36 and 46, in October 1967. In any event the overcrowding should stop, even if this involves refusal of admissions, for there is substance in a criticism voiced to the Committee that Friern is regarded as a “dump for geriatrics “. Local Authorities and General Hospitals should be made to realise their responsibilities ; and this may well mean teaching the public to realise their responsibility for the care of the elderly. Furthermore, the badge of being a “dump” which is being attached to Friern has a most damaging effect upon the morale of the present staff (especially the younger members) and upon recruitment.

118.The geriatric wards contain a number of patients who might be dis­charged if outside accommodation were available. There is a lack of local authority hostels with a warden, which can not only provide the right type of accommodation for “dischargeable” patients but also encourage, through the warden and social workers, outside interests for such patients. In this way they could be received back into the community. Moreover if necessary they could from time to time return to the Hospital for brief periods of treatment.

Staff Shortage

119.The Committee cannot condemn too strongly the shortage of staff in almost every sphere, but especially the medical, nursing and domestic. The Committee do not accept that lack of finance is the sole cause: and indeed according to the evidence from the Regional Board they would provide the necessary money if the additional nursing or domestic staff were obtained. This, however, is not enough—a new approach is required, not merely within Friern but by the Board as well.

120.The need for at least two more consultants was expressed by more than one medical witness who indicated tl\at the individual “case-load” is at present excessive and precludes really adequate attention to patients, whereas a smaller number of patients might also be reviewed more frequently and discharged more quickly. Another requirement is for additional junior medical staff—two more were suggested—because of the gaps that occur owing to illness, holidays or study leave : and these temporary gaps result at present in junior doctors being moved around to fill them instead of remaining in their assigned wards and looking after their patients properly.

121.There is an acute shortage of nurses, and particularly trained nurses, as was emphasised by almost every witness, whether from the medical, nursing, administrative or religious side of Friern, and as was admitted by the Chairmen of the Management Committee and the Regional Board respectively. This shortage applies throughout the Hospital, in both male and female wards, although the evidence was to the effect that female nurses were the more difficult to obtain. The complaint related to all shifts but is most serious as regards night-time when several of the wards are virtually unstaffed, save for an hourly visit by a charge nurse or sister. The shortage is accentuated by the overcrowding of the wards and by the gross shortage of domestic staff, which results in nurses and even sisters and male charge nurses being obliged to do domestic work, e.g. cleaning of the wards, and so being diverted from their proper functions. It also results in some younger nurses leaving Friern for the natural reason that they do not expect to do domestic duty.

122.Other reasons were advanced for the shortage of nurses and are set out—not necessarily in order of significance—so that they may be carefully considered. First, the type of work is in itself not popular; and having regard to its nature, e.g. dealing with frail and doubly incontinent patients, this is understandable. Secondly, the pay is poor, not only in contrast with numerous other occupations but in the case of junior nursing staff it may be less than that earned by ward orderlies, which seems to be absurd. Thirdly, the actual hours of duty do not appeal to younger nurses who, when on the afternoon shift (2 p.m. to 9 p.m.), tend to resent the departure of the administrative, kitchen and some domestic staff, at 5 or 6 p.m. The solution may be to attempt a different shift system. Further the actual hours of duty, including weekends, Bank holidays, etc., contrast unfavourably with those in offices or industry. Fourthly, the indifferent communication hitherto between nurses and the medical and administrative staff.

123.Another reason for the nursing shortage concerns residential accommodation, the inadequacy of which was stressed by the Principal Nursing Officer. Although the Board have recently caused twelve bungalows to be built this has not in itself solved the problem, because the staff consider that they are cheap, cramped, unattractive and useless for any family. This aspect of the provision of facilities for nurses merits very careful investigation, bearing in mind how high local rents are; and if better bungalows cannot be provided consideration might be given to rent subsidies.

124.There is a shortage of students and there is a tendency for them either not to stay on after qualifying or to leave prematurely. The Committee suspect that this shortage is partly due to the relatively bad name that Friern has got; and that the tendency to leave is partly due to the poor morale that exists. But there are more positive reasons which should be investigated, and they include the following matters, again not necessarily in order of significance. First, the training allowances are too low. Secondly, there is inadequate time for study. Thirdly, the hours of work, particularly at night. Fourthly, a badly planned programme of clinical instruction. Fifthly, inadequate instruction by charge nurses or sisters. Sixthly, excessive time devoted to domestic chores.

125.There is a serious shortage of domestic staff, and the Committee found it difficult to assign a reason save that the methods of recruitment were inadequate, and that the work in Friern is unpopular and relatively underpaid. The position of ward orderlies also appears to be anomalous. They are well-paid for what they do, but their duties seem to be ill-defined.

126.Two initial and important remedial steps have been taken, namely the appointment of a Principal Nursing Officer and of a Domestic Superintendent. It is, however, essential that promises made to them on behalf of the Management Committee be kept. Thus the Principal Nursing Officer was assured some months ago that he would be provided with the really essential centrally situated office ; but nothing has been done. This type of failure in administration is inexcusable and helps to explain the poor morale and atmosphere of defeatism among the other staff.

General Administration

127.The administrative side of the Hospital requires drastic overhaul, especially to ensure that all work appropriate to the Secretary’s Department is located there in future and is not scattered piecemeal around other departments. At the time of inspection the reception arrangements were practically non-existent, and there was no proper reception office or receptionist. It may be argued that all this will be remedied when the new reception centre is completed in the summer of 1968. All the Committee can say is that it must be.

128.There is no satisfactory or adequate social work department. There are no trained psychiatric social workers, and there is a lack of efficient (though untrained) social workers. One reason given for the shortage is that higher salaries are paid by the local authorities.

129.Both the Craig and the Gasson reports on the nursing services (presented during 1965) implied some serious deficiencies in the administration of these services, and until they are repaired it seems unlikely that there will be any substantial improvement in the nursing situation. What is now needed is a thorough appraisal and reorganisation of the work of the senior nursing officers—the assistant matrons and assistant chief male nurses. The policy of employing two charge nurses to a ward with equal authority must inevitably result in neither being able to exercise the control which the job requires. If this policy is to continue, it is essential that one of the charge nurses should be designated as senior, both being responsible to the nursing officer in charge of the unit.

130.In her survey of the female side of the hospital, Miss Craig stated that in her opinion the Assistant Matron’s Office would seem to be the key to many of the difficulties in the nursing service. The Committee endorse this view and also her conclusion that the work in this office needs urgent study and review. The Assistant Matrons are carrying out many functions which should be discharged by ward sisters and yet others which should be transferred to clerks or other departments of the hospital. They were critical of the Hospital Management Committee’s failure to follow up the suggestions in Miss Craig’s survey ; and one extremely important omission to comply with their requests arising out of the survey concerned the provision of better office accommodation and more telephones. The Committee are amazed by the antiquated arrangement whereby only one external telephone exists for the whole of the female side of the hospital and that so little has been done to supply the clerical and other assistance which these senior nurses so obviously need. It is not surprising that despite the hard work put in by these Assistant Matrons their office is not efficient in the matters upon which it ought to be concentrating.

131.One other matter which affects the efficiency of qualified nurses at all levels concerns the provision of management training and refresher courses. Inquiry showed that few members of the staff have had the opportunity to attend refresher or other courses outside the hospital and there appeared to be no regular programme of training for the senior staff. The development of such a programme, which should include systematic training in management for charge nurses and all higher grades, would do much to restore morale and increase the efficiency of the nursing service.

132.Another cause of dissatisfaction is the failure by the Management Committee to implement the recommendations contained in reports specially obtained about the loss and shortage of nursing staff at Friern. The Committee received evidence to the effect that if the recommendations in the Craig and Gasson surveys had been acted upon the nursing situation would have been greatly improved: but as far as could be ascertained the Management Committee ignored them entirely, at all events until recently, although even now many of them remain unadopted—e.g. remedying the shortage of domestic staff, improving conditions for the nursing staff, providing separate accommodation for merely geriatric patients, reorganising the Assistant Matron’s Office with its single telephone.

133.In fairness to the Management Committee, however, it must be said that they have sought further authority from the Regional Board to employ more nursing staff, if obtainable. The Committee found the responses discouraging, and so must the Management Committee. In particular a letter to the Management Committee purporting to deal with the proposed nursing staff establishments at Friern and Halliwick was most confusing. It was obviously an attempted pruning operation based upon the Board’s minimum ratio of 30 nurses per 100 beds; and in the Committee’s opinion is over­whelming evidence that the particular needs of Friern have been at times discounted if not disregarded by the Regional Board.

Problems of Management

134.It is the conviction of the Committee that it is not fair to impute all the blame for inefficiencies to senior members of the hospital staff. A fundamental factor in the hospital’s malaise is the present state of managerial attitudes and practice. Certain of the evidence available made the Committee wonder whether the Regional Board and the Management Committee realised the seriousness of the problem facing them. Moreover the Committee think that the Board is evincing a defeatist attitude especially towards the problems of staff shortage ; and this is bound to be reflected, and indeed is reflected, in lowered morale among the staff. As far as financial assistance is concerned the Committee are far from convinced that Friern has had its fair share of even the limited amount of money available to the Regional Board.

135.The working of the Management Committee requires re-appraisal in order that the defects discovered may be eradicated. The ignoring of reports was inexcusable and so was the misunderstanding about recruiting ward orderlies. Finally the view commonly expressed that everything will be all right now that a Principal Nursing Officer has been appointed is too facile, and without strong and energetic support from the Committee this hope will almost certainly be dashed.

136.In short, principles have been ignored ; and the remedy for consequential personal shortcomings lies in the study and application of sound principles of management, and not in personal recrimination. Yet the Committee hope that in the light of their report and the recommendations that follow the Regional Board will indeed be able to render Friern the guidance, support and assistance, both moral and material, that it urgently requires, and that a more flexible and sympathetic approach and attitude towards the devoted, and, as the Committee think, inadequately appreciated staff will restore not only their confidence but also the good repute of the Hospital.

Recommendations

1.That immediate and vigorous steps be taken to augment the medical, nursing and domestic staffs.

2.That the admission policy be critically reviewed: and that in this connection consultations be held with local authorities about their responsibility for the provision of care and accommodation for elderly persons in their areas.

3.That the local general hospitals be informed that Friern will no longer admit their rejected elderly patients whose illnesses are essentially physical.

4.That the “upgrading ” of the wards proceed with the utmost despatch, overcrowding in the wards to cease, greater use of partitions be made, and more and warmer lavatories be provided.

5.That separation of the mentally and physically infirm patients from those requiring active psychiatric treatment be further considered.

6.That mixed day wards be established and extended as experience is gained.

7.That the standard of clothing be investigated and improved.

8.That “official” visiting hours be extended and the fact publicised.

9.That more industrial, occupational and diversionary therapy be provided.

10.That better residential accommodation and other amenities be provided for the nursing staff and consideration given to subsidising rents.

11.That hours of duty be reconsidered and a different shift system be devised if practicable.

12.That urgent consideration be given to re-organising the work of the senior nursing officers and to providing them with adequate secretarial assistance.

13.That communication and consultation between the medical, nursing and administrative staff be improved.

14.That arrangements be made for regular refresher courses for all qualified nurses and for management training for senior nursing staff.

15.That all the conditions affecting students, including pay, hours of work, instruction and time for study be improved.

16.That the pay structure for junior nursing staff in relation to ward orderlies be reviewed and, if necessary, referred to the appropriate Whitley Council.

17.That the administrative and secretarial departments be re-organised, with particular reference to proper office accommodation, telephones and re-allocation of duties at present performed in the Assistant Matrons’ office.

18.That adequate office accommodation be provided forthwith for the Principal Nursing Officer and his senior nursing administrative staff.

19.That more voluntary help within the Hospital, and by way of domiciliary services outside the Hospital, be sought and encouraged, in co-operation with the local authorities.

20.That implementation of the proposals in the Craig and Gasson reports be no longer delayed.

21.That consideration be given to the desirability of greater integration of Halliwick Hospital with Friern.

22.That inasmuch as these recommendations will involve additional expenditure, the Regional Board should allocate more funds to Friern.

23.That copies of this Report dealing with the allegations in the book “Sans Everything” and with the situation in the geriatric wards, and setting out the recommendations, be made available to all grades of staff concerned.

Douglas Lowe

Muriel Powell

Alan B. Monro

Isabel Graham Bryce

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