2.1 Mr. Weston worked in this ward as a Student Nurse for three Months at the end of 1970 and the beginning of 1971. It was then a locked refractory ward containing about 46 disturbed male patients. In August, 1972, it became a Male long stay Ward for the same number of patients.
2.2 We are satisfied that the attitudes and practices of many of the nurses on this ward between 1970 and 1974 were out of date and unacceptable. Although some patients Went out to Occupational and industrial therapy and a nurse came in to try and occupy the remaining patients on two afternoons a week, there were no multidisciplinary, or even nurses', meetings to discuss the progress or treatment of patients, and there was no real programme to keep the patients interested. In late 1972 a new Principal Nursing Officer found that the ward "was in a state of apathy and needed to be pushed". The ward had a strict unbending routine and patients Were herded around in groups rather than treated at individuals. Moreover, as we shall relate, patients were handled with unnecessary force and were subjected to uncouth indignities which denied them self respect. We do not think, however, that any of the staff who indulged in this behaviour intended to be cruel. They were doing their best in their own out of date ways, and, strangely as some will think, formed a rapport of some warmth' with the patients.
2.3 One young Charge Nurse who gave evidence before us contrasted Box Ward at that time with Holly, a long stay ward, in which he had found a team of nurses working together effectively in a relaxed, informal atmosphere to bring out the individual personality of each patient and combat institutionalisation. This contrast between Box and Holly is an excellent example of what the authors of the Critique Part I were attacking when they said "The management in this hospital exercise a policy by default with regard to the treatment of long stay patients ... If, as a nurse you offer patients custodial care, then that is acceptable. If, however, you wish to involve yourself in doing more for the patients in a therapeutic sense ... then it is up to you ... The sad part is that if you don't do it there is no policy implemented that says you should, and no-one Will tell you that you should".
2.4 Mr. D, S.E.N. spent the years from 1965 to 1974 on Box Ward. In many ways he personified the ward. Although he was unable to give evidence to us because of ill health, we were able to build up a good picture of him from several witnesses who spoke of both the good and the not so good. "He was firm, very firm" with the patients "and very physical, but, he was like this with all the patients and they knew where they stood With him". His firmness included regular and frequent slaps on the face, 'cuffing' and other indignities.
2.5 We have no doubt that Mr. D kept order very effectively by these methods and that they were known to his superiors. He and another nurse, who we find-used excessive force on another ward, were regularly used to restore order on wards other than their own where patients were causing trouble. His methods of maintaining order on Box were known and spoken of by staff on the ward and many off it. A Charge Nurse on the other shift made it plain by his conduct and demeanour that he did not endorse such behaviour, but apparently took his disapproval no further. There was evidence, which we accepted, of a nurse jocularly catching hold of a patient's throat and subjecting him to other physical indignities in the presence of the Nursing Officer when the patient had failed to give his name to a prospective member of the staff. Everybody treated it as a great joke.
2.6 A young Charge Nurse put this behaviour firmly in perspective. "I would like to strongly say that people like D and E are essentially to my knowledge, kind people. They are not that malicious. D is a well known character in the hospital, he has a hard attitude, but the thing I question out of all this is that people knew about his attitude with work, just as people know about my attitude but at no time did anyone think to take him aside and offer him any guidance, and I do not think you can blame D and people like him for that. I would like to strongly reiterate that somewhere along the line there should have been some positive guidance available to these people. That was really the point I wanted to make." Another young nurse made the same point. We agree.
2.7 Inevitably in this setting and with inadequate guidance there were other staff who used similar methods. Mr. F a Nursing Assistant on Box Ward during 1972 and 1973, slapped and cuffed patients in much the same way as Mr. D but less predictably. Not all patients were treated by him in this way and sometimes there would be no apparent reason for his action. If patients were awkward when being shaved he would hold them roughly by the nose. His behaviour would on occasions produce angry retaliation from some patients, and other staff would then have to go to his assistance.
2.8 Mr. G a Student Nurse, also slapped patients on Box Ward. We will have to refer to him again later in this Report.
2.9 We now turn to consider Incidents 22, 37 and 63 of Part II of the Critique.
Incident 22
2.10 This is substantially accurate. The patient is a large, very powerful man six feet three inches tall and weighing about 16 stone. He is subject to sudden outbursts of great violence. Mr. 117 the Charge Nurse, could usually tell if an outburst was coming, and would then seek to send him to a side room and there give him a tranquillising injection. If he failed to do as he was told, or had already been violent, Mr. H would send to other wards for reinforcements and then overpower him with five or six helpers and inject him. He said that this reduced the harm to the patient and the danger to the nurses. This was a crude but effective way of dealing with repeated potentially dangerous situations. It is difficult to see what else could have been done in that ward at that time.
Incident 37
2.11 Paragraph 1: This again is substantially accurate. Part of the routine was that patients had to wash and shave each morning. Those who refused or were unable so to do had it done for them.
2.12 Paragraph 2: We find that the patient had been transferred to Box in a very agitated condition. After the meal he was walking up and down with a cigarette pestering the other patients, who were drinking tea, for a light. Fearing a disturbance Mr. H decided to take him to a side room to let him cool down. The patient was unwilling to go to the side room so Mr. H took him by the arm and used such force as was necessary. We do not find that he flung him to the ground. Immediately following this Mr. Weston complained to Mr. H that he bullied the patients. This upset Mr. H who complained about his attitude to his Senior Nursing Officer and Dr. I. Dr. I saw Mr. Weston and tried to explain that he was misinterpreting events. Mr. H is in our view a kindly man although a firm disciplinarian, but there is evidence which we accept from another witness that on occasions round about this time he "clipped patients round the ear in a fairly jocular manner", and that they tended to treat him "much as a servile dog would react to a fairly strict master".
2.13 Paragraph 3: This again is substantially accurate. Mr. H did believe that a walk was good for the patients, but he was not resistant to all suggestions. It was he who at Mr. Weston's suggestion got paint and materials so that Mr. Weston could occupy the patients with painting. It was Mr. Weston who only persevered for two days.
Incident 63
2.14 We accept that patients were commonly slapped and treated with unnecessary roughness.
2.15 On an occasion early in 1972 a Student Nurse heard a sound consistent with a blow from a stick and a commotion in the bathroom area. He went in and found a small elderly patient lying on the floor in apparent pain with Mr. F standing beside him with a grin on his face and a broomstick in his hand. The Student Nurse subsequently examined the patient and found bruising on both shins. He concluded that Mr. F had struck this patient, and told us that he attempted to protest to Mr. F who ignored him and turned away. Mr. F in evidence denied any knowledge of either the incident or the protest by the student nurse. We accepted the student nurse’s evidence, but bearing in mind that he did not see any blow and that the patient had in the past rolled on the floor crying as if in pain, we are unable to be sure as to what happened save that Mr. F applied undue force to the patient. The Student Nurse consulted his Royal College of Nursing steward who advised him that there was nothing he could do as he was the only witness. The steward, however, 'had a word in the right quarter' which did not appear to have any result. This same student nurse explained how difficult it was to complain because the nursing officer had previously been a Charge Nurse on the ward and was a great friend of one of the then Charge Nurses. It appears to have been widely believed throughout the hospital that it was no good making a complaint unless there was more than one witness,
2.16 The same witness told us of an occasion about the same time when a patient, who had been confined to the ward in dressing gown order, escaped and wandered round the hospital. When he was brought back Mr. D 'clipped' him about the ear and put him roughly in a side room where he remained for two days as punishment. We find that this occurred and that there were some other instances of side rooms being used for punishment at this time.
2.17 We heard from another Student Nurse, whose evidence we accepted, of unnecessary force by Mr. D in August, 1973. The Student Nurse brought back to the ward a patient who had been found wandering in the grounds in dressing gown order. Mr. D thanked the Student Nurse and then roughly handled the patient. The Student Nurse asked another to be a witness as to what had happened, but while agreeing that he had seen the assault, he expressed the strong wish to stay well out of it. The Student Nurse then consulted his Tutor who advised him to speak to Mr. D. When he did so Mr. D did not deny what had occurred and told him that he admired him for speaking to him about it. He assured him that he would not do any patient any harm, and we accept that he meant it.
Box Ward at the time of the Enquiry
2.18 During 1974 the position on Box steadily improved. The patients had fallen to 38 by the end of the year and to 33 by May of 1975. There were also changes in the Charge Nurses. We believe that with their guidance Mr. D until his absence through ill health, was using less vigorous and more acceptable ways to control violent patients. As we live already said, he could and should have been helped in this way far earlier. Instead it must have seemed to him that his methods were being endorsed.
2.19 In the Autumn of 1975 there were regular multidisciplinary meetings at which the patients were reviewed in turn. There were effective changeover meetings and the standard of student teaching was good. The patients were divided into three groups according to their ability, and each group received a different approach. Those patients with the greatest difficulties in normal activities were taught, for example, how to wash themselves and how to eat properly. There were regular trips out of the hospital to the seaside, public houses and so on. Some patients went to the Industrial Therapy Unit and others were taught painting. Unfortunately there was still no Occupational Therapist visiting the ward, and the nursing staff were doing their best to fill the gap.
2.20 In spite of all these improvements, real problems remained. The age range was between 24 and over 70. There were four patients who use violence with varying degrees Of frequency both against other patients and members of the staff, and, there were another ten patients who have been violent in the past. The patient who was discussed in Incident 22 was still on the ward. He was the most dangerous patient then in the hospital and at times behaved in a most aggressive manner to other patients and staff. This presented a constant problem in the ward.
2.21 In May, 1975, an episode occurred between one of the Charge Nurses and this patient which caused some of the Student Nurses considerable concern. The patient had been very disturbed for ten days previously and on the day in question had been refusing his medication. The Charge Nurse was sent for and decided to have a final attempt at persuasion before giving an injection under physical restraint. The patient attacked him as he knelt beside him, but the other staff who were waiting to help if forceable administration of the injection became necessary did not come to his aid sufficiently quickly, probably because his instructions to them had not been sufficiently clear. We are satisfied that he was with good reason a very frightened man and that he used all his strength to overcome the patient. We have no doubt some blows were struck. This reflex reaction in a moment of peril explains not only the rumours which the Charge Nurse told us subsequently circulated in the hospital about him, but also the fact that one of the Student Nurses felt that he must refer the matter to us. We are satisfied that the Charge Nurse used what would have appeared to onlookers to be excessive force in a moment of great peril to himself. We do not think that he can be criticised in reacting as he did.
2.22 It is difficult to see how this incident could have been avoided, and it demonstrates the problems caused by disturbed patients when there are insufficient experienced staff. If the Charge Nurse had instructed his inexperienced staff more fully as to what might occur and how they should react it is possible that the patient would have been brought under control earlier without the struggle which some of those present clearly found distasteful. We would add that there was only one member of staff on duty at night and that this did not seem sufficient, even though this patient was said to sleep very soundly.
2.23 Even with this patient, however, the Charge Nurse felt that they were making some progress. He took part in group therapy on the ward, and it had been found that a shampoo helped to calm him when he was disturbed. He spoke in a somewhat disjointed manner to a Member of this Committee of Enquiry at the end of November, 1975, and said that he had been home to his parents once a week in the recent past. The nursing staff confirmed that this was so, but felt that he remained unpredictable. It was inevitable that they had same fear of him.
2.24 The ward had been upgraded and had a bright, pleasant appearance. On the occasion of our visits the atmosphere was quiet and everything seemed orderly.
2.25 This ward has emerged from the doldrums. Staff need to continue to be selected with care and to be increased in number when possible. Patients should be reduced to 25. Instruction and regular counselling of staff on how to deal with disturbed and violent patients is essential.
09 February 2025
