2.40 The ward's condition before the 1972 reorganisation was described to us by a witness whose evidence we accepted. "This ward", he said "contained approximately 60 elderly, demented and confused patients. It was locked, and I was shocked at the standard of care given to the patients. In my opinion there was a good nursing team on this ward, but the team were battling against impossible odds, e.g. Often you were left to give these patients total care with sometimes as few as three nurses. This situation affected the morale of the nursing staff such as it was." He added that there were no multidisciplinary or ward meetings at that time.
Incident 35
2.41 We accept that the first paragraph is substantially correct, although extravagantly written. As to the second paragraph, see Incident 64.
Incident 61
2.42 We were satisfied that some of the nurses were in the habit of teasing a blind patient, and that this annoyed and upset him. Another member of the staff on one occasion reproved an S.E.N. he had seen behaving this way. The S.E.N. apologised to the patient and did not behave in this way again. To this extent only we accept the allegations in this incident.
Incident 64
2.43 The regular night nurse on this ward had the reputation of treating patients rather roughly. There was an occasion when the same member of the staff, referred to in our Report on Incident 61, saw the night nurse push an old patient off his bed because he had urinated on it. The member of the staff protested vigorously to the night nurse and reported the behaviour to the day Charge Nurse On the next shift. The Charge Nurse spoke to the night nurse who subsequently modified his behaviour.
2.44 To this extent only we accept the allegations in this incident.
Magnolia at the time of the Enquiry
2.45 In 1972 Magnolia became a long stay male psychogeriatric ward of 54 patients. By the Autumn of 1975 the numbers had been reduced to 38.
2.46 At that time the physical condition of the ward was poor and redecoration was necessary. There were no curtains between beds, but there were four portable screens. If these were used for the routine tasks of getting patients up and putting them to bed the staff felt that with their limited numberstoo much time was taken up dragging the screens round. More than four portable screens were necessary on occasions but the Charge Nurses had been told that there was no chance of getting them. There were two baths side by side with no division or curtaining and the lavatories had stable type doors. The dark plastic flooring material was very difficult to keep clean with incontinent patients.
2.47 This ward provides good examples of the frustrations of the requisitioning system which we will consider in some detail later in this report. The kitchen had a dirty old cupboard which, although quite unsuitable, was used for storing bread and jam and some other provisions. Repeated efforts were made by the Charge Nurses, Nursing Officer and Ward Medical Officer to get two Formica cupboards in its place. After 18 months of being told that not even one cupboard could. be supplied, two were provided.
2.48 Another example is provided by the attempts to get new commodes. When a new Charge Nurse arrived on the ward in February, 1975, he found that they were having to use three old and rusty commodes which had been condemned for over a year. He joined in the attempts to get replacements, but was told that the Unit Administrator had marked the requisition 'noted and deferred'. The help of the Ward Medical Officer was again enlisted and after a great deal of persistent nagging the commodes were eventually replaced more than 18 months after they had been condemned. The requisitioning system had no effective means of identifying priorities, and far too often those who sent in requisitions received no explanation for the failure to supply the items except that the requisition had been 'noted and deferred'. These words came to be treated with derision throughout the hospital.
2.49 On our visits to the ward we saw that the television area was carpeted and separated from the rest of the ward by some dividing units, This had been achieved in spite, and not because, of the system. When requisitions for the carpeting and dividing units had been 'noted and deferred' one of the Charge Nurses had then successfully asked the W.R.V.S. for help. He was, however, reproved by his Senior Nursing Officer for this display of initiative.
2.50 We found a warm, friendly and lively atmosphere. The patients appeared to have pride in themselves and were well dressed. On one unannounced visit a patient was busy preparing: food in the kitchen and another very old and unsteady man was carefully laying the tables. Another patient came up and told us that the Charge Nurse had gone to get the minibus key as a number of them were going out to a pub that evening. The staff assist patients in ordering new clothes (many have two good suits), and wash many of the clothes themselves in a ward washing machine because the laundry spoils many articles of personal clothing.
2.51 This ward in the autumn of 1975 was an example of what can be achieved by enterprising nursing staff, for there were no multidisciplinary meetings to assist them. The Charge Nurse who joined the ward in February 1975, told us that by the end of September he had never seen a Consultant on the ward, although he had heard from the other Charge Nurse that a locum Consultant had recently been in and said that he would do his best to visit Magnolia on the fourth Friday in every month to discuss problems. The Charge Nurse told us that he had spoken to the Ward Medical Officer, for whom he has considerable respect, about his attendance and that of Consultants at ward meetings, and had been told by the Ward Medical Officer that the Consultants had too little time and that he felt it was sufficient if the Charge Nurse cted as his link with the other ward staff. There were no individual treatment programmes for any of the patients in the sense of a multidisciplinary team getting together and discussing a patient and then deciding what his total needs are and how far they can be provided in the hospital. The nursing staff, however, were doing their best to fill this gap assisted by an unqualified occupational therapy helper who started work on this ward in the Spring of 1975 for 15 hours a week, and whose contribution to the life of the ward was felt to be considerable.
2.52 The Charge Nurse had also attempted to enlist the help of his Senior Nursing Officer in obtaining more medical participation, but had received the same answer — lack of time. The Charge Nurse told us that he did not feel that the Consultant's presence Was essential at all multidisciplinary meetings on that ward, but that if the Ward Medical Officer could devote more time "things would be better. To be frank? I probably have not pushed it because I did not want to mar my own professional relationships with him". The Ward Consultants were Dr. Q (until his retirement on 31st July 1975) and Dr. R.
2.53 Much more could be achieved on this ward if true multidisciplinary team work could commence. The staff feel, with some justification, that the contrast between the decoration, furnishing and facilities on the acute admission wards and the long stay wards is too great. The allocation of the admittedly very limited resources should in our view be adjusted in order to reduce this disparity.
09 February 2025
