The Circumstances in which Miss OA left Hazel Ward
2.182 After she had been on the ward for a few weeks Miss OA saw Mr. L, her Senior Nursing Officer, and asked for a transfer away from the ward and geriatric nursing. In the course of the interview she mentioned most of her complaints regarding Hazel which are set out in the 'incidents' already considered We accept her evidence that Mr. L did not ask her for details and conveyed the impression of wanting to get through the interview as quickly as possible.
2.183 Mr. L told us that he decided that the best way to deal with the situation was to have an open discussion on the ward without revealing the source of the complaint. He and Mr. M, the Nursing Officer, held a ward meeting a week or two later. The first Miss OA knew of the meeting was when she arrived on duty at 1.30 p.m. and found it about to begin. There was very little dispute between Miss OA and Mr. L as to what followed. Mr. L told the meeting that a member of the staff, who would remain anonymous, had made allegations that the ward was badly run and that a patient had been stuck by a member of the staff he did not name. He invited discussion, but there followed a generally embarrassed silence. Mr. L said Mrs. NE "was quite exercised to find out the source of, my information, but I put it to them that these points had been raised and that they should examine their role in the ward to see if there had been justification for the allegations, and, if so, could they come back and say what they would do to remedy it, or, if it was untrue, to let me know that it was untrue, and then I could take it back to the source." We are not surprised that Miss OA felt confused. "I felt in a very difficult position", she told us, "because he had described me as being anonymous. I was not sure what the procedure was. I did not know whether I should remain silent or wait for other people to voice any disquiet. So feeling confused, and in a way embarrassed, I just kept quiet... I felt that the meeting had been neutralised, because I did not know what to do. I did not know whether to declare myself or not."
2.184 The whole Of Miss OA's complaint was handled ineptly. Mr. L and Mr. M ought to have done more investigation before the meeting and Mr. M should have ensured that Miss OA had ample warning of the date and time it was to be held. We do not understand how the meeting could have been expected to achieve anything under the cloak of anonymity. Mr. L and Mr. M really had no idea of how such a meeting should be conducted. Mr. L spoke to us of "group dynamics". We feel that he had been given a smattering of information about 'open discussion', without any real assistance as to what this really meant.
2.185 Following the meeting Mrs. NE and Mr. RC went to see the Chief Nursing Officer and asked for the complainant's identify. This was given to them. Mr. L concluded that Miss OA's position had become untenable and moved her to Elm Ward.
2.186 It is sobering to reflect that Miss OA's complaints really achieved nothing except her removal from the ward, whereas we are satisfied that the great majority of those complaints were well founded.
Hazel Ward between Miss OA's departure and the beginning of the Enquiry
2.187 It will have been clear from what we have already said that no improvement had occurred by the time Miss QB started work on the ward in October 974. If anything, the position had deteriorated, although the number of patients had been reduced to 39. Staff on duty fluctuated between two and five. Often staff who had reported for work were redeployed by the Nursing Office to meet cries for assistance from other wards. Miss QB often spoke about the situation to Mr. M during his daily visits to the ward. He is a man of charm and goodwill, but we accept Miss QB's account of his response. "If one asked him about any situation, either on the 'phone or person to person, he was an absolute master of the art of putting off, of calming you down in a situation with promises, and not doing anything. I always felt this about him."
2.188 There was no improvement, and no effective support from Mr. L and Mr. M, until all the staff joined in sending Mr. L a letter dated February 22nd, 1975. It was written at the end of a period of 10-14 days during which there had been an outbreak of diarrhoea. Every day, for at least part of every shift on which Miss QB worked, there had only been two nurses. The letter included these passages: "This ward is nearly always under staffed and so we have found it impossible to put into practice any policy regarding such basics as bathing, regular toileting nail cutting and hair washing: so the patients are becoming neglected at this very fundamental level. When the ward is properly staffed a nurse is almost always taken out, and the ward situation is becoming so depressing that the morale of the staff is being seriously undermined.
2.189 "There is a lot to do here besides the basic nursing care: the staff also have to make 39 beds, make sandwiches for two-thirds of the patients for tea and breakfast, and at night after the domestic staff have gone home it has become essential to wash over half the day room floor and wipe down about 15 of the chairs.
2.190 "We must mention that we have pleaded for a heated trolley for years without success and consequently nearly half the patients always have cold food.
2.191 "Because of the staff situation the patients when they arrive here quickly become difficult (lack of attention), chair-bound, (insufficient time to walk them) and incontinent (lack of toileting). Also, if we had the staff, the patients could go out on the minibus once a week as on other wards, whereas at present most never leave the ward.
2.192 "The minimum of staff required we feel is four nurses plus one Charge and often now we are left with two."
2.193 This letter was followed by a meeting with Mr. L and Mr. M who promised that the staffing situation would improve. Staff who had been detailed for duty on Hazel were no longer diverted elsewhere, and the numbers detailed for duty increased.
2.194 Why did Mr. L and Mr. M fail to do anything before? Miss QB said "I personally feel very strongly indeed that the Nursing Officers were to blame, and that they knew the situation and that they simply did not care." By ‘Nursing Officers' she meant Mr. L and Mr. M. At the end of her evidence she was asked what she hoped the Enquiry would do to bring about change. She replied "Above all, I hope that the people who are effectively running the hospital, the Nursing Officers, will never let a situation like that on Hazel arise again. I feel that it was a neglected backwater, and that basically nobody cared. If that happens with the people who are administering the place the whole feeling will run right through the staff."
2.195 It is impossible to quarrel with this apportionment of blame. Mr. L and Mr. M failed in the course of their visits to discover the situation, or, alternatively, failed to take appropriate action. In particular, they did nothing until after the letter to lift the morale of the nurses. This is an essential element in leadership. What can, and must, be said, however, is that Mr. L and Mr. M needed more training for, and counselling in, their important roles than they received. Mr. M had attended a Middle Line Management Course, but this is not adequate for the role required of him. Mr. M told us that he believed patients were bathed once a week. If he had asked the staff or patients he would have found out that this was not so. He never checked whether there were bed sores. He indulged in the form of leadership which claims to give support when problems are raised. Unfortunately the support was too often not forthcoming when problems were brought to him.
2.196 Mr. L agreed that patients in Hazel Ward had failed 'for a limited period of time' to receive an acceptable standard of care. When asked why he had not taken action before the letter he replied "I have not got a crystal ball. When complaints are brought to my attention I take action as I can". In our view Miss OA's complaints following the circulation of the first part of the Critique should have led Mr. L to make searching enquires and satisfy himself about conditions in Hazel.
2.197 Mr. L and Mr. M agreed that the heated food trolley referred to in the letter had been on order for years. Mr. M said he had been told it would cost £2,000 and that money was not available. Mr. L told us the cost of such a trolley "runs into thousands of pounds". Such an estimate of cost was nonsense. It is probable that the confusion crept in because the hospital required four heated trolleys costing in all £2,000. It is sad, however, that for two years Mr. L and Mr. M had never doubted or queried the information they believed that they had been given to explain the delay. This inactivity and lack of questioning throws light on why Hazel had continued for so long in its quite unacceptable state. The four heated trolleys, including that for Hazel, arrived between our two spells of hearing evidence.
2.198 We have quoted at length from Miss QB's evidence as we found her an impressive witness. Let us put what she told us, and the sorry state of affairs in Hazel, into perspective by one last extract from her evidence. She was asked her experience of other parts of the hospital, and replied "I have never worked on a long stay young people's ward. On the young admissions ward on which I am now working I have nothing but admiration for the staff and what goes on there. It is superb. I only hope that I shall be as good as they are. Generally I do not feel in any way at odds with the way the patients are spoken to and the way things are done. Occasionally you come across a nurse whom you think is rough or someone with whom you do not get on. Most wards go through periods when their administration goes kaput because the Charge Nurse is away or something like that. But I have never felt anything like I felt when I was on Hazel Ward in the way of criticism. Before T worked on Hazel Ward I really loved every ward on which I worked. In fact when people asked me 'Is it a depressing job?' I did not know what they Meant. But when I was on Hazel Ward I understood for the first time what it meant, or could mean."
Hazel Ward at the time of the Enquiry
2.199 On our visits we found that the layout was similar to that already described. The decoration was unimaginative, and the curtains drab. It contained 38 patients, 30 of whom were incontinent (12-14 doubly). There were normally four nurses on duty, but this might rise to five or fall to three. Incontinence was inevitably taking up a great deal of the nursing time by day and night.
2.200 The most noticeable feature of the ward was the high proportion of severely demented old ladies who required a great deal of attention with feeding and dressing. The patients got up early: some of them on Saturdays between 6 and 7.00 a.m. They were put to bed between 6.30 and 8.15 p.m. having had their last meal at 4.00 p.m.
2.201 Bathing remained a problem. A Nursing Assistant came to help with the bathing on the morning shift. If she made a fifth member of the staff she was able to bath five or six patients. If, however, the total staff was less than five this was not possible. Although the aim was that each patient should have a weekly bath, this was frequently not achieved.
2.202 At the end of August, 1975, an occupational therapy aide started attending the ward for four hours on three or four mornings each week. She worked with six or seven patients. In the four weeks prior to November 18th only four patients had been out of the ward. In the three months before that same date no patient had been out in a hospital coach or minibus. It is not surprising that, apart from the basic tasks of feeding the patients and keeping them warm and comfortably seated by day, the ward presented to us an atmosphere of inactivity.
2.203 The arrival of the heated food trolley has ended the serving of cold food, but there seemed to be lack of imagination in the planning and presentation of meals for the 20 or so patients who require assistance with feeding, in that there remained an excessive use of mince. The Catering Officer was willing to meet requests for alternative diets from nursing staff, but the trouble was that this needed initiative from the nurses and would make more work for them at meal times. It is clear that they will need advice and encouragement if they are to look beyond mince for other alternative diets.
2.204 There is no doubt that Hazel Ward has suffered from staffing problems, both in the numbers of staff allocated to the ward and the quality of the nurses in Charge. It was evident that they had worked hard in their own differing Ways, but there seemed to be a lack of organisation and due sensitivity to the physical and emotional needs of these long stay patients. The Senior Nursing Officer and Nursing Officer for this ward in the Autumn of 1975 were unlikely, without further training and support, to provide the stimulus and sense of direction that the ward requires.
06 April 2026
