2.205 This is the ward to which Miss OA was moved in January, 1974. Prior to August, 1972, it was a large ward with patients sleeping on the floor above. It was then attractively upgraded to accommodate 30 patients on the ground floor and has since served as a mixed psychogeriatric admission ward for Clinical Area 3. There are now 20% men and 80% women and it has three Consultants. To some extent it serves as an assessment and treatment ward from which patients may be discharged or transferred to long stay wards like Hazel.
2.206 Mr. Weston worked in the ward for four months early in 1973. Two of them were spent on night duty. He was responsible for giving the information contained, in Incident 45, but the information contained in Incidents 5, 20, 32, and 38 came from Miss OA. Care on this ward was for a time of the same basic nature as we have discussed elsewhere. Several witnesses told us that when there were shortages of male or female nightwear and underwear garments there were occasions when patients had to wear clothing belonging to the opposite sex. Although supplies of new clothing were received from time to time, this was often withheld from incontinent patients who Were given older garments. This may seem logical at first sight, but the long term result is that deteriorating patients were made to feel even more deprived, and their deterioration was thereby accelerated.
Incident 45
2.207 We accept this as substantially accurate. Mr. TM was in charge of one shift and Mrs. UG of the other. There were differences in approach between the two shifts. Mrs. UG agreed that she did not regularly carry out the aseptic technique for dressing, but she maintained that there was not time for this and that the patients did not suffer as a result. Other examples of the differing approaches were that Mr. PM's shift encouraged patients to use knives and forks and sit where they liked, whereas Mrs. UG's preferred them to use spoons and sit in fixed places. Mr. TM's shift dressed the patients when they got them up: the other shift got them up in dressing gowns and dressed them after breakfast. Mr. TM's shift favoured outings and tea parties: the other did not, as Mrs. UG felt that the escorts and those preparing the tea were needed for basic care. No effective steps were taken to end this thoroughly confusing and unsettling position for both patients and students until March, 1975. Since August, 1972, the Senior Nursing Officer and Nursing Officer had been the same as for Hazel.
Incident 32
2.208 We agree that there was virtually no discussion of policy regarding patients treatment. Junior staff did not attend ward meetings and were discouraged from discussing treatment directly with doctors. We find that there was a patient who it was very difficult to persuade to leave her bed, and that Mrs. UG tried to encourage her to get up by the temporary withholding of food. We do not accept that she used the words attributed to her, or that the patient became more intractable. Neither do we accept she lapsed into a worse state than before after receiving E.C.T. We find no grounds for criticising this experiment. We find the allegations in the last half of this incident to be proved.
Incident 38
2.209 We find this incident proved. The nurse concerned is Mrs. UG, who agreed that she referred to some patients as ‘Dumbos', but explained that she did so in a jocular, friendly manner. Nevertheless we are satisfied that what she said, could, and probably Would, be interpreted by at least some of the staff as derogatory and unkind.
2.210 We must at this point say more about Mrs. UG. She has been nursing since about 1957, and has spent all her time at St. Augustine's. She qualified as a Registered Mental Nurse in about 1964, when she won a prize for practical nursing. She was also a member of the team that won Agnes Pavey Award, a competition in practical nursing open to staff from all hospitals. She became a ward sister in 1967 and commenced Work in Elm Ward in August, 1972. She has always been conscientious and hard working: nevertheless we are satisfied that there came a time when she found herself out of sympathy with, and unable to show compassion for, the more disabled and demented patients. Mrs. VH, a reliable witness, and a good State Enrolled Nurse, Who had worked with Mrs. UG for five years, always received consideration from her, told us that Mrs. UG regarded that category of patient as deliberately awkward, and that she Was unable to hide her feelings and appeared not to understand them. We are satisfied that on occasions this attitude led to roughness of handling and inconsiderate speech by Mrs. UG to the more demented patients. She got on well, however, with the less disabled patients, and this inconsistency Was the subject of some puzzled discussion by ward staff. We are satisfied that at no time did Mrs. UG intend to be unkind to any patients, but that with some she was unable to help herself.
Incident 5
2.211 Mrs. UG agreed that she instructed staff to use the method described in this incident to make this patient release her urine. When this patient was moved to a different ward, under a different regime with different medication her incontinence was cured. We find that on occasions Mrs. UG handled patients roughly as alleged in this incident.
Incident 20
2.212 The complaints set out in this incident were made against a Student Nurse, Mr. GI who we have already referred to in connection with Box Ward. The police decided not to prosecute him, and he was subsequently disciplined in the hospital for failing to make out an accident report in respect of the cut which he claimed he had discovered on the patient's head. He was then moved to another ward where there were further allegations against him. He refused to give evidence to us. In spite of this record he was permitted to qualify as a Registered Mental Nurse and received his certificate at St. Augustine's in 1975. We do not understand how this came about. From an early time in his training there were signs that he was unsuitable for this form of nursing and his training should have been terminated. Pairs of hands alone do not give adequate care or maintain morale.
The manner in which complaints about Mrs. UG were dealt with
2.213 In about February, 1974, Mrs. VH and a Nursing Assistant, Miss WI, spoke to Mr. TM and said that they could no longer tolerate Mrs. UG's attitude to some of the patients. As they were reluctant to report the matter to the Nursing Officer Mr. TM did so. Be also mentioned it to Dr. XK, the Ward Medical Officer.
2.214 Mr. M decided to convene a ward meeting and invited Mr. L to attend, but it could not be held for about a week as Mrs. UG was on holiday. In the intervening period he made none of the enquiries which he claimed he would normally have made to prepare for the meeting, because he attributed the unrest to the arrival of Miss OA in Elm Ward. As in Hazel Ward, the time of the meeting seems to have been fixed at very short notice, for Mrs. VH first heard of it 20 minutes before it was due to commence. After an introduction from Mr. 1119 which did not make the purpose of the meeting clear, the staff were invited to put forward their points of view. Miss WI started and was followed by Miss OA who made most of the allegations about Mrs. UG which we have already considered. Mrs. UG denied them. When Miss WI supported Miss OA on one matter Mr. L asked why she had not raised it at the time it occurred. This did not encourage further contributions from Miss WI. After accusation and counter accusation between Miss OA and Mrs. UG, Mr. M intervened. He explained "In an attempt to break this personality difficulty between them I think I suggested really that we should try to leave personalities out of it and look at attitudes, which I think Miss OA was driving at." The muddled thinking behind Mr. M's intervention is demonstrated by the following questions and answers by him.
Q. What did you mean by 'attitudes'?
A. This business of Miss OA thinking (Mrs. UG) was unnecessarily harsh, or, if you like, rough with the patients. I thought that discussion of the question of attitudes was essential, because my opinion of (Mrs. UG) is that she was firm on occasions, but that she was basically a kind person.
Q. Forgive me, but how on earth is it possible to discuss attitudes in that kind of situation and leave personalities out of it, when there really are only two personalities involved, (Mrs. UG) and (Miss OA)?
A. I am not saying that what I did was necessarily right, but I was purely
attempting to break up this verbal battle between them.
2.215 Mr. L supported Mr. M's request to concentrate on attitudes. The effect this had on Mrs. UG and Miss OA is illuminating.
2.216 Mrs. UG said "The nurses were asked to say what their complaints were about me. (Miss WI) spoke, (Miss OA) spoke, and I suppose I misunderstood, but I thought that it was a meeting where we would each discuss our opinions of each other, but When I expressed my opinion of (Miss OA) I gathered that I should not have done it. I got the impression that I was not supposed to do that and I was told that it became a personality clash. I did ask for a further meeting so that everyone could say what they had to say and tell me what their complaints were about me, but Mr. L thought that there might be another personality clash and that it would be better to forget it.". Miss OA on being asked if anything useful came out of the meeting replied "I thought it was a complete whitewash of Mrs. UG because it felt as if the meeting was being directed to generalities, not to discuss her behaviour, which was of great concern to most nursing staff. Suggestions were made that she took too much responsibility on herself, did too much physical work, and so on, which I did not feel was the. case at all, so I felt very much more it was a question of protecting her."
2.217 We have set this out in some detail as we wish to demonstrate as clearly as possible that it is no good talking to middle management nurses about "open discussion" and "concentrating on attitudes rather than personalities" and then leaving them to get on with it. The conduct of an open discussion, if it is to be useful, needs considerable skill and much practice. This is an area in which all middle management need continuing instruction, counselling and practice.
2.218 Following that meeting Mrs. VH was away from work for some weeks because of ill health. When she returned She saw Mr. M and said that although she had not spoken up at the meeting she did not wish to go on working on Elm Ward because of the harsh way Mrs. UG behaved to the patients. In the weeks that had elapsed since the meeting Mr. M had not given any advice to Mrs. UG, although he felt that there was some substance in the criticism. Neither had he spoken to Miss OA about the meeting or her attitudes which he believed had precipitated the discontent. He sought to explain "I see my job as not, if you like, to stir up trouble".
2.219 Following his discussion With Mrs. VH Mr. M spoke to Mrs. UG and told her that some of her actions could have been misinterpreted, and warned her to refrain from attitudes which could be considered harsh. He advised her to examine her attitudes and be rather more flexible towards staff and patients. He felt that she subsequently modified her behaviour.
2.220 Round about this time Mrs. UG found Miss OA becoming increasingly resentful every time she asked her to do anything. She spoke to Mr. M and Mr. L and explained that she did not think that Miss OA would ever make an acceptable nursing assistant, and that she really should not be on the wards. They told her "that there was a shortage of staff, that she was another pair of hands, and that there Was no one to replace her". So Miss OA remained on Elm for two or three months longer until she resigned in July, 1974, on obtaining a job that suited her better. Neither Mr. M nor Mr. L attempted to speak to her about her attitude or to seek to understand her resentment. This really was management by default.
2.221 Following the circulation of the second part of the Critique in February, 1975, Dr. XK asked some of the nurses on Elm Ward whether there were any matters causing concern on the ward. He set out what he was told in a memorandum which he sent to the Chief Nursing Officer. After referring to the earlier complaints about Mrs. UG's "attitude to and handling of geriatric patients", he continued, "On 1.3.75. a Staff Nurse complained to me on lines similar to above. She felt unnecessary force was being used in toileting and "force feeding" and that incontinent patients were told that they were being dirty intentionally and such was not the case especially one patient who has Paget’s Disease with an associated pathological fracture who is unable to leave her chair. On Mr. TM's shift apparently this patient was potted regularly and there was no problem."
2.222 The Staff Nurse concerned confirmed that this memorandum accurately summarised her complaints, save that she wished to amplify the reference to force feeding. "I was", she said "referring to an occasion when I saw Mrs. UG giving medication to a particular patient. I have not seen her force feeding as a general rule". No one sought to obtain further information from her, although about the same time Mr. M had a similar complajnt about Mrs. UG's roughness from another nurse.
2.223 At the suggestion of the Chief Nursing Officer Mir. L and Mr. M saw Mrs. UG and suggested that she should move to another ward. Mr. M was "beginning to feel" that she was not a satisfactory Ward Sister for that ward, and that it was getting her down a bit after two or three years. Mr. L also thought that Mrs. UG should move "in the best interests of the ward". Mrs. UG after some hesitation declined to be moved. We were anxious to discover why a move was not then insisted on. Mr. L sought to explain "I would not move anyone against their will, and particularly in a situation like this where a lot of the logic of management of wardships would bear scrutiny from either direction".
2.224 At Mrs. UG's request a ward meeting was held. During the meeting Mr. L announced that Mr. TM would be responsible for ward policy. This had not been discussed with either Mr. TM or Mrs. UG before the announcement was made.
2.225 There followed an uneasy compromise. Mrs. UG told us that she had received no advice or counselling from Mr. L or Mr. M between that meeting and giving evidence to us. Neither does she seem to have sought it. She said that the atmosphere was strained, and that she had the feeling that she was being watched and everything she said or did noted. She appeared to us to be under very great strain. She expressed a willingness to move to another ward, and this has since taken place. She ought to have been moved in March for her own good and for the good of the ward.
2.226 Mr. L and Mr. M attributed the discontent on the ward to the arrival of Miss OA. When Mrs. UG asked for her removal they declined to take any action. When they felt that Mrs. UG should move and she declined, they gave in. No investigation was made as to whether the complaints made in March were well founded or ill founded. This sorry story indeed exposes some of the weaknesses of middle management.
2.227 On our visits we found the atmosphere was bright and pleasant, and the patients lively and responsive. The number of nursing staff allocated to the ward seethed reasonable, although additional help would have been an advantage in assisting with occupational, social and recreational activities.
09 February 2025
