Incident 36
2.88 Mrs. Z worked at St. Augustine's for 15 years, first as Nursing Assistant and then, having qualified by length of service, as a State Enrolled Nurse. When she Was first employed the Hospital was divided into male and female sides, and she worked on the male side. When that division was abolished she preferred to continue working with male patients. For the three—and-a-half years before the 1972 reorganisation she worked on Ash Ward and then after on Heather until June, 1975. She then worked for a short time on Myrtle, a female long stay ward, and finally, after a spell of night duty, she resigned in the Autumn of 1975 because of poor health.
2.89 We are satisfied that Mrs. Z was totally unsuitable to work as a nurse, in the context of modern psychiatric medicine. Her knowledge of basic nursing skills was poor and she was incompetent in handling medication. We are not satisfied that she deliberately gave the patient referred to in this incident more than the prescribed dose. The prescription left it the nurse’s discretion as to whether to give 100mg or 200mg of Largactil three times a day, but she interpreted this discretion too liberally, and her dispensing methods were primitive. She was intolerant of junior staff: and treated the patients as children. Although she formed a rapport with a few patients, particularly those who had moved with her from Ash, she treated the majority with a harshness that caused real concern to almost every young nurse who worked on the ward. She did not distribute all the patients supplies such as jam and butter, but kept back a percentage "against a rainy day". Where the undistributed supplies went we were unable to discover. It is not suggested that Mrs. Z removed them from the ward. When serving the lunch or supper she gave small helpings, and frequently refused second helpings, although this meant that food was put in the dustbin. She did administrative work rather than help with getting the patients up or putting them to bed or washing or shaving them because she felt that such work was unsuitable for a woman in a male ward: yet she insisted for as Long as she could in working on a male ward. She had an undue influence on her Charge Nurse and obstructed progress.
2.90 It is unnecessary for us to go further into the other allegations contained in this Incident. Although what we have said amounts to formidable criticism, it must always be remembered that Mrs. Z had no help in bringing her ideas up to date, and that she was left on the ward long after She should have been moved, not only for the good of the patients and of other staff, but also of herself. Her superiors, we are satisfied, knew of her defects. They realised that she represented the older generation and out, of date systems, and they knew that she was failing to cope with change, but they themselves seemed incapable of dealing with the situation, and so failed to provide the kind of support which she so desperately needed.
2.91 A young nurse of considerable insight, who qualified in 1974, saw her predicament as follows: "I think Mrs. Z was a frightened person on a very difficult Ward which was potentially quite dangerous at times. I think it was wrong — it crossed my mind while I was working there, not just in retrospect — that such a person should be left in control of a ward with approaching 50 long stay patients. The general impression was that she was unable to deal with any difficulties, and difficulties arose daily. That is my general impression." When asked about her manner he gave a reply which was repeated in different terms by others: "I think her manner Was highly critical and very institutionalised. I can remember one conversation that I had with her when I tried to tackle her On a matter. She seemed to have formed the impression that the main problem with the long stay patients was laziness rather than the specific mental conditions which kept them in this hospital."
2.92 As we have already said, Mr. AZ, the Charge Nurse on Mrs. Z's shift, was unduly influenced by her. He comes from overseas and has some speech difficulty which prevents fluent and lucid communication. Mr. CX fairly said of him "He had years Of knowledge and wisdom in looking after patients. This has to be assessed against his lack of professional knowledge. He May not have been highly professional or always had a crisp white coat… but he was not afraid to throw his arms round a patient's shoulder, give him a hug and say "Do not worry, Tommy, Mother will come tomorrow" or something like that, depending on the psychological need of the patient." In our view he was unable to come to terms with the new ideas coming into the ward and was content that the ward should remain as it was. Although he personally became more sympathetic with the aims and methods of the other shift after discussions at ward meetings, he did not try to influence Mrs. Z and left her to lead in many matters, such as the allocation of staff duties.
2.93 We now turn to consider how much of this information reached the Nursing Officer and Senior Nursing Officer. Mr. DW, the Nursing Officer, agreed that he had complaints about Mrs. Z from both the Charge Nurses who had served on the other shift. That from Mr. U had been rather vague, but it had been followed by complaints by Dr. Ankers and Mr. Weston to Miss BY, which we deal with under Incident 70. Their complaints, which covered most of the allegations in Incident 36, were followed by complaints from Mr. V who had succeeded Mr. U as a Charge Nurse. Mr. V's main allegation was that Mrs. Z controlled her Charge Nurse, but it was also clear that Mr. V and Mrs. Z did not get on together and that there were differences of approach between the two shifts. Mr. DW was also repeatedly approached by a Student Nurse, now a Charge Nurse, who told-him of Mrs. Z's incompetence and harshness.
2.94 Mr. DW told us that he found himself out of his depth in the problems of Heather Ward. He was subsequently relieved of any responsibility for any ward in July, 1974, and after a short spell as a Duty Nursing Officer he was transferred to night duty. He told us, and we accept, that he suggested to Miss BY that Mrs. Z should be moved to another ward, but that Miss BY had told him that whatever ward Mrs. Z had worked on in the past the same kind of difficulty had arisen. He formed the view that Miss BY "felt that there was not much point in moving her to another spot where there might be some other trouble."
2.95 Mr. DW also raised this matter with Mr. CX, the Principal Nursing Officer, who after discussion with Miss BY, accepted her judgment that Mrs. Z, although a difficult woman, was a good nurse and should be left on Heather Ward.
Incident 70
2.96 This relates to a complaint made by Dr. Ankers and Mr. Weston to Miss BY about Mrs. Z, almost certainly in October, 1973. We find that the conversation was substantially as set out in the Incident. Not long afterwards another student nurse told Miss BY that Mrs. Z was 'wrong for the ward', and was told that it was very difficult to move staff within the hospital.
2.97 Following the complaint from Dr. Ankers and Mr. Weston Miss BY consulted with Mr. DW and decided to ask both Charge Nurses for written reports on Mrs. Z. That from Mr. AZ was, predictably, good. The report from Mr. U was equivocal. Miss BY told us that she thought that Mrs. Z would have benefitted from a change to a female ward, but when she offered her the change it was refused and she pushed this suggestion no further as she wrongly understood that Mrs. Z's contract specified that she should work on male wards. Her recollection is that she sought to find a male ward for her, but that there was none that wanted her services. In her evidence to us Miss BY was very reluctant to accept that Mrs. Z's departure would have benefitted the ward.
2.98 Miss BY told us that she thought at this time that Dr. Ankers was disrupting the ward and undermining the authority of the Charge Nurses by a hostile attitude towards the administration, and that although some of his ideas may have been good the trouble they caused was greater. Holding these beliefs it is unfortunate that Miss BY did not seek to talk to Dr. Ankers or Mr. Weston about the problems she felt they were causing by their criticism, or seek to help them or Mrs. Z to work through the problems inherent in the challenge of youth. We accept Dr. Ankers' evidence that when visiting the ward Miss BY expressed approval of what the young nurses were doing.
2.99 Mrs.Z should have been sent on a training course, and then sent to work on another ward. If she refused her contract should have been terminated, Instead the position was allowed to drift. As in so many parts of the hospital, people talked together about the problems but shrank from taking decisions. Some were even unable to tell us how or by whom a decision on a matter ought to be taken if the imagined panacea of 'talking together' failed. In our view an approach to Mrs. Z's Union steward for assistance in solving this intractable problem might have led to an acceptable solution.
2.100 Decisions were eventually taken and staff moved in the summer of 1974 following complaints by a patient, Mr. EV. These events will be related in due course.
Incident 51
2.101 This Incident concerns Dr. W who came to St. Augustine's as a Consultant for Thanet (Area 2) in November, 1972. Until that time the hospital had four Consultants responsible for a population of 600,000. The size of this burden of work will be appreciated in the light of the Department's guideline of one Consultant to each 60,000 people.
2.102 On arrival Dr. W was responsible for a population of 1277000. He had patients in 14 wards at St. Augustine's and in eight, wards at St. Martins. He also had duties at a Day Hospital in Margate with 80 patients, For many months he had no Registrar and only half a share in a Senior House Officer. At Margate the Clinical Assistant resigned shortly after Dr. W's arrival, and for the next six months he was without assistance there.
2.103 Dr. W's workload was grossly excessive and as a result he felt that he must concentrate his efforts on the acute admissions wards. This meant that he was unable to give as much time as was necessary, or he would have liked, to the long stay wards until the arrival of Dr. FU as a Consultant for Ramsgate (population 45,000) in July, 1974.
2.104 Dr. W said that in the 18 months before Dr. BTU's arrival he visited Heather once every two to three weeks. He would stay an average of 15 minutes and go through the list of his 24 patients with the Charge Nurse and see any patient who was disturbed. Mr. AZ recalled that Dr. W was mainly concerned during this period with a patient, Mr. GT, and then Mr. EV, a patient who took Mr. GT's place. We do not think he was able to see many of his patients during these brief visits to the ward office, and this accounts for the evidence of many junior nurses who at this time either never saw him, or only saw him once in three or four months. Dr. W agreed that because of the little time he was able to spend on the ward "the patients might not receive the attention that they were due", and that for some patients "it could have been harmful".
2.105 Mr. CX,-the Principal Nursing Officer, described how he and his Nursing Officers were very perturbed by Dr. W's attendance. "I talked with the man. Miss BY pleaded with the man." Mr. CX told us "It was being taken up repeatedly because we were very aware of the lack of medical cover especially on Heather Ward, but there were other wards. Dr. W felt that he had very genuine reasons, and he was a very difficult man: I think that is the honest term. He is a man of very few words, he would make his case very plain that he was overworked, that he did not have the time etc. and he made a categoric statement that until such time as he got help he could do nothing about it. At the same time we got an old friend, Dr. X, to bend over backwards and stretch his workload yet a bit more, to go into Heather Ward, to give his cover to this ward and see patients there. Nevertheless, We got this difficulty with Dr. W which we never really resolved satisfactorily, because he always had these pressures and he had other reasons for not wanting to involve himself in certain wards of the hospital."
2.106 It is easy to understand in these circumstances how Dr. Ankers and Mr. Weston felt that Dr. W neglected his patients. Although a Ward Medical Officer visited the ward each day, some of the patients were deprived of appropriate treatment. Dr. X already had over 20 patients in Heather and could not hope to give to this additional workload the attention it required. Dr. Y only had three patients and rarely visited the ward. In July, 1974 they were joined by Dr. FU who took over about ten of Dr. W's patients.
2.107 The Consultants were cast by the rest of the hospital in the role of leaders in the wards. They were content to be so cast, but they were failing to lead the long stay wards away from custodial care. They attributed this failure, with considerable justification, to shortage of time, but they never informed the Management Committee that they were in default or invited the nursing staff into a joint partnership of care to help fill the gap they left unfilled. It was left to individual nurses or groups of nurses to try to fill the gap if they so desired. It was management by default.
2.108 Since July, 1974, Dr. W has visited the ward once a month for multidisciplinary meetings, and once a week for 20-30 Minutes at a time to discuss his patients which are now down to 14. As we will report in due course there are still problems in Heather Ward. If Dr. W had more time he would not give it to his long stay patients. He expresses his dilemma clearly and we sympathise With him in it. "As a Consultant I have to make the best use Of my time, to provide a psychiatric service for a community of 80,000 people. This includes a day patient service, an outpatient service, visits to the general hospital to see overdoses and consultations." If he had more time he "would devote it to the people in the community who are crying out for psychiatric treatment and are not getting it because there is no time at the outpatient clinics for them to get it," He continued "I think prevention of chronic illness it the most important function I have to perform. My aim is to prevent admissions, to prevent chronosity in patients, so I feel one should concentrate one's efforts in one's acute admission wards to prevent chronosity, and also on one's outpatients and day patients to prevent their admission to the hospital in the first place."
2.109 Heather Ward like many other wards, has suffered from sharing too many Consultants. It must be obvious-that when a Consultant has a few patients in several wards he can waste a considerable amount Of time in going' from ward to ward taking meetings. Equally if all the Consultants with patients in a ward held regular meetings On the wards, a good deal of nursing staff time would also be taken up attending meetings and the problems of differing attitudes and expectations between Consultants would become more marked, particularly as no one Consultant had overall responsibility for policy making. The Consultants seemed to have a limited awareness of the problems caused by this multiple sharing of wards.
14 December 2025
