2.228 The incidents concerning this ward are 6, 9, 11, 31 and the second part of 47. We will consider Incidents 6 and 11 under a separate section dealing with electro-convulsive therapy.
2.229 Mr. Weston worked in this ward for one month in 1970 and three months in 1971. It was then a male admission ward for the whole hospital. The senior Consultant for the ward was Dr. Q. Since 1972 it has been a male admission ward for Clinical Area 3. The Consultants have been Dr. Q, until his retirement in July, 1975, and Dr. R. Dr FU joined them in 1974. Patients have numbered between about 40 and 36.
Incident 9
2.230 We do not find this proved.
Incident 31
2.231 The information in, and wording of, this incident came from Mr. Weston. The State Enrolled Nurse referred to is a Mrs. YL. She has worked in St. Augustine's since 1953, and qualified as an S.E.N. by length of service in 1965. She has worked in Maple Ward since about 1966, and has normally been the only woman on duty.
2.232 We accept as substantially accurate a description of Mrs. YL which was given by Mr. ZO a Registered Mental Nurse who worked in Maple Ward as a student nurse shortly after Mr. Weston. He described her as tempered, arrogant, impatient and bad mannered with patients. When she wanted patients or staff to do anything she commanded rather than asked. She used to spend much of the day sitting on a chair by the door watching people come in and go out. This behaviour did not help newly admitted patients to settle down, and there was a lot of muttering and cringing by them when she came on duty, although she had some favourites. When she was on duty the door into the ward was locked more often than when she was not on duty. Dr. Q made no mention of this when she let him into and out of the ward.
2.233 Mrs. YL agreed that the ward was locked on occasions, but claimed that this was never done without the authority of -the Charge Nurse, and that it was always duly reported. However, examination of the ward reports during the time that Mr. Z0 worked on the ward revealed no occasion when the ward was reported as locked. We are satisfied that the ward was frequently locked, often on Mrs. YL’s own initiative, and that no proper records of locking were kept at this time. To this extent only do we find Incident 31 established, and we regret the lurid language in which it was expressed.
Incident 47 (second part)
2.234 In April, 1971, a patient, Mr. ABC, then aged about 41, was admitted to Maple Ward from Broadmoor Hospital under Section 60 of the Mental Health Act, 1959. From that time until Dr. Q's retirement in July, 1975, he was kept in pyjamas and dressing gown, apart from one period of four months from January to April, 1974. Dr. Q described him as very psychotic with very disordered thinking. The purpose of keeping him in dressing gown order was according to Dr. Q, to let him adjust to mental hospital conditions. The period of four months to which we have referred was when Maple Ward was closed for redecoration and the patients had to go elsewhere. While they were away from Maple they went to the patients cafeteria for meals, and Mr. ABC and other patients who were in dressing gown order had to dress for this. Dr. Q told us that when the patients returned to Maple he told the staff that as Mr. ABC had returned to familiar surroundings he should be put back into dressing gown order. When one of the Charge Nurses protested Dr. Q agreed that Mr. ABC should be allowed to dress, but told him that time would prove that this was wrong. Some time later he absconded, but neither threatened nor did anyone any harm. He was returned to the ward after about six hours.
2.235 Dr. Q agrees that the decision to keep Mr. ABC in dressing gown order was his. The time for which he was kept in this attire cannot be justified, particularly in the light of Dr. Q's evidence that after the first 12 months he only reviewed this patient about once a year. The case notes suggest that the intervals had been rather greater than that. Dr. Q told us that he tried in vain to get Mr. ABC readmitted to Broadmoor, and agreed that he had formed the view that this patient was incapable of any rehabilitation. Since Dr. Q's retirement there have been frequent reviews of this patient's treatment, and some improvement in his condition.
2.236 Dr. Q was well known for his practice of keeping patients in dressing gown order following admission. He said "I was the only Consultant in this hospital who used this system fairly regularly. Other patients from Broadmoor have been kept thus for over a year." Even informal patients often spent three or four weeks in pyjamas and dressing gowns. Mr. CX the Principal Nursing Officer, told us that he had recorded and reported his displeasure at, and disapproval of, Dr. Q's insistence on dressing gown order, and that the Chief Nursing Officer told him "I am very sorry this is the Responsible Medical Officer's decision, and it must be abided by". The Chief Nursing Officer in his evidence agreed that some of the nurses found it a shocking situation but he never raised the issue with Dr. Q.
2.237 Dr. Q said, in effect, "What else could I do? The only alternative was over medication to prevent the patients absconding." When asked if he was suggesting that other Consultants over medicated patients he said "No". He emphasised that the ward had a full size billiard table on which the patients could' play, and that in sunny weather they could go outside. It was the spectacle of numerous patients outside the ward in pyjamas and dressing gowns that Mr. CX found so distasteful.
2.238 Dr. Q agreed that the nurses might be in a better position to judge whether a patient should be in dressing gown order than he, but maintained that where there is a conflict it is the Consultant who must decide as he is the person who will carry the responsibility if the patient escapes and causes injury or damage. This seems to have been the widely held view, and is part of the mystique of the clinical autonomy of the Consultant. We are satisfied that this view is wrong. The decision as to whether a patient needs to be in dressing gown order must be a multidisciplinary one, and if it turns out to be wrong the Consultant will carry no greater responsibility than any other member of the team. There are various factors, and conflicting interests to be balanced, and each member of the Team has an important contribution to make in striking the right balance.
2.239 The manner in which Dr. Q was permitted to adhere to his quite unreasonable insistence on prolonged "dressing gown order" illustrates yet again the extent to which doctors were allowed to hug to themselves decisions which were essentially multidisciplinary. For example, Dr. Q knew that the Occupational Therapy staff protested that his insistence prevented patients attending the department for occupational therapy, but he remained quite undeterred.
09 February 2025
