22. XY is the man whose initial complaint was the cause of our Inquiry. He gave more detailed evidence than any other witness. An assessment of his character and reliability is, therefore, fundamental.

23. XY was born in Cyprus. There was some doubt about his date of birth; he claimed that it was three years earlier than the date shown on his passport, 12th May, 1918. Certainly he was a student at the American Academy, Larnaca, Cyprus from 1927 to 1933. From 1934 to 1940 he worked with a mining company, successively as an interpreter, stores clerk and shift boss; during this time he obtained a First Aid certificate. From 1941 to 1946, he served in the Cyprus Regiment, attaining the rank of Lance Corporal. During his military service he did courses in hygiene and sanitation; and after the War served as a Health Inspector with the Government of Cyprus. He worked in Australia between 1951 and 1953, in a series of jobs—which included a period of six months in a mental hospital. Thereafter he spent 12 years in Central Africa, once again having a variety of jobs: these are said to have included six years as a quarry and brickfield manager, about 12 months as a malaria control officer in Zambia, a short period with Rhodesian Radio and, finally, some time as the proprietor of his own grocer’s shop. In October, 1965, he came to the United Kingdom because, as he put it, he wanted to practise his “profession” as a Health Inspector. He came to Cardiff because his daughter was married to a Welshman in that City. After attempting to do a course at the Cardiff College of Advanced Technology he came to Ely as a Nursing Assistant on 26th September, 1966 at a salary of £570 per annum.

24. From this account of his career it is apparent that XY is something of a rolling stone. He tends, moreover, to have a grievance against the world—perhaps because his qualifications (which we suspect he is prone to exaggerate) and attainments have always fallen short of what he might have hoped to achieve in view of what his Commanding Officer in the Army (we think with some justice) described as his “outstanding ability”. His tendency to be a natura1″outsider” is accentuated in this country by the fact that he is obviously not British-born—although his command of English is very good, surpassing that of many less well-educated Britons. He did not seem to have a natural enthusiasm for hard physical work, tended to resent being given jobs which he regarded as beneath his status and thus seems, understandably we believe, to have impressed other members of the nursing staff as “the man who tended to make beds with one hand in his pocket”.

25. The picture we have painted thus far may make XY seem an unattractive and not very impressive personality. This is to do him less than justice. Certainly he is a natural critic. But his criticisms seemed to us to be prompted by a very genuine and, as it turns out, not unfounded concern. (They were not made in the hope of monetary gain; he received no payment from the News of the World). He thought, as he told us, “that it would be a service to the patients and the public of this country if people knew” about what he felt to be wrong. His sincerity appeared to us to be confirmed by the extent to which he was prepared to acknowledge the difficulties and good qualities (in many respects) of those about whom he complained. Finally, we are in no doubt that he is a highly intelligent man.

26. What then of his credibility? Initially sceptical about this, we were more and more impressed by the number of points on which other, independent evidence finally came to confirm what XY had told us. Several examples can be used to illustrate this point: —

(a)XY’s account of the incident in which Charge Nurse “A” abusively told Staff Nurse “B” to go back to his own country was confirmed in detail by “B”—and not substantially challenged by “A”;

(b) XY’s suggestion that Charge Nurse “C” absented himself for long periods in the middle of the day was confirmed by former Staff Nurse “D”;

(c).XY’s suggestion that the occasion when he and the patients were directed by Charge Nurse “A” to remain in the “airing court” on an unduly cold day (as against “A’s” suggestion that the weather was more consistent with “March or April”) tends to be confirmed by the fact that the only days on which XY, “A” and the witness identified by “A”, Staff Nurse “E”, were on duty together were 22nd and 29th November, 1966, 10th January and 7th February, 1967;

(d) XY’s entire account of pilfering by other members of the staff-flatly denied by all those still employed at the hospital—was confirmed in many circumstantial respects by the evidence of former Staff Nurse “D” who was not named as one of XY’s witnesses (he had been dismissed from the hospital service in November, 1967).

27. Further confirmation can perhaps be derived from the fact that one of the other potential witnesses named by XY, Nursing Assistant “P”, repeatedly declined our invitations to give evidence.

28. On the other hand, however, the case of “Addison” (with which we deal in paragraphs 30-37 below) shows that XY was disposed, in matters which depended upon inference, to put the worst construction on them, if not actually to exaggerate. His interpretation of the significance of what he saw and heard struck us as unreliable and, in some instances, mistaken. But he seldom, if ever, identified smoke in the absence of fire. He struck us as substantially accurate in his direct evidence about what he had actually seen. We are, therefore, disposed to accept his evidence in general except where it was substantially inferential or where it was unimpeachably refuted by other evidence.

Ward 17A

29. This ward, on the ground floor of one of the older Victorian “barrack blocks” contains some 40 beds. It has, in addition, one side or isolation room On our visits to the ward, it appeared to be reasonably well managed and pleasant in atmosphere. The patients appeared well-cared for. Throughout the material period it was under the charge of Deputy Chief Male Nurse “G” whom we discuss further in paragraph 274 below). We were told at the outset of our Inquiry that the patients in the ward were “largely” psycho-geriatric; subsequently it was stated that only ten of them fell into this category and that the remaining thirty were sub-normal (for the most part severely so).


30. This patient, who was born in 1882, retired from coal mining after sustaining facial and other injuries in an underground accident about 40 years ago. The accident, treatment for which involved a number of stitches round the left eye, produced some permanent deformity of the left orbit. He sustained a left-sided hemiplegia in 1961 and subsequently spent two and a half years in Caerau Hospital, near Cardiff, before being transferred to Ely. He had proved very difficult to manage at Caerau having injured at least one member of the staff there. The patient’s daughter who gave evidence to us confirmed the experience of the Ely staff that he was a very difficult, and sometimes violent patient, given to the use of much obscene language. He was doubly incontinent.

31. It was not possible for us to obtain any satisfactory evidence from Addison himself.

32. His daughter relayed to us a complaint from Addison to the effect that the baths which he had were too cold. This probably meant, however, no more than that they were unduly tepid. We received no other complaint of this kind and we do not regard it as of any significance.

33. Addison’s daughter also stated that she had several times observed bruises on her father’s hands and head, which he attributed to ill-treatment by members of the staff.

34. XY described one specific incident when he was helping a male and a female nurse in holding the patient while his bed-sores were being treated. The allegation was that because Addison’s one moveable hand accidentally struck the female nurse, the male nurse slapped him hard on the face, so as to cause him injury.

35. In his statement to the News of the World, XY identified the male nurse as “Holworth” and in his evidence to us as “Hall”. The person probably referred to is Staff Nurse “H”. The female nurse was described in XY’s statement to the News of the World, as Mrs. “I”. XY before us, however, was uncertain about her identity and thought she might have been Mrs. “J.” (who is now the wife of Staff Nurse “H”). Both “H” and Mrs. “I” denied that any such incident had occurred. Mrs. “J” was unavailable to us because of sickness.

36. XY also alleged that on the day following this incident the male Staff Nurse (presumably “H”) stated that if Addison’s family asked for an explanation of any mark on his head, it should be stated that he had hit it against the bed. ” H ” denied this. He agreed, however, that he probably had told the family, on some unidentified occasion, that Addison had struck his head against a locker or the bed. The patient’s daughter recollected having been told by members of the staff that some bruises on her father (on his hands or arms)had been caused by the necessity for holding him, while treating him, in order to stop him striking out. The ward report books do record, on a number of occasions, bruising of this patient.

37. In our view the truth of the matter probably is this: Addison was inevitably bruised slightly (he was frail and tended to bruise easily) on a number of occasions, because his admittedly violent tendencies had to be controlled by hand when he was being treated. There was probably at least one occasion which bore some resemblance to the incident described by XY, when the patient was struck in the face as a result of an unduly rough and clumsy attempt to control his unpredictable movements. This was caused by lack of skill and some lack of sympathy in handling an extremely difficult patient—and probably not by malice. In view of the uncertainty of XY’s original identification of the male nurse involved in this incident and of its comparative innocence we should not regard it as justifiable to impute blame to any person on account of it. Moreover, it is plain that XY’s impression of this incident certainly exaggerated its gravity, since he sought to suggest that the continued weeping of the patient’s eye for four or five months thereafter was attributable to the blow complained of. This conclusion was plainly not justified, since it is common ground that Addison’s left eye, in particular, had been in this condition for many years on account of his mining accident.


38.This patient, born in 1912, was admitted to the hospital in July, 1963. He is severely sub-normal, suffers from psoriasis and syncopal attacks. He came to our attention because XY (going outside the bounds of his original statement to the News of the World) reported two occasions (probably in about October, 1966) when he, XY, suggested to Deputy Chief Male Nurse “G” (in charge of the ward) that Byron should be allowed out of the side-room off the ward, in which—according to XY—he was usually confined, by means of what turned out to be the bolt on the outside of the door. “G” is said to have refused this (even to allow Byron to take a walk in what was referred to by all the witnesses as the ” airing court”), because he regarded Byron as a “Nuisance ” who, so XY said, “might go out on the road” and “always asks for cigarettes and is a trouble to everybody”. XY also spoke of an occasion when he reported to “G” that Byron was drinking his urine, to which “G” is said to have replied: ” Dirty bugger, he always does that.”

39.”G” acknowledged that Byron was indeed dirty in this way. The patient’s notes also record that he was prone to urination and defaecation on the floor of the ward. Byron’s habit of pestering other patients for cigarettes and tendency to wander abroad was similarly confirmed. It was also recorded in the patient’s notes—and this is not inconsistent with the tendency to wander —that Byron frequently sought isolation and seclusion in the side room. “G” described as a “complete fabrication” the remark about Byron which was attributed to him.

40.We believe that “G” did indeed make a remark of this kind; in view of the extremely difficult nature of the patient, such occasional lack of sympathy —although to be regretted—is not perhaps surprising.

41. “G” acknowledged that Byron was indeed locked into the side room on occasions between the hours of 7 p.m. and 8 a.m. We are satisfied that he was, on other occasions during the day, similarly restrained. The Physician Superintendent was not aware that Byron was ever bolted into the room and had been assured by the ward’s day staff that he has never been bolted in during the day time.

42. The hospital’s rules (since, with the coming into effect of the Mental Health Act, 1959, there ceased to be any statutory requirement for the recording of seclusion) permitted a patient to be secluded only’ with the permission of a Medical Officer and required any periods of seclusion to be reported in the ward report book and to the Chief Male Nurse. No such permission had been given nor had any seclusion been recorded in the case of Byron.

43. Plainly the hospital’s rules have not been complied with in respect of this patient. This betokens some laxity of supervision and the rest of the Byron story implies some, possibly understandable, lack of sympathy in the handling of a patient, who must, on any view of it, have posed many problems of extreme difficulty. Specifically, it was suggested to us, and we recommend accordingly, that the bolt on the outside of the sideroom door should be replaced by an ordinary lock (in order to prevent the door being locked ” by accident”).


44. This patient, born in 1919, who had previously been in Ely for about one month in 1964, was re-admitted in February, 1966—when his mother, who had been caring for him at home, was disabled from doing so by reason of a stroke which she suffered at that time. Chaucer himself suffers from spastic paraplegia, is severely subnormal and suffers from faulty articulation. In general terms, however, he is reasonably able to look after himself and to walk with the aid of sticks.

45. Mrs. Chaucer, supported by a witness, transmitted to us a confused complaint which her son had made to her in about August, 1966, to the effect that he had been struck on the face and (possibly) on the hands by a member of the night staff of his ward. The account which Chaucer had given of this incident was of the utmost brevity and imprecision. He identified the Male Nurse responsible as “Bob Staff”. We were unable to carry this identification any further; and we conclude that the allegation is, in itself, too imprecise to be acceptable.

46. Two other matters did, however, emerge from the evidence given to us by Mrs. Chaucer:

(a) The Hon. Secretary of the Cardiff and District Spastics Association wrote to the Medical Superintendent to complain about the alleged ill-treatment of Chaucer, as reported to him by Mrs. Chaucer and her witness. The letter of complaint was promptly acknowledged by the Physician Superintendent of Ely, who had investigated the matter as far as he could at that time—in the absence (on holiday) of the night nurse on duty in the ward at the material time. (The name of this night nurse bore no resemblance to “Bob Staff “). A promise was given that the matter would be further investigated when the night nurse in question returned from holiday. There is no evidence that such further investigation ever took place. No further letter was written to the Hon. Secretary who had made the original complaint. (It is only fair to add that he made no further enquiry of the hospital.) Such an oversight could, we readily accept, occur in the best managed institution; but it might, in this case, be regarded as mildly symptomatic.

(b) More seriously, from a general point of view, Mrs. Chaucer transmitted her son’s more general complaint that there was, at Ely, “nothing to do”, save that on Wednesdays somebody came into the ward to conduct a drawing class.

47.This pattern of inactivity compares unfavourably with the picture which Mrs. Chaucer painted (and which we readily accept) of Chaucer’s life at home, before she became unable to care for him there. He was, as she put it, “quite active at home in his own little ways”—doing jig-saw puzzles, making a scrap book and constructing out of Meccano things which “even a normal person would not be able to do”. Mrs. Chaucer said that ” when he was at home there were many things in the house he would do for me”, such as cleaning the cutlery, setting the table ready for a meal and so on.

48.The contrast was presented to us between his “very active” (although simple) life at home and the position at Ely where, said Mrs. Chaucer, “it is just the fact he had nothing to do”. Her impression of the almost complete lack of therapeutic or diverting activity for most patients on the ward coincided entirely with our own—and is consistent in tone with the drab entry in the patient’s notes that he has settled well to present environment”. This again is symptomatic of the inactive monotony of the atmosphere, which seemed to us to characterise Ely.


49.This patient, who was born in 1892, was admitted to Ely in July, 1966, suffering from senile dementia; he died of broncho-pneumonia and cardio­vascular degeneration on 3rd October, 1966.

50.The patient’s daughter wrote to us on behalf of his family to complain about several things, notably including the manner in which they were notified of his terminal illness and death and of the way in which patients’ dentures were handled on the ward. The family did not, however, feel justified, in view of the time which had elapsed, in coming to give evidence to us. We thus confined our investigation into the one matter, namely the handling of patients’ dentures, about which we had other evidence from members of the hospital staff.

51.Deputy Chief Male Nurse “G” told us about the incident of which the Dryden family complained. When the wife of the late Dryden was visiting him and wished to feed him a pear, she asked a female member of the nursing staff to obtain his dentures. The nurse returned with a bowl containing a number of dentures, mixed up together, and proceeded, by trial and error, to fit some into the patient’s mouth. The patient’s son went immediately to Deputy Chief Male Nurse “G” and, in “G’s” words, was “expressing his horror and indignation about the fact these false teeth were being fitted into his father’s mouth”.

52.”G” there and then rebuked the female nurse and told us that on the following day he reprimanded both the female nurses, who had conducted or organised this bulk cleansing or storage of dentures. “G” expressed himself surprised that two State Enrolled Nurses, each with some years service at Ely, should have found it possible to behave in this way. We refrain from naming the nurses concerned, since one of them was not able to give evidence before us and we had not sufficiently identified the other as being involved in this incident when she was before us.

53. In view of the extent to which “G’s” evidence confirms what was said in the letter from the patient’s family about the incident which he did observe, we think it probable that, as the family alleged, the nurse in question, also tried to fit into the patient’s mouth a set of teeth which she had removed from the mouth of a sleeping patient, and “rinsed under the tap”. It also seems likely that she did indeed explain to the family that most of the dentures in the communal bowl “belonged to dead patients”.

54. The incident is, however, disturbing and revealing enough without these embellishments. One other male nurse did confirm to us that he had heard of occasions when patients’ dentures were subjected to communal washing of the kind complained of.

55. The evidence about this incident satisfied us that there has in the past been regrettable laxity in enforcing the hospital’s rule that individual denture containers, suitably labelled should be used for the dentures of each patient. The fact that experienced nurses could behave in the way described is once again symptomatic of the prevailing standards.

56. In the same sense we were impressed by the apparent laxity in the provision and handling of toothbrushes. It may well be impossible for anything like all the severely sub-normal patients in the hospital to be provided with, or to use, their own toothbrushes, but attempts should obviously be made to see that such things are identifiably available for, and used by, each patient. When our Nursing Member inspected the Hospital on 6th February, 1968, some improvement was evident—and toothbrushes, marked with the patient’s name were in evidence in lockers or in a bathroom cupboard. This contrasted with the position observed, on an earlier inspection in December, 1967: toothbrushes were then conspicuous by their absence, not one toothbrush was, in fact, seen —and evasive replies were given to enquiries about such things. This again is suggestive of laxity in nursing standards, which did, indeed appear (in some respects at least) to be improving during the course of our Inquiry.


57. We found no evidence of deliberate maltreatment in this ward but low nursing standards and some lack of sympathy appeared to us to be evidenced by the following:

(a) At least one incident of undue roughness in handling the patient, Addison;

(b) Unjustifiably extended seclusion of the patient, Byron, coupled with some lack of sympathy in his treatment and complete laxity in reporting the periods when he was secluded;

(c) Insufficient attempts to provide for Chaucer any suitable occupations, which would enable him to lead a fuller life—within the limits of his capacity;

(d) Insensitivity towards the family of the patient, Dryden, and laxity in the care, provision and control of false teeth and toothbrushes;

(e) Apart from the foregoing matters which call for more general recommendations, we recommend the provision of a lock, rather than a bolt, on the side room in this ward.

Ward 17B

58.This ward, on the upper floor of the Block containing Ward 17A, contains 43 beds. All the patients are severely sub-normal; 22 of them are doubly incontinent; at least a dozen are bedridden and about 5 are under 16 years of age. On our visits, the ward appeared to be reasonably well-managed and the patients well-cared for. We noticed, however, that there was an insufficient supply of towels and face-flannels which had, in consequence, to be used for more than one patient. Throughout the material period the ward was under the charge of Charge Nurse “C” (whom we discuss further in Paragraph 275 below).

59. Apart from allegations of pilfering (with which we deal below), XY made no complaints about Ward 17B. Many specific complaints of ill-treatment by the Charge Nurse “C”, were, however, made by a former Nursing Assistant at the Hospital, “K”. We should say at once that we were unable, with one or two exceptions referred to below, to accept most of the evidence of this witness, but much of what he had to say caused us considerable disquiet in respect of other matters. It is, therefore, necessary to deal with him in some detail.

60. “K” was born in 1943. After being discharged from the Royal Air Force on medical grounds, he joined the staff of the hospital on 21st May, 1962, and—with three interruptions, discussed below—left during a period of sick leave on 16th January, 1965. He was engaged by the Chief Male Nurse, who interviewed him and obtained an oral reference from the Royal Air Force; no details about the reason for his medical discharge appear to have been ascertained. During his employment at Ely, which was largely in Ward 17B, he was admitted to Whitchurch Hospital and off duty on three occasions as follows: —

  • 28th December, 1962, to 7th January, 1963;
  • 12th February, to 2nd March, 1963;
  • 9th September, to 13th October, 1963.

Certainly the first, and probably the last, of these three admissions was on account of barbiturate overdoses. Some two months before the termination of his employment he once again went off sick, on account of an anxiety state.

61. He volunteered to give evidence to us, after having read in the Press of the setting up of our Inquiry. He made a number of allegations of maltreatment. Although he was cross-examined to some extent, he declined to return for the conclusion of his cross-examination by the representatives of the people whom he had accused. We do not, therefore, deal in detail with his allegations, since we must regard those, in the absence of corroboration, as without foundation.

62. We have already said enough of his history to explain why we regarded “K” as a complex, insecure and unstable character. His evidence was too internally inconsistent to be reliable in itself; and the incidents of which he spoke were too confused for us to be able to accept the bulk of his evidence.

63. “K” himself was accused by one patient, who gave evidence before us, of several acts of violence. On the other hand, Charge Nurse ” C”, and two Staff Nurses who gave evidence to us, had heard nothing which would corroborate these allegations and we reject them.

64. It was not possible, in view of his unco-operative attitude to our committee, for “K” himself to challenge other matters which were alleged against him. Subject to this qualification (which we do not, in this context, regard as being of practical importance) we were satisfied of the following matters:

(a) “K” was by reason of his conduct “always upsetting” the patients; this is probably because he did from time to time try, with the support of threats, to borrow money from them;

(b) “K” had on occasions returned to the ward, after his mid-day break, slightly the worse for drink;

(c) All the other members of the ward staff had, from time to time, complained about” K’s ” conduct as a colleague and one in particular, Deputy Charge Nurse “H” (a Registered Mental Nurse) resigned from the staff of the hospital in 1964 largely because, as he told Charge Nurse “C”: ” I am fed up with ‘K’, and if something is not done about it I shall have to go “;

(d) Former Staff Nurse “D” on one occasion reported to Charge Nurse “C” that “K” had struck a patient and that he, “D”, had in consequence struck “K”; as a consequence of this, no disciplinary action appears to have been taken against “K” but “D” was, on the next following day, transferred to another ward.

65. All these matters combined to make us very anxious at the length of time for which “K” remained on the staff of the hospital, until his employment was terminated after his fourth period of sick leave had persisted for more than 2 months. It proved impossible to obtain a fully satisfactory explanation of this disquieting state of affairs. “K’s” colleagues on the staff of the ward gained the impression that they were to put up with him and indeed to look after him because, as they were told by Charge Nurse “C”, the Physician Superintendent did not want him “put on the scrap heap”. The other, more senior, members of the staff gave us the following impressions:

(a) The Physician Superintendent, who appears to have known little of “K’s” history but who had discussed him with the psychiatrist who had been treating him at Whitchurch Hospital felt that “K” ought, for his own sake, to be given “another tria ” at Ely;

(b)The Chief Male Nurse, who knew of “K’s ” medical history and (after he had been at the hospital for some time) of his instability and also that he had been borrowing money from two or three patients, appears to have been encouraged by the Physician Superintendent’s sympathetic attitude to keep “K” on the staff. As the Chief Male Nurse explained to us: “The Physician Superintendent and I discussed this. … if we had discharged him he would probably have had difficulty in getting outside work. He had applied himself fairly well to normal duties previous to his first admittance to Whitchurch Hospital. … we both decided to give him another trial here”;

(c) Charge Nurse “C” also claims to have lent upon the combined advice of the Physician Superintendent and Chief Male Nurse; he also appears to have had something of a special relationship with “K”, who wrote to him asking to come back; in consequence of this, “C” claimed to have treated “K” “like a father” and acknowledged that he ” probably spent more time with him than I should have done really”.

66.Our conclusion is that “K”, who was manifestly an unsuitable person to be concerned with the nursing of patients, was allowed to remain on the staff for what we regarded as an unduly long period because of: —

(a) Undue tolerance, involving a degree of irresponsibility, on the part of Charge Nurse “C”;

(b) The sympathetic attitude of the Physician Superintendent in respect of a matter for which he had no direct responsibility and about which he was much less than fully informed;

(c) A failure on the part of the Chief Male Nurse to exercise sufficient leadership in respect of a matter for which he plainly held the ultimate responsibility; he ought to have “got hold of ” the situation sooner than he did instead of allowing an unsatisfactory state of affairs to drift on.

Other Disciplinary Matters:

67. “K” told us that he was told by Deputy Charge Nurse “H” that he was unlikely to win promotion at Ely if he chose to make any complaint about conditions there. This was denied by “H”, whose evidence on this point we reject. “K” also alleged that Staff Nurses “L” and “D” had reported to the Chief Male Nurse incidents involving ill-treatment of patients by Charge Nurse “C” and were each thereafter transferred to different wards.

68. Staff Nurse “L”, Charge Nurse “C” and the Chief Male Nurse all agreed that Staff Nurse “L” was indeed transferred away from “C’s ” ward —but, .very surprisingly, not one of these three people was able to identify the cause of such transfer. Former Staff Nurse “D”, however, explained that he had been told by “L” of an occasion when he,”L”, had complained of “C’s ” conduct but before he got to a Committee he had to back down because everyone had backed out by that time “. “L” explained to “D”: “I wouldn’t back another member of the staff here after what happened to me.” (We prefer “D’s” evidence about this to that of “L” who denied this conversation).

147.We have already recounted, in Paragraph 67 above, how ” D ” himself was rewarded for his activity in reporting ” K’s ” alleged misconduct to Charge Nurse ” C ” by being himself transferred to another ward on the following day.

148.All this evidence taken together convinces us that, on these matters at least, “K’s ” evidence was substantially correct. Both “D” and “L” were, in our judgment, transferred to different wards after having attempted to report what they believed to have been instances of misconduct on the part of “K” and Charge Nurse “C” respectively. The allegations which they wished to make were never investigated properly, if at all. At least in “L’s” case (and probably also in the case of “D”) the matter had come to the ears of the Chief Male Nurse.

71 In these circumstances, it is not at all surprising that both “K” and “D” should have received the impression from their colleagues on the staff that they would be ill-advised to do anything but accept the standards of conduct and treatment of patients which they found to prevail.

72. The Chief Male Nurse and Charge Nurse “C” must share the responsibility for this most regrettable state of affairs.


73. Our attention was drawn to this patient when “K” made certain allegations about the circumstances surrounding his death. Most of these were uncorroborated; we do not accept them. We confine ourselves to the admitted facts.

74.Emerson was born in November, 1906, and admitted to Ely in December, 1955, as a severely sub-normal epileptic. On 28th December, 1963, he became pyrexial and developed right-sided pneumonia. The Physician Superintendent last saw him on Saturday, llth February, 1964, and prescribed treatment as appropriate at that stage. On the following day, a Sunday, he appears to have been seen by the Junior Hospital Medical Officer (to whom we refer hereafter as ” the JHMO “) who authorised a Sick Notice to be issued in respect of him; in other words he was placed upon the Danger List, on account of his pneumonia.

75.Later that day, at about 5.30 p.m. he left his bed to use the toilet or commode. When returning to his bed, he collapsed with what is said to have been an epileptiform seizure. Oxygen was administered by Deputy Charge Nurse “H” and “K” and the Charge Nurse “C” was called. The patient appears to have died at about 6.15 p.m. He was placed upon his bed. After about one hour had elapsed the last offices were performed and he was taken to the mortuary by “H” and “K”.

76.No doctor attended. Charge Nurse “C” followed what appears to have been the usual procedure by telephoning a message to the porter, to the effect that the patient had died after an epileptiform seizure; this message was then to be transmitted by the porter to the duty doctor. We have no reason to suppose that the message was not duly transmitted.

77.We were not told whether or not the patient was thereafter seen by any doctor although Charge Nurse “C” assumed that on the following (Monday) morning the duty doctor, in course of his rounds, would have called at the mortuary to see the body. No note of the circumstances surrounding the death was made on the patient’s notes. The ward report book records that he did die after an epileptiform seizure but does not indicate that this did not take place in bed. The Physician Superintendent believes that either he or the JHMO completed the death certificate on the Monday morning, after the patient’s notes and the death certificate book had been placed on his office table. He does not think that he had any idea that the fatal seizure took place other than in bed. No post-mortem examination took place.

78.The facts surrounding this patient’s death, as we have recorded them, caused us some concern for two reasons: —

(a) The contemporary records were insufficient in themselves to dispel the allegations about the patient’s manner of death which were made by “K”. This is a regrettable—although understandable— omission;

(b) The whole manner in which the patient’s death was “established” without the attendance of any doctor (and thereafter certified) appears to us to be unduly casual. For even though the patient was on “the danger list” he died not from the pneumonia (from which he was known to be suffering) but from an epileptic attack, which had occurred in what Deputy Charge Nurse “H” described as exceptional” circumstances. The story of Emerson’s death betrays what seemed to us to be an unduly casual attitude towards death at Ely.

79.Our concern at the lack of information in the contemporary records about Emerson’s death led us to inspect the records in several other cases in which patients of interest to us in other connexions had died. We were not reassured that the paucity of information in Emerson’s case was exceptional. On the contrary, our impression that the standards of reporting in clinical and nursing notes has generally been poor was largely confirmed. One case requires further comment.


80.We received a letter from Flecker’s mother in which she wrote “my son has a boxed up ear”. When we went at the beginning of December, 1967, to Ward 23 in order to examine him, we found that he had just run away and was not available. He was quickly brought back to Ely but we did not have a further opportunity of seeing him until we returned in February, 1968. We then learned that he had died suddenly on 15th December, 1967.

81.He was a man 29 years of age, who suffered from severe subnormality and epilepsy. He first became ill in the middle of the night. The Senior Hospital Medical Officer (to whom we refer hereafter as “the SHMO “) who examined him at 2 a.m. found him to be seriously ill, and, on the basis of his rapid respiration and physical signs in the chest, to be suffering from broncho-pneumonia. He gave him an injection of penicillin immediately and then oxygen by inhalation. An injection of coramine was given later on in the night. The patient died at 10 a.m. Death was certified as due to broncho-pneumonia. There was no post-mortem, and further investigation into the cause of death was not made.

82.We were surprised that more had not been done in an effort to discover the cause of death in a relatively young man dying within 12 hours of first becoming ill, and we asked both the Physician Superintendent and the SHMO about the case. We were told that severely sub-normal patients may die suddenly, most commonly from epilepsy, and that resistance to broncho-pneumonia is sometimes very poor, death occurring within a few hours of the onset of ill­ness. The Physician Superintendent gave three as an estimate of the number of sudden or rapid deaths each year in the hospital. At the time of Flecker’s death there were no facilities for post-mortem examinations at Ely, what was formerly the post-mortem room having been turned into a mortuary, which has recently been reconstructed.

83.We recognise that it is a matter of clinical judgment whether a case of this kind should be followed up (e.g. by arranging post-mortem or bacteriological studies) and a decision must depend in some degree upon the facilities available. However, we think it important that cases like Flecker should be sufficiently investigated. To do so provides a safeguard of one kind against a decline in nursing care or medical treatment. There are resources within the group, we suppose, which would make possible more than was done in this case. Flecker was a young man, who had been physically fit and active up to a few hours before his death. His death appears to have been accepted with less concern and less enquiry than the circumstances seem to us to have warranted.


84.This boy was born in August, 1952. He is epileptic, paraplegic, with dislocation of both hips, doubly incontinent and severely sub-normal. His mental age is said to be about 3 1/2 years; his speech, consisting only of single words, is very indistinct. He was admitted to Ely for five weeks in July, 1965, and again on 5th October, 1965. His parents complained by letter about what seems to have been a misunderstanding between themselves and the staff of the hospital, which led to his initial discharge in August, 1965. This appears to us to have been the kind of incident which could have happened anywhere without any fault on either side.

85.The parents have also been anxious for their boy to be transferred to the Glamorgan County Council’s new residential school for educationally retarded boys at Bryncoch, which is near to their home. This is obviously not possible for a child with the disabilities which we have described—and the suggestion has rightly been rejected.

86.The parents’ other complaint was about the virtually complete inactivity of their son at Ely. They would like him to be able to leave his bed and dress every day and “maybe go to school”. The Physician Superintendent explained that it did not seem to him to be possible in present circumstances for the boy to be given more to do in the ward; he was too vulnerable to be placed in the ground floor male wards, 21 or 23; he was too young to be placed in the other ground floor ward, 17A; he thus had to be retained in the upstairs ward, 17B, which precluded the prospect of any further mobility. The Physician Superintendent was hopeful that “when new wards were constructed”, Goldsmith could be transferred there—with an increased prospect of some mobility. We understand and sympathise with the Physician Superintendent’s difficulties with this patient (as with many other similar cases) but (as we discuss in Paragraph 359 below) we do regard this case as another illustrative instance of the way in which an unduly inactive existence appears to be too readily regarded as the only possible regime for many of the patients at Ely.


87.Once again we found no evidence of deliberate maltreatment in this ward. But low standards of patient care, as well as lack of effective leadership on the nursing side appeared to us to be evidenced by the following:

(a) The story of Nursing Assistant “K’s” continued service at Ely— which appears to be explained by an unduly tolerant attitude on the part of Charge Nurse “C”, a possible excess of sympathy on the part of the Physician Superintendent and a lack of sensitive leadership on the part of the Chief Male Nurse;

(b) The lack of any, or any effective, investigation of complaints of misconduct on the part of “K” himself and of Charge Nurse “C” —which laxity appears to have passed into the folk-lore of the hospital and thus encouraged the acceptance of unduly low standards of nursing conduct;

(c) The unduly casual attitude towards the deaths of Emerson and Flecker (the last named in fact in another ward);

(d) The passive acceptance of a life of virtually complete inactivity for the patient, Goldsmith.

Ward 21

88. This Ward is a separate ground floor unit, comprising (apart from sanitary office and kitchen accommodation) two dayrooms and two dormitories 0f 33 and 42 beds each. At the time of our inspection the ward was in fact accommodating 77 patients. The dormitories were severely overcrowded with double lines of beds down the centre of the ward in addition to those along each wall. All the patients were generally ambulant and sub-normal (most of them severely so). 16 of the patients are epileptic. Throughout the material period the ward was under the charge of Charge Nurse “M” (whom we discuss further in Paragraph 276 below). The ward appeared to be reasonably well managed and the patients well cared for.

” Housman”:

89. This patient was said, in XY’s original statement to the News of the World, to have been “given a beating ” by Charge Nurse “M” and Staff Nurse “N”. This allegation obviously called for close investigation.

90. Housman was born in March, 1929, and is a severely sub-normal epileptic. The Physician Superintendent described him as “probably the most violent man we have” and said that many members of the staff were “really frightened of him”. The patient’s notes record more than one occasion when he has sustained head (i.e. scalp) injuries either in course of an epileptic fit or while fighting with another patient. The ward report book for 4th March, 1967, describes an occasion when he became “very aggressive and violent” and sustained slight discolouration of one eye “during fracas when being restrained from breaking windows”. Charge Nurse “M” is also recorded as having sustained a laceration on this occasion whilst assisting in restraining patient”. (This last occasion was probably the second one of those in respect of which XY alleged that undue violence was used in dealing with the patient. This particular allegation was not, however, sufficiently substantiated by the evidence we heard).

91. Whatever the precise nature of the other, substantial incident reported by XY to the News of the World there is no doubt that he was referring to an occurrence on Friday, 25th November, 1966. The entry relating to Housman in the ward report book for that day reads as follows: — ” Fitty and confused today. Has had periods of aggressive behaviour to himself and to Staff Nurse “N”, biting Staff severely on right forearm. Paraldehyde I.M. 5 c.c. given at 11.15 a.m. with settle effect. Oral paraldehyde given at 12.30 with good effect, repeated at 4.30 p.m. Sustained incised scalp wound necessitating one suture at 11.15 a.m. to be kept in bed in morning. Aperient given 11.15 a.m.”

92. The participants in or witnesses of this incident, apart from XY, were: Charge Nurse “M” , a State Registered and Registered Mental Nurse, Nursing Assistant Mrs. “O”, who joined the hospital service as a cleaner, became a Ward Orderly at Ely in 1953 and a State Enrolled Nurse (by virtue of service at Ely) in March, 1965; Staff Nurse ” N”, who was born in 1921, came to Ely as “an Attendant” in 1941 and became State Enrolled in April, 1965.

93. None of the witnesses were wholly reliable in their account of this incident. XY had difficulty in dating the incident but thought that it had occurred after Christmas, 1966; and was unsupported by contemporary documentary evidence (and, therefore, possibly exaggerating) in stating that the patient’s head wound was large enough to require, and to receive, six sutures. There were many inconsistencies in the accounts given by “M”, “N” and Mrs. “O”; by no means all of these appeared to be due to the difficulty in remembering such an incident after the passage of some 15 months. In particular, “M’s” assertion to us that he had been expressly congratulated by some colleagues on the staff of the ward about the quality of his report of the incident in the ward report book (quoted above) was quite frankly incredible—and satisfied us that he was attempting in his evidence to “gild the lily”. In the upshot we believe that XY’s account was at least more accurate than that of the other witnesses.

94. Doing the best we can to establish the truth in the face of much conflicting evidence we believe that the incident happened along something like the following lines. At some time before 11 a.m. near the door from the Dayroom to the Bathroom, the patient became “troublesome” either because he was “disturbing” other patients or possibly because he was inconveniencing the ward staff. He was described as going through an ” epileptic furore “; but he had offered violence to nobody and did not, then or thereafter on that day, develop a fit. In these circumstances ” M ” began trying to “restrain” him with a view to putting him back into bed in the dormitory. Blows were exchanged; and “M” and Housman fell to the floor. “M” explained that he found it hard to remember exactly what happened “when one is fighting like that”. “N” then entered the Dayroom and helped “M” to get the patient off the floor and remove him to the dormitory. In the course of this transit the patient bit “N’s” right forearm. “M” and “N” were the only witnesses of what occurred in the dormitory; they agree that the patient was protesting at what was being done to him. While they were changing the patient from his day into his nightclothes he “escaped” from them and in some way fell, striking his head most probably against part of a bed frame. After some little time had elapsed he was brought into the bathroom. He and his bloodstained clothing were there washed in the bath. “M” shaved the relevant area of hair from his head and stitched the wound, which appears to have been about one inch in length. According to XY’s circumstantial account, six stitches were inserted but we do not feel justified in accepting this evidence, in face of the contemporary note quoted in Paragraph 91 above. (Our medical member was unable because of the lapse of time to derive any assistance on this point from an examination of the patient’s head). The patient was then returned to bed. Without any prior or subsequent reference on that day to a medical officer, “M” then administered intra-muscularly 5 c.c. of paraldehyde and gave to the patient an aperient.

95. The JHMO (who was, on that day and regularly at that time, in charge of the male wards and who did his ward rounds before going off duty at noon on that day) knew nothing of the incident until he returned to duty on the following Wednesday. The incident itself is not referred to in the patient’s clinical notes; this in itself is not, however, conclusive—since the clinical notes on this patient (as in the case of many others) are very intermittent; many of the entries appear moreover to have been made by members of the nursing and not of the medical staff. The SHMO (at this time normally in charge of the female wards but on duty for the male wards during this weekend) was told of the incident during his ward round on the following day and then examined the patient. We are unable to decide whether, as XY suggested, the JHMO was told anything by members of the nursing staff during his round on the day of the incident, which may have had the effect of diverting him from any examination of the patient on that day.

96.We consider that there are 4 unsatisfactory features about this case:—

(a) The patient’s condition and conduct was not such as to provoke or justify the unduly rough handling which he received in the day room; the handling of such a difficult patient is, of course, an extremely difficult matter but more sophisticated nurses, with more guidance in the up-to-date approach to such patients, would have realised that the course adopted was likely to be positively counter­productive in its effect;

(b)The patient must at least have been mis-managed in the dormitory for him to be wounded in the head as he was;

(c) It is hard to see any justification for the administration of paraldehyde (once intra-muscularly and twice orally) by a member of the nursing staff, without any contemporary reference to a Medical Officer. The practice of the hospital was said to require medical approval for the administration of this drug. “M” claimed that he obtained such approval on the telephone. We could not accept his evidence to that effect. And we suspect that the hospital practice was honoured more in the breach than in the observance.

(d) Although no undue harm seems to have flowed from this incident, it cannot be regarded as satisfactory that the patient was not seen by any Medical Officer on the day on which it occurred. It is true that the practice of the hospital permitted “M”, as a qualified nurse, to suture a “minor wound ” without prior reference to a doctor. But a Medical Officer was on duty in the building when the incident occurred. It would certainly have been preferable for him to be called to attend to the patient. We question the wisdom of the hospital practice of allowing nurses to suture wounds, without direct instruction from a Medical Officer. For the practice had the result, in this case, of allowing,24 hours to elapse before the wound was in fact examined by any doctor (the SHMO, on the following day).


97. We heard from XY of his suspicions that a patient whose Christian name he knew (but whom he could not further identify) had been ill-treated on this ward. He could give us, however, no direct evidence about this, since he was founding himself upon what he had heard from other members of the nursing staff. This allegation was not corroborated and seemed, upon its face, to be improbable in some respects. We treat it, therefore, as being without foundation.


98. The treatment of the patient, Housman, although not in our view prompted by malice, appears to us betoken:—

(a) the continued acceptance of old-fashioned, unduly rough and undesirably low standards of nursing care; (b) the acceptance of a system whereby members of the nursing staff are, as a matter of practice, permitted to administer drugs to and stitch wounds of patients who sustain physical injury—without any or sufficient reference to or supervision by the medical staff.

Ward 23:

99. This ward is similar in general design to Ward 21 and is in the form of a self-contained ground floor block. Apart from a small central dayroom, toilets, office and kitchen accommodation, it comprises one dormitory/day room, containing 14 beds and a second dormitory containing 48 beds. At the time of our inspections, the ward actually accommodated 64 patients. The main dormitory was acutely overcrowded, again with a double row of beds down the centre in addition to the beds along each wall. The patients were severely sub-normal males, almost all of them generally ambulant. They appeared to be reasonably clean and well cared for.

100. But all the rooms comprised in the ward presented a very depressing appearance; they were shabby, poorly equipped and organised. The bathroom appeared to be in a very poor state: the showers functioned spasmodically and one W.C. was, during one of our inspections, without a seat. Stored together in the kitchen cupboard were butter, soap, boxing gloves, socks, rags, and many other things. We observed a dressing drum being used as a container for non-sterile dressings. We were told, on a visit to the ward, that the patients carried their toothbrushes in their pockets. One patient, on request, produced a tin of toothpaste—but not a brush. There were no face flannels and communal towels were used. There appeared to us to be sufficient space in this ward for the storage and care of all requirements, provided that such space was properly used. Since 1956, the ward has been under the charge of Charge Nurse “A” who has been, since March, 1966, Assistant Chief Male Nurse at Ely.

101. Certain allegations about this ward made by XY in his original statement to the News of the World were not substantiated by the evidence given before us, as follows: —

(a) The suggestion that Charge Nurse “A” used to take a “thick stick ” on his rounds and threaten the patients with it if they were not quick enough. “A” himself was at pains to tell us that he used a window pole every morning to open the windows and thus expel the smell of urine and faeces which customarily built up in the ward overnight; and that he used this pole from time to time to recover articles which the patients had thrown onto the roof of the ward. But he denied having used any pole or stick for the purpose of “encouraging” or “threatening ” the patients. In the absence of any corroboration for this allegation made by XY, we feel obliged to accept that denial of Charge Nurse “A”;

(b) The account of an occasion when Charge Nurse “A” was said by XY to have taken some patients outside the ward and hosed them down with cold water, having been assisted in this exercise by one of the patients (of whom we shall say more hereafter), Jonson. XY had not observed this alleged incident himself but said that he had been told about it by one of the witnesses named in his statement to the News of the World, Nursing Assistant “P”. “P ” was unwilling to give evidence before us. We were, therefore, unable to pursue this allegation.

102.This serves to illustrate, perhaps more clearly than any other aspect of our work, the difficulties under which we laboured in the absence of any power to compel the attendance of witnesses. Even the assistance of a solicitor in presenting the case to us might have been sufficient to cast some light on this allegation, if not actually to secure the presence of “P” before us.

103. XY told us (but not the News of the World) about another incident concerning this ward: the altercation between Charge Nurse ” A ” and former Staff Nurse “B” referred to in Paragraph 26(a) above. This incident more logically forms part of “B’s” story, and is accordingly considered in that context in paragraphs 182-183 below.

“Keble Lovelace”

104. XY’s original allegation about this patient in his statement to the News of the World, was amplified and corrected in his evidence before us. He alleged that a young epileptic patient, who had the habit of playing with buttons, was teased by a Nursing Assistant, said to be “Q”, so that what began as a joke became an angry and violent incident. It was alleged that on at least two occasions within the space of about 15 minutes “Q” got the patient to the floor, struck him a number of times in the chest and stomach and used foul language towards him—and that this conduct was persisted in despite XY’s protests. The patient is said to have sustained at least two epileptic fits within the hour or so which followed this incident. XY claimed that he was so upset by all that he had seen that later that afternoon he asked a colleague, whom he thought to have been Staff Nurse “E”, for some aspirins. But he did not at any time report the incident to the ward Charge Nurse on that day, whom he believed to have been “R”. XY claimed to have remained off work on the following day, because of his distress at the incident—but without obtaining a medical certificate. On the next following day, he claimed to have reported the incident to the Chief Male Nurse, who is alleged to have reacted by telling XY that he was “seeing too much” and that things could be “unpleasant” for XY if he chose to make an official complaint about it. XY claimed that he was thereafter required to do unbecoming and menial tasks.

105. XY’s account of this incident was denied not only by the Chief Male Nurse but also by Nursing Assistant “Q”; the latter was, for part of the time, separately represented before us—and he returned, of his own volition, specifically to challenge two parts of XY’s evidence, which he felt had not been adequately tested in cross-examination by his solicitor.

106. In connection with this incident, in particular, we felt ourselves substantially handicapped by the fact that the evidence bearing upon this, as well as the associated documents, had not been investigated in advance of our Inquiry by any solicitor. We have probed and tested it in detail by reference to contemporary documents; the ward report books, the ward fit book and the records of XY’s absences on account of sickness. Some of the documentary inconsistences have only become apparent to us as a result of further investigation after we had concluded hearing the oral evidence.

107. At the end of the day, the following difficulties remained apparent:

(a)At no material time was there any patient on Ward 23 with the surname Keble. When it was suggested to XY that he was possibly referring to an epileptic, who was born in May, 1961, called Keble Lovelace, he accepted this identification. Some witnesses who gave evidence after XY suggested that Lovelace never played with buttons and that another epileptic (born in June, 1960) called Masefield was the only one that had this characteristic. Other evidence did, however, support XY at least to the extent of acknowledging that both these young epileptics did play with buttons. In the upshot, therefore, there can be no certainty about the identity of the patient said to have been involved.

(a) Although XY appears to have told the News of the World that the incident took place during a night, he was in no doubt in his evidence to us that it took place by day. We believe that this confusion was certainly due to a misunderstanding by the News of the World reporter.

(b) XY was insistent that this incident of violence was the first which he had seen. It will be remembered that the incident involving Housman (about which XY told us—see paragraphs 89-96 above) almost certainly occurred on 25th November, 1966. Yet XY, in his statement to the News of the World and, initially at least, in his evidence to us, began by dating the incident at present under discussion towards the end of December, 1966, or beginning of January, 1967. XY and “Q” do not appear to have been on duty together in Ward 23 after 20th November, 1966.

(c) There appears never to have been an occasion when XY was on Ward 23 at the same time as all three of the persons referred to in his evidence (see Paragraph 104 above): “E”, “Q” and “R”. Moreover, “R “—although on occasions in charge of the ward—appears never to have been in charge of the ward when XY was on duty there.

(d) XY never appears to have been absent from duty for one day (whether with or without a medical certificate) on any day which followed any of the comparatively few occasions when he and “Q” were on Ward 23 together.

(e) On no occasion before 25th November, 1966 (the date of the Housman incident) was XY off duty fot a single day without & medical certificate, following a day on which he had in fact been on Ward 23.

108. This list of inconsistencies might seem sufficient in itself to lead to the conclusion that the incident of which XY spoke could never have occurred. In fairness to him, however, it should be noted that there are one or two dates which fit his evidence in a number of respects and on which entries appear in the ward report book in relation to Lovelace that could be regarded as consistent with XY’s allegations. Only one of these dates is before 25th November, 1966. And neither “E” nor “R” was on duty on that date, which was in fact followed by four days’ absence on XY’s part. For all the foregoing reasons, we feel obliged to accept the denials of “Q” and the Chief Male Nurse. Although we believe that an incident of the kind described by XY probably did occur, it seems only right, in view of the confused state of the evidence, that “Q” should be acquitted of this charge. Similarly, we cannot be satisfied that the Chief Male Nurse received from XY any report of such an incident and had with him any conversation of the kind alleged.


109. This patient, who was born in June, 1955, is a severely sub-normal epileptic who is not able to speak and communicates only by means of subdued shrieks. Many entries in the ward report books and the patient’s notes confirm that he is inclined to be over-active, noisy and restless—and likely, from time to time, to go wild and attack other patients. He has a habit of wandering into the ward kitchen in search of food, and all members of the staff, including XY, had frequently to get him out of the kitchen.

110. XY (once again confirming, with some clarification, his statement to the News of the World) described one occasion (said to have been towards the end of an afternoon in about March, 1967) when Staff Nurse ” R”, in the kitchen, slapped the patient on the face and, about an hour later, Charge Nurse “A”, in once again removing the patient from the kitchen, also slapped him twice on the face.

111.Both “A” and “R” denied ever having treated the patient in this way. They explained—and we can entirely accept this—that they were constantly removing him from the kitchen; that “R” had a particular ” father/son ” relationship with this patient which made him better qualified than most to handle him; and that “A” frequently was able to quieten the patient down, by putting him to sit in his (“A’s “) office, while “A” was working there. The ward report book for 22nd February, 1967 (when “A”, “R” and XY were all on the ward together) records one incident when, during the morning, Masefield, in the course of a “maniacal outburst”, sustained what is said to have been a self-inflicted injury to the left eye, and had thereafter to be physically restrained from causing further damage to himself. This incident is recorded, however, as having occurred during the morning and he is said to have been quiet thereafter. It would, therefore, be wrong to regard this entry as corroborating XY’s account of an incident said to have taken place during the afternoon.

113. Nevertheless, and notwithstanding the firm denials of “A” and “R”, we believe that each of them has on at least one occasion of the kind described by XY, attempted to control Masefield, a patient of the most aggravating and difficult kind, by slapping him on the face. We regard this conduct as symptomatic not of malice towards the patient but rather of old fashioned and unsophisticated nursing techniques.


114. This patient was born on 22nd November, 1930, suffers from sub-normality and difficulty in articulation. He has been at Ely since 28th August, 1943. Plainly he acts, on the ward, as a cross between a messenger boy or runner and a non-commissioned officer. XY acknowledged that he was capable of making himself “very useful “. XY, however, complained (in his statement to the News of the World, as well as before us) that Jonson was permitted to treat other patients with undue violence, particularly by slapping them, when marshalling them into line to be shaved.

115.Such conflict of evidence as there was about Jonson’s role and behaviour turned only on questions of degree. We were able to form a reasonably clear picture. Charge Nurse “A” told us that Jonson could be “a bit impulsive” and had struck other patients, in the course of arguments, on a number of occasions. He had often been checked for doing this. His parole had on occasions been withdrawn and he had been threatened with loss of his pocket money. Charge Nurse “A’s ” concern was to persuade Jonson “to keep his hands down”. It was said by other members of the nursing staff that Jonson liked acting as a “sergeant major”, and effectively “in charge of the squad”. Certainly he was accustomed to “shove” other patients into place for the barber. State Enrolled Nurse “S” (who unconsciously illustrated Jonson’s typical movements by “flapping his hands about” as he was giving evidence to us describing Jonson) agreed that he did sometimes push the patients hard, if they were a bit stubborn. We believe XY’s allegations that Jonson’s conduct was, on occasions at least, permitted to go rather beyond this, so that he did indeed slap them about the head.

116. The Physician Superintendent described this kind of allegation about Jonson’s conduct as ” a big surprise “. And we do not believe that he was in fact aware of Jonson’s capacity for occasional violence when being “employed” in a supervisory role. Charge Nurse “A”, however, was undoubtedly aware of Jonson’s tendency to act, on occasions, with the undue violence which XY described.

117. Staff on the ward was, of course, always short. And Jonson was, in comparison with many of his fellow patients, a potentially useful person. However, in view of his known capacity for impulsive violence, we consider it preferable for him not to be employed in any role which gives him even apparent authority over other patients. Indeed we question the wisdom of using patients at all in the capacity of “assistant nurses ” with such apparent authority. It gives scope for favouritism of a kind that one associates with the use of “trusties” in a custodial setting and suggests the persistence of some aspects of this out-dated concept.

The airing court incident :

118. This incident (not referred to in XY’s original statement to the News of the World was cited bv XY as an illustrative occasion when Charge Nurse “A” was said to have used his “big stick” to chase the patients— on this occasion out of the ward and into the airing court. We have already indicated, in Paragraph 101 (a) above, that we feel obliged to accept “A’s” denial of ever having used a stick in this way. In Paragraph 26(c) above, however, we explain why we prefer XY’s evidence to that of “A”, to the effect that the incident did take place on a wintry day in February, rather than in March or April as “A” suggested. Even so we do not feel able, in the absence of corroboration on this point, to accept XY’s further suggestion that “A” was insisting on keeping the patients out, notwithstanding XY’s protests that the weather was too cold for them to be outside. We believe that XY’s complaints were, on this occasion, on his own behalf—since it is probable that he, comparatively unaccustomed to the Welsh climate, did find it too cold to remain on duty outside himself.

119. The incident thus has, in itself, no bearing upon the method in which patients were being treated. It is, however, significant that both XY and “A” agreed that “A” ordered XY to remain outside the ward and in the airing court and that XY did not obey this order. Notwithstanding this admitted disobedience on the part of XY, “A” denied that he at any time thereafter reported the incident to anyone in authority as an example of misconduct on the part of XY.

120 In fact, the Chief Male Nurse told us that this incident was reported to him, by Deputy Chief Male Nurse “G” after Charge Nurse “A” had originally reported it to “G”. The Chief Male Nurse did, moreover, speak to XY about it and “smoothed things out” by reminding XY that it was his duty to obey instructions given by his Charge Nurse.

121 Having found the “airing court incident” (as it came to be known) established only to the limited extent to which we have indicated, it appears to us to be significant in two respects:

(a) As an illustration of the way in which XY and Charge Nurse “A” did not exactly “hit it off” together; and of the slightly explosive way in which Charge Nurse “A” reacted to insubordination. “A”, whose representative before us suggested that “his bark was worse than his bite” agrees that he said to XY: “You are trying to tell me. I have been over 20 years at this game, how to do mental nursing. You have only been here a couple of months, you are not going to tell me what to do.”

(b) As an illustration of the closeness of relationships between the senior members of the nursing staff, at least when it came to the question of their hearing about alleged misconduct on the part of new or junior members of the nursing staff. The Chief Male Nurse appears, in this respect, to have been kept well informed about the views of Charge Nurses about their junior staff.


123. This patient, who was born in October, 1937, is a mongol. He was admitted suffering from schizophrenia in March, 1961, to Ward 23. At the time of admission to Ely and to a varying extent since, he has suffered from a depressive condition—being described as withdrawn, preoccupied and suffering from hallucinations. He has become reluctant to speak. This depressive condition appears to have persisted, notwithstanding the administration (during 1961 and 1962) of electro-convulsive therapy. He was transferred on 22nd November, 1967 (in circumstances to which we refer below), to Ward 17B. He possesses some ability, since he is able to read and write and also to play the piano. Prior to admission he had attended elementary and special schools, received special tutoring at home and attended a training centre in 1955 and from 1956 to 1960. He was regularly visited by his mother, who was obviously very fond of her son. She herself, for example, changed and laundered his underclothes; and had provided for him at the hospital two pianos—the second being provided when the first ceased to be serviceable.

124. The case came to our notice by reason of a reply from the patient’s mother to our circular letter to the relatives of all patients. She complained specifically about the “non-segregation of the different types of patients”. As long ago as 5th July, 1966, Newbolt suffered an injury to his head (not serious enough to require sutures), when he was struck with a broom by another patient. In the weeks before receiving our letter, his mother had apparently heard from other patients on the ward that her son was still subject to attack by other patients in this way. We heard no independent evidence to substantiate the alleged recent incidents of this kind; but it was acknowledged that they could possibly have occurred, in view of the large number of patients (including some whose violence was always likely to break out) accommodated in Ward 23.

125. Having written to us in this way, Newbolt’s mother understandably felt that she/ought to see the Physician Superintendent lest he should fear that she was “going behind his back”. She appears to have had a good relationship with him as well as with the Chief Male Nurse. And, until a few weeks before writing her letter, with all the ward staff on Ward 23. When she saw the Physician Superintendent, Newbolt’s mother also complained to him about two other matters with which we deal below. He suggested that Newbolt should be transferred to another ward. This did not immediately appeal to his mother, since she felt that there was something to be said (from her point of view as well as from her son’s) for keeping him in the ward to which they were accustomed. The Physician Superintendent, however, insisted upon transferring him to Ward 17B, where, according to his mother, he appears to have settled down well in what struck her as a quieter atmosphere. (As we have explained above there are more patients confined to bed in Ward 17B, so that there is correspondingly less activity on the ward.)

126. The Physician Superintendent was insistent that the reason for the patient’s transfer was not the mothers’s complainst about the “non-segregation” of different types of patient on ward 23. He arranged for the transfer because the other complaints made by Newbolt’s mother (to which we refer below) suggested that she would, in consequence of them, not be confident in her relationship with the staff of Ward 23. We accept what the Physician Superintendent told us in this respect.

127. He acknowledged that difficulties did, of course, arise from the necessity of putting together in the few, very large, male wards in the hospital, patients of widely differing types. He agreed that in a more ideal world, it would certainly be desirable to avoid this kind of mixing. But it is plainly impossible, as he explained, to secure the ideally desirable degree of separation in a hospital where the few large wards necessitate this kind of mixture.

128. Newbolt’s mother complained specifically of two matters, both arising in the early part of October, 1967: —

(a).The appearance of two red marks on one of the patient’s feet which could not be attributed to uncomfortable footwear and were not otherwise explained.

(b) The fact that his toenails had been cut “not only to the quick but … so that the flesh was visible where the nail should have been”.

129.The first of the foregoing allegations could not be investigated or explained any further. No specific suggestion was made that it was due to ill treatment of any kind. And plainly it is possible for such marks to have been caused in a number of innocent ways. Newbolt’s mother did not suggest that they were more than a cause of anxiety to her. We do not regard them as being, in themselves, of any significance.

130.(Similarly, we do not attach importance to one other matter about which Newbolt’s mother made a gentle complaint, namely the fact that on one recent visiting day she found her son wearing trousers which were unduly tight. We can accept the suggestion that this might have happened because he himself had changed his own clothing, as he was from time to time said to do.)

131.More important, however, was the other complaint made by his mother about the treatment of Newbolt’s toenails. Although Staff Nurse “R” challenged her evidence about this, we are satisfied that on one of the Wednesdays when she visited her son, probably 18th October, 1967, she drew the attention of Staff Nurse “R” to the uncut state of Newbolt’s toenails. She offered to cut them herself but Staff Nurse ” R ” explained that he would do them. On the following Saturday, when Newbolt’s mother took him home for the week (as usually happened at the time of his birthday) she observed that his toenails had indeed been cut excessively and to an extent that must have been painful. They were cut down below the quick so that the flesh of the toes was visible.

132.Charge Nurse “A” agreed that, on her first opportunity after the discovery of what had been done to her son’s toenails, Newbolt’s mother did complain to him about this. He said that he examined the nails later, on the day of her complaint, and saw nothing untoward. He did not accept her evidence about the terms in which she had complained, but did agree that she was drawing attention to the fact that the toenails had been cut into the quick. We are satisfied that Newbolt’s mother also asked: ” If whoever did this has any children of their own, how could they do such a thing as this?” and said that if the condition of the nails had been seen by an NSPCC Inspector he would have been caused to ask: “Who is responsible for this sadistic brutality?” While the complaint may have been over-dramatic, we are satisfied that she had real and substantial grounds for complaint.

133.It was not possible to discover who had in fact cut the patient’s nails. “R” denied having done so. Charge Nurse “A” thought that they had been cut by Nursing Assistant “Q”; but since this suggestion was made after “Q” had given evidence, he had no opportunity of dealing with it. Charge Nurse “A” sought to explain the occurrence to the patient’s mother by saying, in general terms, that: “You cannot rely on these youngsters; they will not listen when they are told”.

134.Whatever the explanation for this incident (and it should probably not be attributed to deliberate malice), we regarded it as yet another symptom of unduly lax and uninstructed standards of nursing at Ely. As Newbolt’s mother put it to us: “It merely needs a little extra special training, a little tuition, to put that sort of thing right.”

135.One other aspect of the treatment of Newbolt caused us some concern.While he was no doubt disabled by his mental condition from continuous activity, all the evidence suggests that (even when and insofar as it was possible to encourage him) little if anything was done to secure the performance by him of any training or therapeutic activity. Like the patient Chaucer (whom we discussed in Paragraphs 44 to 48 above), he was said to have been capable, while in his mother’s care at home, of doing a number of simple—but for him interesting—domestic tasks: laying the table, washing dishes, cooking meals—and, of course, playing the piano. His piano playing activities (which his mother obviously tried to sustain) appear, during his stay at Ely, to have been largely confined to those afternoons when his mother came to take him down to the room in which the piano was available.

136.This pattern of inactivity once again impressed us as symptomatic of the tendency at Ely to do less than possible to encourage activity on the part of the patients, so as to give them a fuller life and (in some cases at least) to precipitate at any rate a degree of improvement in their condition.


137. In this ward too we found low standards of nursing and patient care evidenced by the following matters: —

(a) The occasions on which the patient, Masefield, was exposed to the unsophisticated technique of being slapped on the face by members of the nursing staff;

(b)The extent to which a patient, Jonson, with a known capacity for violence, was employed on the supervision of other patients;

(c).The unjustifiable clumsiness and, although inadvertent, cruelty with which the toenails of the patient, Newbolt, were cut by a member of the nursing staff;

(d) The lack of any conscious or sustained effort to encourage therapeutic or other activity on the part of the same patient, Newbolt.

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