Incident 1
2.110 All these incidents are alleged to have occurred during 1973 and to have involved Mr. HS, a State Enrolled Nurse who did night duty in Heather.
2.111 Paragraph i: We find this proved. Mr. HS said it was just a figure of speech to try to entice the patient back to bed. We are not satisfied that he would have carried out the threat.
2.112 Paragraph ii: We find that this is proved. We are not satisfied that Mr. HS intended that the patient should be permanently deprived of food that night.
2.113 Paragraph iii: We find this proved. The patient involved is powerful and unpredictable. Mr. HS said that he could remember giving him the "odd playful slap or tap to make him calm down or to demonstrate to him that he had done something wrong". When asked how the giving of a playful slap would achieve that end, he replied "I do not know. I would not like to try to answer that question." He later sought, unsuccessfully, to persuade us that he would "tap them on the bottom with the palm of his hand or something like that". Although he did not see other nurses behave in the same way, he understood from conversation that they did so. He said he could not recall, any guidance as to where the Line should be drawn in the application of physical force, and continued "I found that I was left to my judgment on this matter and it was never criticised by any of the senior nurses in the wards that I Worked on."
2.114 We are not satisfied that Mr. HS ever intended to be cruel. He was doing his best to control difficult patients in his own way which he believed was widely accepted. Staff received insufficient guidance as to how to deal with disturbed patients. In our view no patient should be slapped. It is not children that the nurses are trying to discipline, but full grown powerful and often irrational men.
2.115 Paragraph iv: We are satisfied that this same patient was injured as described while Mr. HS was trying to restrain him in a lavatory. There was no eyewitness. We are not satisfied that Mr. HS deliberately struck him. Mr HS left the hospital in 1974 and is no longer working as a nurse.
Incident 3
2.116 We accepted Dr. Ankers' account of this incident as substantially correct. It occurred during 1973 in the following circumstances.
2.117 One morning when Mr. AZ was away the ward became very disturbed, with the patient referred to in paragraphs iii and iv of Incident 1 at the centre of the disturbance. Mrs. Z telephoned the nursing office for help as a result of which Mr. IN, a Charge Nurse who was on duty in his own ward, was asked to go over and assist for a couple of hours. Mr. IN explained "it was because the ward was so disturbed that morning. I was asked to go up there and try to get some form of order." He said "this happens so often. When there is trouble in this hospital or in a ward, it is usually 'Mr. IN, will you go and help them out there?' This is what has happened to me for some time. It is pretty obvious why they picked on me when there is trouble. I am twice the size of an average person, and I have probably twice the strength, plus a good deal of experience in dealing with disturbed patients."
2.118 When he reached the ward he found it in a state of Confusion and uproar. He called for some quiet and got some response. Then this patient appeared with his fly buttons undone and his penis exposed. When Mr. IN told him "put it away and do your buttons up" he just grinned. It was then, as we find, that Mr. IN hit him several times quite hard with the back of his hand "above the testicles but below the belly button", saying each time "Do them up." He then removed the patient in the manner described in Incident 3.
2.119 We do not consider that Mr. IN had intended to be cruel. He had be sent to restore order, and when confronted by disobedience he dealt with it in his own way. Indeed, it may be said that the role in which he was repeatedly and, in our view, unfairly cast almost demanded this response from him. We agree with his comment, which applies with equal force to the similar use of Mr. DI "It is not very nice to get an unearned reputation of being the heavy gang. I do not like it."
2.120 Mr. IN should have persevered with peaceful persuasion, but the atmosphere in the ward, and the purpose for which he had been sent, were not conducive to these more peaceable remedies.
Incident 14
2.121 We accept this incident as described. It occurred during the night January 3rd-4th, 1973. The patient concerned was Mr. GT. He was a well known and longstanding source of trouble in the hospital, and was transferred to Broadmoor in January, 1974. He had been disturbed for some days prior to the night in question. On the morning of January 3rd he struck another patient several times and attacked yet another patient in evening. It was unfortunate that the Charge Nurse's judgment was rejected and doubly so that it was treated with such insensitivity.
Incident 27
2.122 Mr. KR was admitted to St. Augustine's in 1955 aged 17. He is suffering from schizophrenia, with epilepsy and mental handicap. His behaviour has been aggressive, threatening and childish and this led to his attendance at the Occupational Therapy Unit being brought to an end. In August, 1972 he was transferred to Heather. His home was in the area for which Dr. Y was responsible, but he was apparently unable to give him sufficient attention until 1975, and therefore Dr. X agreed to look after him until his Consultant colleagues had more time. There came a time when he was unwilling to leave the ward or be on his own. This was probably caused by delusions and the lack of volition which is often found in long term schizophrenia.
2.123 During 1973 Mr. U and Dr. Ankers wearied of What seemed to them to lack of any treatment programme for this patient. Dr. Ankers described how be began to take him to the public house outside the hospital gates, and, later, further afield, and how as the patient's confidence returned, he encouraged him to go Out with other patients. In January, 1974, a multidisciplinary meeting chaired by Dr. X confirmed this programme. Unfortunately Mr. KR's confidence and liking for alcohol both grew and although for a time his progress was such that he was working on another Ward, he presented a serious alcoholic problem in the Autumn of 1975.
2.124 This is an example of an initiative by nursing staff that at first achieved its object and then went wrong, probably because of lack of co- ordination with the doctors, combined with lack of experience by the nurses who were implementing the programme.
Incident 29
2.125 This is true.
Incident 41
2.126 Mr. LQ was born on 31st March, 1945. He entered St. Augustine's in 1961, suffering from hebephrenic schizophrenia, which had started in early adolescence. His IQ was assessed at 85. It is of some significance that in 1959 a doctor reported from an Adolescent ward, where he was then being treated, that "when Largactil was discontinued increased excitement and sexual activity became noticeable". The drug was therefore recommended at 50 mgs t.d.s.
2.127 Since he entered St. Augustine's the case notes have been of variable quality. They show that at times Mr. LQ has responded to a variety of treatment including medication and E.C.T. On occasions he has been well enough to go home, but these Visits have not always been satisfactory, and on one of them he punched his mother. There are references to sexual behaviour since his arrival at the hospital. In 1962 the notes point out that he was on considerable medication, but that without it "he tended to develop gross restlessness with absconding from the ward, overt masturbation, tongue sucking etc."
2.128 LQ was transferred to Heather in August, 1972. The staff found that he frequently left the ward and followed females about the hospital causing them annoyance. Sometimes he tried to look up their skirts and sometimes to touch them. When the nursing staff asked for guidance messages were received from the Chief Nursing Officer that they should keep him in dressing gown order, and from Dr. X, his Consultant, that he should be confined to the ward and suitably medicated.
2.129 Several of the ward staff became increasingly unhappy at this apparently negative attitude to Mr. LQ's problems. At ward meetings they asked that the Consultant should come and discuss the case with them. They shared, we believe, the concern that was well expressed to us by Dr. Ankers, "I would like to have discussed with Dr. X the situation in regard to Mr. LQ. I felt concerned about Mr. LQ. I felt that if I was involved in his treatment I should treat him as best I could. If I was to be a party to confining Mr. LQ to Heather Ward I wanted Some reassurance from the doctor that this was justified." Mr. U told us that Dr. Ankers asked him to arrange for Dr. X to attend a ward meeting to review the case. Mr. U approached Dr. X Who replied that he was too busy. Mr. DW was also approached with the same request and received the same response from Dr. X. Mr. DW continued "I think at the end of the day it was indeed left to the initiative of the individual nurses to think out and implement Other methods of helping Mr. LQ.
2.130 At the beginning of December, 1973, after about 12 months of effort by Dr. Ankers, he and Mr. Weston persuaded a comparatively new Ward Medical Officer to review the case of Mr. LQ and it was then decided to encourage more contacts with his parents and home and to seek to stimulate his interest in films and socials. In view of his abnormal behaviour with women it was agreed that he should have some supervised contact with them. His medication was also to be reduced slowly and his progress reviewed after one month.
2.131 The efforts to carry this programme out were probably misguided in some ways. For example, showing Mr. LQ pornographic books probably excited his curiosity more than satisfied it. The nurses required more supervision than they received; and without supervision errors of judgement of this kind were inevitable, Dr. Ankers, at one time in his evidence sought to persuade us that the programme instituted by the review resulted in improvement in Mr. LQ's behaviour. This was an example of his slanted advocacy, for any improvement which occurred was very ephemeral. In February, 1974, Dr. X had to confine him to the ward and increase his medication in order to prevent him pursuing women and causing them annoyance and he was still continuing to behave in this manner during our Enquiry.
2.132 The problem of helping concerned young staff to understand the difficulties remained in 1974. On March 3rd, a Student Nurse wrote the nursing notes "WHY SHOULD THIS PATIENT BE ISOLATED ON THE WARD WHEN THE TREATMENT HE REQUIRES IS COMPLETELY IN THE OPPOSITE DIRECTION?" He said he hoped to some acknowledgement from the medical staff, but that none was forthcoming. From his nursing superiors he received "sympathy, I think, and apathy as well. I think that several of them felt the way I did about the situation. Again I felt that some thought 'What is the use of trying if you are not going to get anything done in the long run about it’”
2.133 Incident 41 stated that Mr. LQ "just stared at the girls". As Dr Ankers knew, he did more than that. Apart from this, however, the complaint is well founded. Nothing positive was being done. No initiative was shown by those off the ward. The nurses needed guidance which was not given. They were left to do their best for a patient who posed many problems in an overcrowded and understaffed ward, and whose treatment seemed to lack any consistent pattern.
Mr. EV
2.134 The second part of the Critique was dedicated to the memory of this patient who was admitted to St. Augustine's from Broadmoor in January 1974, and who died in strange circumstances on February 14th, 1975 on the eve of being returned to prison.
2.135 We deal with the circumstances of his admission and his time in St. Augustine's in Appendix 5 in order to avoid devoting a disproportionate amount of the body of the main Report to one patient. The events set there drive home yet again the importance of proper multidisciplinary at all levels.
Heather at the time of the Enquiry
2.136 The ward consisted of a large square day room without any subdivision and the dormitory presented a typical picture of an overcrowded sleeping area with four rows of beds separated only by a narrow locker space. No partitions or curtains were provided. Quiet and privacy were not available to any patients, other than those who were occupying the few side rooms. Heather could properly be described as the male disturbed ward for Clinical Area 2. It contained some extremely disturbed patients who together, or in rotation, frequently disrupted the life of other patients and added to the work of the staff for days on end. Indeed our first impression of Heather in August, 1975 was reminiscent of the male refractory wards seen in most mental hospitals 20 years ago. There was an atmosphere of disturbed noisy behaviour. The 47 patients varied from fit young men to frail, elderly patients. Some wore dressing gowns and pyjamas, which further visits confirmed as a frequent mode of dress. The lack of divisions in the day room made it impossible for the quiet, anxious and easily upset patients to escape from the noise and interference of those with disturbed psychotic behaviour.
2.137 This ward should be reduced to 25-30 beds and given a good concentration of well trained nurses. In the Autumn of 1975 numbers seemed low by day and night, and there was a marked shortage of trained, experienced nurses. In a reorganised ward, providing some privacy and opportunity of grouping patients of a like nature together, the level of disturbed behaviour could well be lowered quite considerably. Occupation must be provided for the patients who remain in the ward throughout the day.
2.138 In conclusion we emphasise that the tensions between the shifts, and the absence of any consistent medical policy which preceded the circulation of the first part of the Critique led directly to the kind of unstable atmosphere and disturbing incidents which we have described.
14 December 2025
