2.71 Since August, 1972, Heather, has been a long and medium stay ambulant male ward. During the intervening years its numbers have only fallen very slightly from 54 to 48. Ages ranged from the early 20's to over 70. Dr. Ankers worked on the ward as a Nursing Assistant from August 15th, 1972 until he was moved to Hawthorn Ward on July 7th, 1974. Mr. Weston worked there from August 5th, 1973, until his resignation from the hospital on April 30th, 1974. During the first three to four months he was awaiting the outcome of his examination. From December, or thereabouts, onwards he was a Staff Nurse.
2.72 The difficulties immediately following the reorganisation were great. Mr. U, one of the two Charge Nurses at that time, said that many of the patients "had become very institutionalised. When they first came up to Heather Ward half of them would not speak, and half of them would do nothing for themselves. They were totally dependent on nurses to do everything for them."
2.73 We shall subsequently point out that the programming of the August, 1972, reorganisation seems to have had far too little thought. The same Charge Nurse told us what happened in Heather. "Before reorganisation it was a long stay female ward. When Heather ward patients inherited it they took over an ill—equipped ward. There were not enough knives, forks, spoons, plates, cups and saucers. The bathroom was full of brick rubble. There were no facilities for bathing the patients. No provision had been made for patients clothes or other basic requirements. For a whole month 54 Heather Ward patients had only the clothes in which they stood. There was no change of underwear, shirts, jackets, nothing. When you tried to do something about it, you were told that you were grumbling." He explained that female wards are equipped with female requirements. "On reorganisation the majority of the females were taken over to Areas 1 and 3 and they took their own basic requirements with them." The male wards which remained male wards "retained all their basic requirements like underwear, shirts, vests, pants etc. The female wards which were handed over to the males had nothing. They were just blocks with nothing in them."
2.74 At all times since August, 1972, Heather has presented problems of management because of the mix of patients, many of whom were transferred from Box, the locked refractory ward, on reorganisation. Some were informal patients, some were admitted under the Mental Health Act 1959. Dr. Ankers in our view described it accurately when he said:— "It was regarded as a disturbed ward, and at times it was very disturbed. Patients on that ward had an extreme range of diagnoses. They were regarded as chronic schizophrenic, catatonic, suicidal, manic depressive and suffering from anxiety states. There were sub—normal people and old people who had suffered mental illness in the past."
2.75 The position had not changed by the end of 1973. A Charge Nurse, Mr. V, who commenced work on the ward at that time said that "When other wards, in Area 2 had a difficult problem they always sent them to Heather Ward, so we had more problems... It was known to be a disturbed ward in the hospital." Dr. W confirmed Mr. V's description of Heather as a disturbed ward. "It is", he said "the only long term disturbed ward for 'male patients in Area 2."
2.76 The numbers of Staff on duty varied. Between 7.00 a.m. and 6.30 p.m. they usually numbered three or four, but occasionally they would rise to five or sink to two. Between 6.30 p.m. and 9.00 p.m. there were usually two, and during the night there was only one.
2.77 Throughout the period since reorganisation there has been very little help given by trained occupational therapists or aides. Even in the summer of 1975 there was only attendance by an occupational therapy aide on one afternoon each week. In the Summer of 1973 Mr. U and Dr. Ankers started to organise minibus outings for patients in their free time. Until then such outings had been few and far between. Both Dr. Ankers and Mr. U had been aware since August, 1972, of the need to do more for the patients, but they had made very little progress because Mr. U felt that innovations, although desirable, were potentially dangerous unless recommended by doctors, and the Consultants failed to devote sufficient time to the ward to initiate such changes. Moreover, the other shift was unsympathetic to change, and Dr. Ankers during his first year on Heather was still only finding his feet. Elementary ward meetings of staff and patients began in late 1972 after encouragement from Mr. U and Dr. Ankers, and formal staff meetings attended by the Senior Nursing Officer and the Nursing Officer began in February, 1973, but there were no multidisciplinary meetings until Dr. X began to hold them very irregularly at the end of December, 1973. Such meetings became regular following the publication of the first part of the Critique. Dr. W held no multidisciplinary meetings until July, 1974. Dr. Y had held no such meetings by the Autumn of 1975.
2.78 Although changeover meetings for all staff were started, they were not properly used and were mainly the occasion for a cup of tea. During the first half of 1973 Dr. Ankers raised at meetings the need for more outings and greater participation by residents in the life of the ward. He also raised the question of the differing approach by the two shifts and the suitability of Mrs. Z (see below). Dr. Ankers, however, was only a Nursing Assistant and his protests were of noavail, although he felt that Mr. AZ, the other Charge Nurse, became less opposed to change.
2.79 The arrival of Mr. Weston after he had completed his training added strength to the reform movement, and Mr. V, who took over from Mr. U in December, 1973, was more ready to adopt the suggestions of the younger staff than the more cautious though sympathetic Mr. U. had been.
2.80 During the next nine months, Mr. Weston, Dr. Ankers and other junior members of the staff endeavoured to plan and put in effect improvements in the ward. Many of them were only attempted after the arrival of Mr. V. We list them briefly, not chronologically nor in order of importance.
(i) Patients were encouraged to make their own beds and do other odd jobs on the ward. Although the older school of thought disapproved, they did not seek to prevent this experiment. Within two or three weeks 95% of the patients were regularly making their own beds.
(ii) Monthly ward 'socials' were started.
(iii) The number of outings was increased both for groups and individuals. The ward staff negotiated a special reduced rate of 5p per Patient at a Canterbury cinema. Because efforts to get an allocation of hospital funds for outings failed, staff helped to pay for them with their own money and assisted the patients to save some of their pocket money which was used both for the outings and for the purchase of clothes. As a necessary part of this scheme the pocket money paid to many of the patients was increased.
(iv) Chairs in the ward, instead of being lined against the walls, were put in groups of three or four to create a more informal atmosphere.
(v) Much old clothing was thrown away and replaced, in part by the hospital, and in part by what the patients were able to afford. Because ties were in short supply in the hospital, Dr. Ankers bought 30 at a jumble sale in Chartham.
(vi) Pressure was put on the Consultants and other doctors to come and speak to the nurses about problem patients (see for example lower down under Incidents 27 and 41) and to review medication more frequently. As a result of this pressure Dr. X began his irregular multidisciplinary meetings at the end of 1973, but these had not resulted in any individual treatment programmes for patients before the circulation of the first part of the Critique.
(vii) A ward notice board was acquired on which was exhibited information about outings, each patient's pocket money entitlement, and what that amounted to in terms of cigarettes or sweets per day.
(viii) A ward routine was written down and posted on the board together with a staff duties delegation system. This delegation system set out six different groups of tasks. Three of the groups covered, all the routine work. The other groups were intended to cover therapeutic activities which had been so notably absent in the past. In addition there was a teaching programme and list of suggested projects.
2.81 In spite of these initiatives by this group of nurses the shift which was headed by Mr. AZ and Mrs. Z followed its old method of working, and as a result the life of the patients was strangely variable. These 'old school' nurses undoubtedly felt threatened by these new ideas, but, so far as we could ascertain, received no counselling or worthwhile advice from their superiors on how they should react or could adapt to them. In this situation confusion and unhappiness were inevitable. Their opposition was manifested not so much by open disagreement as by indifference. There were comments about "These young nurses who are only interested in going out” and difficulties were placed in the way of arranging outings. The systems on the notice board were not followed when they were on duty, and after Mr. Weston left most were removed. On the few occasions when Mrs. Z was required to work under Mr. Weston after he had become a Staff Nurse she declined to carry out any work under the delegation system if it was not her normal work.
2.82 Progress, however, was made and we accept Mr. Weston's description of this. "The patients were starting to open their eyes, to see what they hadn't seen for years, and they started to enjoy these outings and to ask if anything was arranged for that day. Patients who never spoke or responded started to smile and answer questions. Other patients we encouraged to go out on their own and they became more confident of themselves. If we arrived back from an outing late and missed the last meal we would encourage everyone to muck in and prepare their own meal; a couple buttering bread, someone' setting tables, someone frying up eggs or making omelettes. The atmosphere on the ward changed dramatically during such events. Patients were happier, more relaxed, showed initiative and enthusiasm, and talked of future possibilities." As will be seen, however, some mistakes were also made, but this is not surprising when the initiative was coming from the most junior nurses, with no effective guidance or support from their superiors, and very little from the medical staff. We will try to set out shortly why this was so.
2.83 With one exception there seems to have been no understanding of the duty that lies on nursing staff to formulate and implement ward policies. Although this should be carried out jointly with the other disciplines, failure by the other disciplines to participate does not relieve the nursing staff of their duty to do their best. Although the Senior Nursing Officer and Nursing Officer expressed approval of the staff initiatives they did nothing to see that the 'old school nurses' followed this lead. We believe that all, including the reformers, believed that the duty to initiate such changes really lay with the Consultants. The reformers, however, were not prepared to wait, and the Senior Nursing Officer and Nursing Officer, while not prepared to condemn the initiative, exerted no pressure on the others to follow. It was truly a laissez faire management without any real leadership. Miss BY, the Senior Nursing Officer, while recognising that she had a leadership role, found it very difficult to explain her understanding of it. "I feel very strongly", she said, "that the Charge Nurse is responsible for the ward. He is in control of the ward. The Nursing Officer supports him. If there were problems and the Nursing Officer could not cope he would come to me and I would do my best to cope with them." She continued "I see myself as the co—ordinator of my Area... I see leadership as delegation and communication and cooperation."
2.84 This interpretation of leadership has too often resulted in a failure to grasp occasions that should have been grasped, a failure to see that decisions that required taking were taken, and in a failure to lead forward those below for fear of impinging on their responsibility and so stifling their initiative. It is very difficult to get the balance right and We are satisfied that most of the middle management nurses at St. Augustine's need further help and continuing guidance in this field.
2.85 The one exception we have already mentioned was Mr. CX, a new Principal Nursing Officer from outside the hospital. He firmly believed in initiatives coming from ward level. He attended a meeting on Heather Ward in January, 1974, and was asked by Mr. Weston what the ward policy was. He replied, by a question "Don't you know?" and proceeded to explain that if Patients were stagnating the responsibility for this lay on the nursing staff. This was resented by some, largely We believe, because the staff were still imbued With the concept that the Consultants were responsible for giving a lead to the formulation of ward policies. Mr. CX felt that the clashes between young and old were part of the inevitable growing pains of hospitals like St. Augustine's. He had a high regard for Miss BY and his description of the leadership role of a Senior Nursing Officer and the manner in which she fulfilled it goes a long way to explain her failure in Heather Ward at this time, The Senior Nursing Officer leads "by setting an example, by being able to be humble, by being able to be wrong. This is one aspect. There are many aspects to leadership. I think: Miss BY led by gentle persuasion, guidance and counselling. She is this sort of lady, and I think she achieved quite a bit." He went on to say "I think she got remarkable results in many areas of the hospital." In our view Miss BY's difficulty was that she lacked experience and guidance in leading her staff to fill the gap left unfilled by the medical staff: indeed she and others had grown up, and still, deep within, believed in a system under which it was the prerogative of the doctors to order all matters concerning the life of patients in the ward.
2.86 We believe that the Consultants, perpetuated this belief. Dr. A was asked to comment on the criticism that the decision as to the kind of care to be given to patients was left to the staff on the ward. He replied "I will accept that in a way in some areas it must have been so, but I have no doubt at all in my own mind that the responsibility for altering that state of affairs rests with the individual Consultant. That is how I see my job and I regard it as my responsibility for my patients." Dr. A had no patients in Heather, but he had been Medical Superintendent and was Chairman of the Medical Executive Committee from 1972 until 1975. We are satisfied that that view was supported by the other medical staff as well as the nursing and administrative staff. If the Consultants were too busy to carry out this function in the long stay wards, no—one else apart from Mr. CX, considered that anybody else had a duty to fill the gap.
2.87 We consider the Incidents in the order that in our view will throw the most light on the difficulties of the ward.
09 February 2025
