1.1 The greater part of St. Augustine's Hospital was built 100 years ago as a mental hospital for South East Kent. It stands on a high and isolated ridge known as Chartham Down a few miles south of Canterbury. Various additions have been made since that time. It is constructed in red brick, and consists of a central administrative block around which are all the services required by the Hospital. On the outer perimeter lie 15 two storey buildings each of which contains two wards. The buildings are linked by long corridors. It was originally constructed for about 800 patients. Its peak number of 1,678 was reached in December, 1956. In November, 1975 it housed 929 patients.
1.2 Doctor William Brian Ankers, B.Sc(Hons), A.R.C.S., Ph.D. was born in 1946. He is not a Doctor of medicine. After taking his Bachelor of Science degree at the University of London he went to the University of Kent in 1968 to do research work and write a thesis on organic chemistry in the hope that he would be accepted as a Doctor of Philosophy. He fulfilled this ambition in September, 1973, but earlier, on 16th July, 1972, he had commenced work at St. Augustine's as a temporary Nursing Assistant in order to support himself while writing his thesis. He spent four weeks in Ash, a male epileptic ward with about 57 patients. Between August 15th, 1972, and July 7th, 1974, he worked in Heather, a Male long stay ward with 54, falling to 48 patients. Thereafter he served in Hawthorn, a male geriatric ward with 48 patients, until his resignation on December 7th, 1974.
1.3 Most people who worked with Dr. Ankers rightly regarded him as a hard-working Nursing Assistant, but he had a tendency to involve himself closely, sometimes too closely, with the patients. As a result of this involvement, he continued to work in the hospital after obtaining his Doctorate. He resigned at the end of 1974 through frustration and growing anger about the treatment of the Critique. Since that time he has devoted himself to the preparation of a further part to the Critique and to its annotation for the Enquiry.
1.4 We found him a reliable witness when he was describing what he had seen or heard. Sometimes, however, he deliberately presented a one- sided, distorting version of events.
1.5 Mr. 0lleste Weston, R.M.N. was born in 1945. He left school aged 15 years and for the next four years worked in a factory, timberyards, bakeries, shops and labouring jobs. He then commenced training at a hospital for the mentally subnormal, but did not complete the course because "I was rather an idealist … I was not satisfied with the hospital and what was happening there. At the same time I had the opportunity to go and work in a sort of refugee camp in France. I felt that was the thing." After about four months in France he returned to work in various office jobs in this country, and in September, 1970, he commenced work as a Nursing Assistant at St. Augustine's in Maple, an acute male admission ward with 44 patients. After four weeks he became a student nurse, and during the next three years he worked on most of the male wards under the direction of the Principal Tutor at the Lawson School of Nursing. He qualified as a Registered Mental Nurse in November, 1973, and thereafter worked on Heather Ward first doing relief work, and then as a Staff Nurse, until his resignation on April 3rd, 1974. About the time he came to St. Augustine's he took the name of Etsello in place of Weston: he has since reverted, to his original name.
1.6 He explained his return to nursing thus:- "At the time I intended to work overseas with the voluntary aid programme. I had applied many years ago and had not been accepted because I would have been no use to anybody with no full training. The only way I could do this work, without having to go back to school was to do a training course, such as nursing, which could give me a qualification which I could use to follow my at- that-time ambition."
1.7 Until the appearance of the Critique in April, 1974, he seems to have been regarded as a satisfactory nurse. One Charge Nurse told us that at the end of 1970 he was able "after a while" to get on very well with him. "He had some good ideas but he never carried them out. He proposed to me once about a therapy for a group of patients that could not go down to the industrial unit, and he suggested painting. I went to the trouble of getting paint and everything else, but he did it for two days and then he did not go on any further." Another Charge Nurse speaking of Mr. Weston on another ward in mid-1971 said that he had "some progressive ideas, but he did not appear to join in and become part of a ward team … I remember Mr. Etsello enjoyed talking with patients, but on occasions he would sit and talk with them and would fail to attend to their bodily needs." He appears to have been articulate in the company of his contemporaries, but to have lacked confidence in the presence of Consultants and the Senior Nursing staff. In our view he was more concerned with ideas than with the patients, and we did not think that he was a good psychiatric nurse. We are satisfied that on one occasion in Heather Ward he slapped a patient's face because "he gets on my bloody nerves".
1.8 Mr. Weston stated that he stayed on at St. Augustine's after qualifying because he had got involved in the life of Heather Ward, but mounting frustration led to his resignation in April, 1974. He has since nursed in this country and in Canada. He was not an entirely satisfactory witness and we have not acted on his evidence unless there is corroboration for it from other sources.
1.9 The hospital into which the authors came had changed greatly since the early 1950's. Not only had many wards been modernised and furnished in contemporary style with attractive colours, but, also, in many wards care and treatment had moved with the times and were such that any patient could enter them with confidence. Credit is due to all those who helped to bring these improvements about.
1.10 Most progress, however, had taken place on the short stay wards at the expense of the long stay wards because it was on the short stay wards that the hard pressed Consultants and doctors had concentrated their efforts. It must be emphasised, however, that a significant number of long stay patients had been discharged into the community and that this represented a considerable effort by many staff without which conditions on the long stay wards would undoubtedly have been much worse than they were.
1.11 The Hospital Group Management Committee was served by a hardworking teat of executive officers in whom it had great confidence. Dr. A came to St. Augustine's as a Senior Registrar in 1948. From 10th August, 1955 until June, 1972, he was Medical Superintendent. Thereafter until August, 1975, he was Chairman of the Medical Executive Committee. Mr.B had been employed in health services since 1929. He first worked for the St. Augustine's Hospital Group in July, 1956, and from April, 1963, until his retirement on March 31st, 1974, he was its Secretary and Finance Officer. Until 1971 he held the appointment of Supplies Officer, and continued to use the title until he retired. Mr. C joined the staff of St. Augustine's in 1946 and spent the remainder of his working life there, apart from two years between 1950 and 1952 when he was seconded to the Kent and Canterbury Hospital in Canterbury. In 1959 he became Senior Assistant Chief Male Nurse, and in 1965 he was appointed deputy to the Matron on the female side. In 1968 he became deputy and in 1970 Acting Principal Nursing Officer pre Salmon. In December, 1971, he was appointed Chief Nursing Officer, In April, 1974, until his retirement on 31st July, 1975, he also took over the nursing administration in four other hospitals in the Psychiatric Nursing Division in the newly formed Health District 2 of the Canterbury and Thanet Health District,
1.12 This Triumvirate exercised great power within the hospital. Mr. C, however, inevitably saw himself in, and played, a subservient role to Dr. A and Mr. B. It was unfair to have called upon him to lead the nurses into their new post Salmon career structure. Likewise, Dr. A recognised that it was a mistake for him to have become Chairman of the Medical Executive Committee. Long established relationships are very difficult to change.
1.13 Many of the nursing and other staff in the hospital have long associations with it. For example one of Mr. C's sons and his wife work there. We came across a Senior Enrolled Nurse whose daughter and son-in-law also worked in the hospital. Three generations are all working in the laundry, and there are several husbands and wives working in the hospital. Promotion within the nursing structure has come almost exclusively from within the hospital and we noted that there are 56 members of the staff over 60 years of age, made up as follows:
age 60 - 64: 31
age 65 - 69: 20
age 70 plus: 5
1.14 All these factors, added to the isolation of the site, have produced a relatively inward looking hospital community with a warm camaraderie and deeply felt loyalties. One Charge Nurse who had been a miner likened St. Augustine's to "the close knit mining community where relationships are very strong".
1.15 In November, 1971, the report of the Hospital Advisory Service was received at St. Augustine's. As will appear later in our Report it did not receive the examination it deserved, and many of its recommendations had not been adequately put into effect by April, 1974.
1.16 In August, 1972, amid much moving of patients from ward to ward, the hospital was divided into three clinical areas, each of which served a different part of the catchment area (see the map Appendix 1). Each area formed a psychiatric division. Heads of Department meetings commenced in 1972, as recommended by the Hospital Advisory Service, but examination of the minutes reveals that they did not deal with policy matters, and much of the administrative work continued to be done in unminuted, informal meetings between the Group Secretary, the Chairman of the Medical Executive Committee and the Chief Nursing Officer.
1.17 During the period December 31st, 1970, to December 31st, 1974, the number of patients fell from 1,293 to 938. The largest reduction was 101 in the last of those years. In 1972 there were 433 nursing staff in post (60% of the Review Establishment). In 1974 the figure had risen to 456 (64.5% of a reduced Review Establishment).
1.18 In 1971 there was the equivalent of 16.75 full time medical staff in post (90.5% of the establishment) and in 1972, 16 (82.05% of an increased establishment). By 1974 there was the equivalent of 19 full time medical staff in post (95% of a further increased establishment). There were included in these figures for each of the four years 1971- 74, the equivalents of 4.7, 5.7, 6.7 and 7.7 full time Consultants in post. This accorded with the establishment in each year apart from 1972 when there was one Consultant short.
1.19 In April, 1974, Dr. Ankers and Mr. Weston sent copies of a pamphlet they had written and called "A Critique Regarding Policy" to the Secretary of State for Social Services, the Department of Health and Social Security, the Regional Health Authority, the Kent Area Health Authority, the Canterbury and Thanet Health District and the Hospital Advisory Service. They also distributed it widely within the Hospital. They did not send it to the Press.
1.20 The Critique is set out in Appendix 2. It is a well written, moderately expressed, but forceful criticism of the position of the long stay patients. We express our general conclusions on it at this stage. The authors were right when they said that the situation regarding policy was untenable, and one which should not be allowed to persist. They were right in their contention "that the management in this hospital exercise a policy by default with regard to the treatment of long stay patients in this hospital. They in fact acquiesce to a policy of laissez faire, which results in either the complete absence of policy in the lone-stay wards, or alternatively the formulation of policy by nursing staff without encouragement or guidance". The extent to which their conclusions were justified is best demonstrated in broad terms by reference to their following summary of their conclusions:
"1. There is lack of policy for treatment of long stay patients.
2. The majority of patients do not receive the benefits of individual treatment programmes.
3. There is an unacceptable standard of care for a great many patients.
4. On long-stay wards the care is primarily of a custodial nature.
5. Far too heavy a reliance is placed on chemotherapy, and medication is often not regularly reviewed.
6. It is our experience that often no guidelines are offered on the ward to nurses regarding a concerted psychotherapeutic approach to their work.
7. Nurses are not required to implement therapeutic activities on wards. If they take the initiative and do so, then it is up to them. But there is no obligation that they do so.
8. The therapeutic community does not exist for the majority of patients.
9. Totally unsuitable staff are permitted to occupy positions of responsibility on wards.
10. Mistreatment and malpractice occur in the hospital."
1.21 Conclusions 1, 2, 3, 4, 6, 7, 8 and 10 were, in our view, well founded. We are satisfied that medication was often not regularly reviewed, as alleged in conclusion 5, but we are not satisfied that the undoubted reliance on chemotherapy was far too heavy in other than isolated instances. Turning lastly to conclusion 9, we agree that nursing staff who were unsuitable without further training and counselling were permitted to occupy positions of responsibility on wards. With one exception, however, we do not consider that the word 'totally was justified.
1.22 Dr. Ankers and Mr. Weston stated in the Critique "The normal channels of criticism within the hospital have proved to be so ineffective and frustrating that we are obliged to try alternative pathways" We agree that their experience on the long stay wards justified them in coming to this conclusion. We trace in some detail at a later stage the steps that were taken by various authorities to deal with the Critique. Many were inept, and we can understand the authors' growing frustration which finally led to the production in February, 1975, of a further pamphlet "A Critique Regarding Policy, Part II - The Evidence", following which this Committee was set up to enquire into the allegations contained in both parts of the Critique and make recommendations. Part II is an angry, bitter, extravagantly written document containing 70 detailed allegations in support of the first part of the Critique. It is set out in Appendix 3. When they wrote the first part of the Critique Dr. Ankers and Mr. Weston had no intention of publishing a second part. They wished the authorities to concentrate on lack of policy, and not be diverted to the pursuit of people who had failed because of lack of policy and guidance. Even when they wrote the second part they gave no names. These were only provided when we said that. we would have great difficulty in conducting the enquiry without them.
1.23 As will be revealed, many of the allegations in Part II are fully proved, many others are proved in part. Few remain completely unproved. The Form of the Enquiry
1.24 Statements were taken from 168 witnesses. These were given to all legal representatives, 78 witnesses were called to give oral evidence. As to the remainder, we said that we would call any witness who any legal representative particularly wished to be called, and that we would treat the statements of those who remained uncalled as less cogent evidence which we might accept or reject. This we have done.
1.25 The hearing of the oral evidence and speeches at the Hospital lasted 23 days in two periods of three and two weeks separated by a gap of seven weeks. Evidence was heard in private, apart from the presence of Dr. Ankers, Mr. Weston, legal, representatives and some members of the District and Area staff. We are all satisfied that a private hearing is to be preferred to one in public. It proved possible to achieve a very good working relationship with all those present, and there was a real desire, shared by all to arrive at the right answer in a constructive, helpful way. This is very much more difficult in public. 'We have no doubt, however, that the Regional Health Authority's decision to publish our findings is right.
1.26 The majority, of our time was spent in a formal setting listening to examination and cross-examination of witnesses by legal representatives. This situation is very unfamiliar to hospital staff and some of them were obviously unsettled by the experience. It is, however, necessary, when a Committee such as ours has to endeavour to arrive at the truth about past events, and a right to cross examine witnesses is an essential safeguard for those criticised. We also made a number of visits to a variety of wards and departments and, as far as possible, attempted to correlate the evidence given verbally with the personal impressions we formed on the wards and elsewhere.
1.27 During our second week of hearing evidence it became clear that there was a gap in the management system of the hospital and that staff were well aware of this. We decided that there would be many advantages if we consulted with staff at different stages of our enquiry to see if agreement could be reached on the key areas of organisational difficulty within the hospital. We therefore arranged to hold a series of informal meetings, the general purpose of which was:
(a) to check our personal observations made. during visits to wards;
(b) to increase our understanding of the many organisational problems within the hospital;
(c) to seek the views of the staff as how best to make changes in the organisation, and to sound out any reactions and resistance to such changes; and
(d) to obtain, if possible, a commitment from a majority of key personnel to undertake the changes.
1.28 As a first step in the process of consultation we circulated through the hospital three short questions designed to stimulate thought and produce ideas. They are set out in Appendix 4.
1.29 At the first meeting in September we talked with representatives of the Confederation of Health Service Employees, the National Union of Public Employees and the Royal College of Nursing. There appeared to be substantial agreement about the difficulties under which the hospital was functioning and on some of the basic steps which would have to be taken to remedy the situation.
1.30 At our second meeting with the Chairman of the Medical Executive Committee, the Divisional Nursing Officer, the District Administrator and the Sector Administrator, we pointed out some problem areas in respect of which remedial action could commence without waiting for our Report. At this meeting members of our Committee with specialist knowledge outlined the kind of developments they had in mind in their particular spheres, and their suggestions were followed by a general exchange of views.
1.31 On our return in November we again met the representatives Of the Confederation of Health Service Employees, the National Union of Public Employees and the Royal College of Nursing and they then put forward views on the need to develop a personnel function within the hospital and to increase the opportunity for in-service training, particularly for middle and senior grades of nursing staff. They emphasised that those grades received insufficient training related to the needs of the hospital, and we discussed various ways in which these needs might be identified.
1.32 The questions which we circulated in September produced helpful and interesting replies from groups and individuals, and in November at our final informal meeting with senior hospital staff and trade union and Royal College of Nursing representatives, we discussed and endeavoured to refine and develop some of those contributions. This was a most successful meeting during which the discussion centred not on problem areas, but on what machinery was needed to bring about improvements in the organisation of the hospital. The general views expressed were that this would best be achieved by setting up a hospital multi-disciplinary Team at St. Augustine's to monitor the level of service to patients and to initiate changes where necessary, instead of simply waiting for problems to be presented to it by the different disciplines or teams. It was agreed that the composition and terms of reference of such a Team would require further careful consideration.
1.33 This attempt to describe briefly the series of discussions held between the Committee and the staff does not cover the many informal discussions which took place between individual members of the Committee and members of staff and patients. Neither does it describe the many meetings held by staff themselves during the Enquiry to discuss the questions set out in Appendix 4.
1.34 In the remainder of this Report we propose to examine looking in turn at the wards which have been most criticised by the authors and other witnesses. Where possible we follow the order in which the authors and other witnesses served in them, but there is inevitably some overlapping. We then seek to extract from these findings some general conclusions and recommendations about the various services which should all contribute to the care and wellbeing of all patients, and we suggest some modifications in the management structure which we hope and believe will enable decisions to be more readily taken.
1.35 We wish to emphasise again at this stage that the Critique's attack was on the long stay wards. In many areas of the hospital there was admirable work being carried on. Even in the unsatisfactory areas, all those whose performance we criticise were, with very few exceptions, doing their best. Those working in the wards were struggling in the face of overcrowding, understaffing and inadequate guidance. Many of the nurses who were given important administrative roles received inadequate preparation and no counselling and the Consultants had very little time to devote to their long stay patients. A true partnership in care between the medical and other services was difficult to achieve because everybody believed, or acted on the basis, that there are some aspects of care which are solely the doctor’s responsibility, but were without any clear understanding of where the boundary lay. It is not surprising that many of those working in the hospital were unable to give of their best.
1.36 St. Augustine's is rich in potential, particularly amongst the new generation of nurses some of whom are of outstanding ability. It is our aim to produce a framework of management that will release this potential. Our proposals require the expenditure of very little, if any, extra money, but they can, and we believe, will, make St. Augustine's a very stimulating place in which to work, and will improve still further the services to all patients.
09 February 2025
