3.1 (Incidents 2, 15, 17, 40, 46, 48, 49, 55, 58, 59 and 69)
3.2 Incidents 2 and 15 we do not find proved.
Incident 17
3.3 This criticism was well founded so far as Heather Ward was concerned. See paragraph 3.104.
Incident 40
3.4 There was overwhelming evidence that the long stay patients received old fashioned, short-back-and-sides haircuts unless they asked for anything different. Many were unable to make such requests. Ward staff can help to solve this problem by encouraging patients to tell the barber how they would like their hair cut, and where a patient is unable to do this, by friendly discussion with the barber when they take him for his haircut. If patients paid for their haircuts this would assist in introducing, or restoring, some dignity and normality. Incident 46
3.5 No catering service will be perfect. In the past food was on occasions substandard and not hot enough. It may have been delivered late on occasions, although it was not proved that this was ever due to the luncheon requirements of the Management Committee. The distance of many wards from the main kitchens, the absence of lifts, the difficulty in obtaining heated trolleys, shortages of staff and large numbers of patients have all created substantial difficulties which have gradually been overcome.
3.6 We have already mentioned that in our view there is excessive use of mince for some patients. If it arrives or is served cold it is particularly unattractive. The catering staff will provide alternatives to mince, and the nursing staff need help in selecting alternatives, and encouragement to order them in time.
3.7 We are satisfied that the food is now good in quality and adequate in quantity. The menus provide a choice, and there are attractive restaurants for patients and staff. For one week we selected food from the patients' menu and for the remainder we chose from the staff menu. Although the menus were different so that staff do not have to eat the same food as they had just been serving and feeding to patients, there was no difference in the standard. The Catering Officer or his Assistant pay regular visits to wards to ensure, so far as they can, that they are providing an adequate service. There have been occasions in the past when wards have had insufficient food, and although more could always be obtained from the kitchen, it must have been very irritating to have to send a nurse to collect it when the ward staff were fully occupied feeding the patients, particularly on the geriatric wards, or helping them to feed themselves.
3.8 The Hospital Advisory Service recommended that last meals should be later than 4 or 4.30 p.m., and as a result about six wards began to have their last meal at 6.00 p.m. Not all of those continued. We were told that meals at 6.00 p.m. interfered with the patients' social life and evening activities. Staff also had less time to put patients to bed before going off duty. However, 4.00 p.m. or thereabouts is in our view too early for the last meal of the day, and we have no doubt that by a concerted effort the life of the hospital can be adjusted so that the last meals can be served at a more acceptable hour.
3.9 We have no evidence that the patients' Utility rand has been misused. Money was requested for ward outings and refused as it was considered that money for these outings should come from the patients' earnings or pocket money. Some staff provided their own money to help finance these outings, and took part in them during their off duty hours. The expenditure of a large sum of money on a rear entrance to the hospital which is rarely, if ever used has seemed to many staff a questionable use of money.
Incident 48
3.10 From what we have already said it is clear that life for the patients on some of the long stay wards would have given this impression.
3.11 Some of the long stay wards are rather dull and shabby but this is gradually being corrected. There are several wards in need of central observation offices: they have been asking for them for years. Privacy is not obtainable in some bathrooms, washrooms, lavatories and dormitories. We know that money is very short, but there must be multidisciplinary systems starting at Nursing Officer level by which priorities can be put forward and agreed for Clinical Areas. The Management Team for the hospital (see Section 6) will then have to balance the needs of the Clinical Areas. What the National Health Service Funds are unable to provide, the Friends of St. Augustine's and other voluntary bodies may be able to produce.
3.12 In April, 1974, many of the patients' clothes were shoddy and institutional. There were difficulties in obtaining adequate supplies, and the laundry had the reputation, with some justification, of being able to shred a piece of steel. There was a tendency in some wards to keep new clothes for special occasions. All this is gradually being put right. Many Charge Nurses have shown real initiative in bringing outfitters into the wards, and in helping patients to choose and save for suitable clothes. However, there is a continuing and urgent need to achieve a situation where all patients have personal clothing. We observed many shabbily dressed patients wandering about the hospital and sitting in wards, but we are confident that as the quality of living for the long stay patients improves they will take increasing pride in their appearance.
3.13 The shortages of clothing were particularly degrading to patients. As far back as November, 1971 the Hospital Advisory Service had reported that on occasions there were no night clothes for patients, and yet these shortages continued. A staff nurse Spoke of occasions when patients were put to bed wearing only vests and of males in female nightgowns. An Occupational Therapist told us of an occasion when she had to search for some clothes that would fit patients as it was impossible for them to take part in occupational therapy holding up their trousers and without socks or shoes. Other witnesses spoke of missing buttons and of having to put dirty clothes on to patients after a bath instead of the clean clothes that they were supposed to have. The supply of clothes improved greatly during 1973 and early 1974. Some shortages, however, continued because of deficiencies in the laundry which were exacerbated by a longstanding and notorious personality conflict between the Group Secretary and the laundry Manager.
3.14 We have already referred to the shortage of flannels and slippers in some Wards. There are many references to the shortage of flannels in the minutes of Senior Nursing Staff meetings and staff in several wards tore up old towels in order to avoid having to use one or two flannels on up to ten patients. The Supply of flannels was controlled by the Group Secretary Who took the view that patients could normally afford to buy their own. Ward staff were, however, unaware of the reason for the shortage. All that they did know was that it was not within their power to remedy the position. During his last five years at the hospital the Group Secretary authorised the issue of an average of 400 flannels each year for the whole hospital, He sought unsuccessfully to persuade us that there was an adequate supply in circulation at all times and that "this matter was never presented to me as one of Very great moment".
3.15 There was some criticism of the failure to provide fire-proofed, non-inflammable night clothes, but we did not feel that this was entirely justified. The Group Secretary took advice from the British Laundry Research Association and decided that there was insufficient justification for obtaining fire-proofed night clothes when they would have to be reproofed after every ten washes.
3.16 For several years there have been many staff without pass keys. The situation has been known to everyone, but until the time of this Enquiry the management system had failed to remedy it. During September, 1975, there were 30 or more night staff without pass keys. It would be pointless to catalogue the three years of talking which achieved nothing. We give one example of the kind of thing that has held up progress.
3.17 In March, 1975, the Chief Nursing Officer sent a memorandum to the Group Senior Nursing Officer of the Night Division reminding him that he had authority to withdraw pass keys from staff and issue them on a nightly basis. The Group Senior Nursing Officer took the legalistic view that as neither he or the Chief Nursing Officer were the 'issuing body’ for keys they had no authority to withdraw them. Each allowed the impasse to remain. This is a classic example of people in authority refusing to shoulder it. At long last in the Autumn of 1975 the District Management Team was taking effective steps to see that there were sufficient keys.
Incident 55
3.18 This was true of the great majority, of the long stay wards at the time of the Critique.
Incident 58
3.19 There Was very little effective training on the majority of the long stay wards because of the heavy workload and inadequate facilities. On some wards there was a great discrepancy, which was still present in the Autumn of 1975, between what was taught in the school of nursing and what is found on the ward.
Incident 59
3.20 There was overcrowding which had the results set out in this Incident and created very difficult working conditions for staff. Overcrowding was still present in the Autumn of 1975.
Incident 69
3.21 There was an occasion in April, 1974, when a Sister was summoned to the Occupational Therapy Department in the circumstances alleged. On arrival she expressed annoyance when she found that the injection was no longer necessary. We do not find that she used the words attributed to her, or that her annoyance was as great as the wording of this Incident, implies.
09 February 2025
