2.139 Dr. Ankers was transferred from Heather Ward to Hawthorn Ward on July 7th, 1974. He served there until his resignation on December 9th, 1974. Some people believed that the purpose of his transfer was to secure his immediate resignation.
2.140 Hawthorn is on the ground floor underneath Heather, and its layout is very similar. Since August, 1972, it has been a male psychogeriatric ward in Area 2, and between that time and May, 1975, the numbers had fallen from 49 to 45.
2.141 Dr. Ankers summarises his experiences and views in Incidents 13 and 43. We accept them as accurate, although we emphasise that patients were only put to bed naked or given urine soaked slippers or radiator dried urine soaked pillows when supplies of replacements ran out. These shortages, however, occurred far too frequently. In addition to the deficiencies spoken of by Dr. Ankers, there was a shortage of flannels which was common to the whole hospital. This shortage resulted in one flannel being used to wash several patients, who were often doubly-incontinent. The supply of pyjama jackets began to improve during the last half of 1974 and flannels have been more readily available since early 1975. Slippers and pillows also became more readily available during 1975.
2.142 There was no occupational or industrial therapy available on the wart while Dr. Ankers was there, but the position had improved slightly by the Autumn of 1975. Five or six patients were then going to the solarium, which we have already described adjoining the ward, and three patients were going to the Industrial Therapy Unit. The need for stimulation and activities for the many left in the ward was great.
2.143 During Dr. Ankers’ time in Hawthorn there were no proper changeover meetings, but these have been in operation since the Spring of 1975. On her arrival in July, 1974, Dr. FU started monthly multidisciplinary meetings. Some other Consultants have gradually followed her example, but in the Autumn of 1975 Dr. X had still not found time to hold such a meeting in this ward.
2.144 In Spite of all the difficulties, the totally insufficient nursing staff have worked hard, Dr. Ankers had great admiration for them.
2.145 We were told by a Charge Nurse that the position in the Ward had changed during 1975 to such an extent that one would hardly know it was the same ward. Things must indeed have been bad before. At the time of our first visits in August, 1975, the number of staff (usually four or five) was insufficient to give the patients more than the most elementary care. The picture we retain is of restless and confused old men wandering aimlessly about and in need of attention to their dress and general appearance. A ward sister who had recently moved to the ward expressed feelings of frustration and hopelessness about her work there. The combination of both overcrowding and shortage of nursing and domestic staff meant that remedial, social and occupational activities were very limited. The position of the nursing office and the ward kitchen removed nursing activity from the centre of the ward. The toilets were considerably further from both living and sleeping areas than the 30 feet now generally regarded as desirable, and this may have contributed to the high proportion of incontinent patients. At the time of our visits the lavatories had unlockable and unboltable stable doors which prevented privacy. This can lead to bewilderment, confusion and embarrassment for even the most demented patients. Although the bathroom and washroom had dividing curtains, space was very limited. This meant that undressing, washing, bathing and dressing lacked the privacy which is so desirable for all hospital patients.
2.146 The beds were in four rows and all were the high type, although some the patients might have preferred, or have been accustomed to, low beds. There were no carpets in the dormitory, and scarcely any sign of personal possessions On the lockers.
2.147 Although it was claimed that Hawthorn was an unlocked ward, the main doors were locked on almost every occasion any of us visited it. No record was made on the ward of the occasions when the main door was locked, as it was asserted that the ward retained its unlocked status because entry could be obtained through an unlocked door into the kitchen. We are satisfied that wards have been locked very much more frequently than have been entered in the ward books kept for that purpose. Between April 22nd 1975 and November 5th, 1975, the Catering Officer, during his routine visits to the wards, recorded in his notebook that a total of seven wards were locked on a total of 21 occasions. Only four of those occasions had been reported in the proper manner.
2.148 Subsequent visits to Hawthorn did not reassure us. At 6.00 p.m. one evening several patients were already in bed, others were wandering round the dormitory half undressed, and many remained in the day room. The limited number of nurses were doing what' they could. One old man lay dying in his bed in full view of the other patients. There were three portable screens available, but these were not in use; indeed the shortage of space round the beds made their use inconvenient. The nurses were distressed at the low standard of care they, could provide. One said "It's not right that these old men should die in a slum like this." On that same day, however, there were a number of empty beds in the sick ward being kept for surgical patients who, at the most, only occupy half the beds retained for them on two days a week, and there were about 130 other unoccupied beds in the hospital. We shall have to consider in due course how this state of affairs was allowed to continue.
2.149 The basic problems of the ward were described by one of the Consultants, Dr. X: "There are far too many patients in a ward of: this nature, being patients of the type they are, senile dements, terminal cases that have come to the end of their life and really have very little to do but sit, and so demented that the nurses cannot really communicate with them, and involving very heavy nursing indeed. A large proportion of these people are incontinent." The problem and the work load have long been recognised, but we emphasize that modern psychiatric services do not accept that such patients have "very little to do but sit", and good nurses are able to form a relationship and communicate with the most severely demented. Lack of a progressive medical policy inhibits the development of nursing treatment for such patients. We need now to consider why nothing was done to reduce the numbers to a level at which the staff workload was tolerable, and a little more than basic care could be provided.
2.150 On June 13th, 1974, the nurses on the ward sent a memorandum to the three ward Consultants and Miss BY, their Senior Nursing Officer, and to their Nursing Officer. It said "Due to the large numbers of High Dependency Geriatric Patients on Hawthorn Ward and the acute shortage of staff, at times only two or three for 43 patients, the staff on this ward would like it known that they would not like to be held responsible for any neglect which might occur while this critical situation continues. Difficulty is experienced in giving minimal care" A similar memorandum was sent to the same persons from Laurel Ward a few days later. Although there followed a plight improvement in staffing, it was minimal.
2.151 On September 3rd, 1974, Miss BY sent the following memorandum to Mr. C, the Chief Nursing Officer: "At the Area 2 Ward Charges meeting yesterday concern was expressed in the strongest possible terms about the staff shortages. The Ward Charges feel that they can no longer provide adequate patient care and they are neglecting the training of learners and the ward administration. They have become another pair of hands, in the struggle to maintain even minimal care. They would appreciate an early meeting with you to discuss the problems and attempt to find a solution. A suspension of informal admissions has been suggested; followed, if necessary by ward closures." Mr. C felt unable to meet the Charge Nurses of Area 2 because of pressure of work, but he said that he would put it on the agenda for his next meeting with the Charge Nurses from all areas. However, the minutes of the Ward Sisters and Charge Nurses' meeting with Mr. C on September 5th contain no reference to this memorandum or the issues' raised therein. This is another example of management failure.
2.152 On July 30th, 1975, Miss BY sent a memorandum to all Consultants in Clinical Area 2 with copies to the Divisional Nursing Officer and the Hawthorn Nursing Officer. She said "A crisis situation has blown up in Hawthorn Ward, staff morale is abysmally low resulting in general dissatisfaction, poor time keeping and the taking of odd days off... Among themselves the staff have discussed the possibility of taking strike action, resigning or requesting a ward move en bloc. Fortunately their concern for their patients has influenced them against taking such drastic action. The main complaints are the extremely heavy workload at the present time, combined with the staff situation. With 45 patients only basic care can be given, resulting in lack of job satisfaction and general frustration. The present bed allocations are Dr. FU 7, Dr. X 12, Dr. W 18, Dr. Y 8." Miss BY went on to suggest that each Consultant should give up a bed as it became vacant and she concluded "The present staff are conscientious and hard working and have a sincere regard for their patients well being. In my opinion they are worthy of our support."
2.153 This memorandum does not appear to have been discussed at the next Divisional meeting for Area 2, although the hope was expressed that when the Elder complex opened after upgrading early in 1976 it would be possible to reduce the beds on Hawthorn by five. Dr. X kept a bed empty in order to help, and Dr. FU promised Miss BY to take a bed down at some uncertain time in the future, but Dr. W said he could not agree to her suggestion because of the pressure of people awaiting admission. The Divisional Nursing Officer raised the matter at the next Medical Executive meeting, but no decision on the number of beds was taken. At the end of September, 1975 there were 40 patients in the ward with five empty beds. Dr. X, the Chairman of the Medical Executive Committee, felt that they should not be taken down because of the pressure for admission that would probably develop during the Winter. When we left, there were 42 beds, with the Consultants and nursing staff all in disarray as to what had been agreed between them at a recent meeting at which all thought that they had agreed on a reduction of beds.
2.154 There is clearly a conflict of interest between the patients and nurses in overcrowded wards, on the one hand, and the doctors who seek to find beds for people outside requiring admission, on the other. How is this conflict to be resolved? Whose decision should it be as to whether a bed is taken down? Dr. W was asked about this conflict of interest and stated unequivocally "I cannot see how one can reconcile the two. We have got to provide a psychiatric service for the community." He said he could not take down any bed, and the only answer he could see was new wards "because our catchment area is expanding and the age group of our population is getting older. This inevitably brings about admissions to the hospital. The community services in Thanet, which is the area I represent, are appalling. There is no support in the community for patients." He felt that the position in Hawthorn with the pressures on staff described by Miss BY's memorandum of July 30th, 1975, was better than a patient not being cared for at all, "which is the case With geriatric home-patients sitting alone in squalor, where the patient's life is in danger and they require admission to hospital". Because of the pressures for admission Dr. W is sure that the opening of the Elder complex will not produce the hoped for reduction of beds in Hawthorn.
2.155 One Of the barriers in the way of resolving this dilemma has been the widespread, but erroneous, belief throughout the hospital that no bed can be taken down unless the Consultant agrees. For example, the Nursing Officer for Hawthorn during 1974 told us "Until the Consultants agree to take a bed down we cannot do anything about it". He was asked how far the nurses were prepared to go in pushing the Consultants and replied "We have discussed this With the Consultants, and they say we have a duty to the Consultants." Dr. W also considered that the Consultant has the final decision, and explained "I represent the community: I represent my Catchment area: I do not only represent My hospital. I have to provide a service for my catchment area."
2.156 There must be an end to this Wrong thinking. The Consultant does not own the bed and has no more authority over it than the nurse. It should be an essential part of ward policy that there is an agreement between medical and nursing staff on the number of patients on any one ward, the function of the ward, and the rate of admission, if it it an admission Ward. Where it is not possible to reach agreement at ward level the problem should be referred to the Clinical Area Multidisciplinary Team and from there, if necessary, to the Hospital Management Team (See Section 6.). Failing agreement within the hospital the problem must be taken to the District Management Team, and from there to the Area Health Authority and ultimately, if need be, to the Region. As noted elsewhere in this Report, it is unfortunate that the District Management Team responsible, for St. Augustines has disproportionate representation on behalf of the medical profession, so that it is difficult for the nursing point of view to be adequately and forcibly represented. There are many hospitals with wards containing too many patients. Where no immediate reduction is possible it should at least be possible to agree forward plans, including the rate at which beds will be taken down and the eventual totals. Monitoring of the progress is an essential part' of the job of both the Hospital Management Team and the District Management Team.
2.157 During the Enquiry an improvement in staffing ratios was achieved, mainly as a result of improved recruitment generally. The reduction of beds to 42 is regarded by staff as a step in the right direction. There are hopeful signs of a patient assignment programme for nurses but this will require a guaranteed minimum number of staff and some prospect of continuity. Incident 47
2.158 The first sentence is intended to refer to a patient in Hawthorn. The person who gave this information is now overseas and we have not been able to identify the patient. A random selection of case notes in each long stay ward, however, revealed periods of a year or more during which patients do not appear to have been seen by their Consultant. We checked a random 30 medication records of patients in Hawthorn and found that 12 of those patients had not had any medication change for 12 months.
09 February 2025
