3.41 The problems involved in the use of E.C.T. were mentioned several times in evidence before us. Later in this section we shall refer to particular instances of its use which have caused us, and others, concern. The doctors at the Hospital and, on a national basis, the Royal College of Psychiatrists, should give urgent consideration to these problems and issue clear guidance.
3.42 E.C.T. consists of passing electric current through the brain while the patient is under anaesthesia, and is a widely used form of treatment in all mental hospitals in this and other countries. It is probably the most effective treatment for moderate or severe depressive illness, and is still one of the most effective methods of treating many forms of schizophrenia. But there are also risks, and those using it must, as in all forms of treatment, consider whether the expected benefits from it outweigh the risks and disadvantages.
3.43 The giving of the anaesthetic and the passing of the electric current both constitute the criminal offence of assault unless the patient has consented to the treatment or is detained under Section 26 or 60 of the Mental Health Act, 1959, or there is some other justification in law for those acts. Many psychiatrists believe they are entitled to order E.C.T. for a patient who has refused his consent, if he is detained under Section 25 of the Act. It is probable that there is no criminal assault if those administering the treatment honestly believe on reasonable grounds that the patient has consented.
Consent
3.44 It is self—evident that those whose illness is such that E.C.T. is considered necessary are likely to have some impairment of judgment: this may vary from the slight to the severe. It is most improbable that a fully informed consent is ever obtained. If a person whose consent to E.C.T. is sought is to be given the full information upon which to give or withhold us consent he would need to be told the details of the treatment, the choice and advantages and disadvantages in his particular case between E.C.T. given with and without relaxant drugs and with and without anaesthetic, the comparable risks of drugs that might be used instead, the probable duration of his illness if E.C.T. is not given, and any additional risk in the treatment due to physical disability or old age. No sensible doctor will go into all these matters with a patient who is already depressed or anxious, or has difficulty in thinking clearly. This is a dilemma which faces doctors in all branches of medicine.
3.45 In each case, therefore, the information given to the patient in order that he may decide whether to give or withhold his consent has to be modified, and often severely modified, in the light of the severity of his illness and his likely degree of understanding.
3.46 Written consent is rightly regarded as preferable in all cases as it is the most readily available Check on whether and, if so, when and to whom, the patient gave his consent. It must be emphasised, however, that a written consent does not mean that it is a fully informed consent: neither is a written consent a continuing consent. It means no more than at the time the patient signed the consent he was willing, on the information given him, to receive E.C.T. As will be seen, in many cases the patient must rely heavily on the judgment, clinical competence and integrity of the therapeutic team treating him. This situation can be seen in other fields. For example, an elderly person whose ability to order his own affairs is beginning to fail, and who wants to give his solicitor a power of attorney, must rely heavily on the solicitor's integrity in deciding whether to accept it and how to execute the powers given him.
Refusal to give consent
3.47 Clearly a criminal assault is committed if E.C.T. is given to an informal patient who makes it clear that he is unwilling to give his consent. It is in our view irrelevant on that issue that the refusal. may only be a manifestation, of the illness from which he is Suffering, or that those wishing to give him such treatment are convinced, that it is in his best interests and know that his family wish him to have it.
3.48 It is, however, the duty of the therapeutic team, when satisfied that E.C.T. is in a patient's best interest, to try to overcome his refusal or reluctance by persuasion and firm encouragement. The team would be neglecting its duty towards that patient if it allowed a temporary whim, a bout of indecision, or some renewed fear or anxiety about the process to prevent the patient receiving the treatment he needs. There is a great difference between the situation where a nurse takes a patient by the arm or hand and leads him to the treatment room, and then, perhaps, holds his hand while the anaesthetic is given, and that in which a patient is dragged, protesting, by two or three nurses, and then held firmly down on the bed while the anaesthetic takes effect. It is the duty of staff to try to overcome a patient's anxiety of or reluctance to have treatment by peaceful, if firm, persuasion. It most certainly is not their duty to force a patient, even though he has given his consent to a course of treatment, to have any treatment when he is flatly unprepared to have it, and it would have to be given against his will.
3.49 If an informal patient cannot be persuaded to consent to E.C.T., and in the view of the therapeutic team E.C.T. is essential for his health, the only way in which it can be lawfully given is to obtain an order under Section 30 of the Mental Health Act 1959 which authorises the detention of the patient for three days while the formalities are completed for admission for treatment under Section 26. Even with a detained patient, however, it will be prudent to make every effort to persuade him, to give his consent to E.C.T., for treatment voluntarily accepted is from every point of view preferable to that applied against a patient's wishes. If this is not forthcoming the position Should be explained to his next of kin or other interested person, for, although they cannot give a valid consent on the patient's behalf, their approval is clearly desirable. Written approval is the best evidence that it has been obtained. If neither the patient nor his next of kin agree to E.C.T., the therapeutic team concerned will be wise to obtain a second opinion in writing from colleagues. The important thing is that the detained patient should receive the treatment that is necessary for his good, preferably with his consent.
Inability to give a valid Consent
3.50 We have in mind here the position where a patient is so impaired, that he is either unable even to to-through the gestures of consent or, if he is able to get thus far, the therapeutic team are satisfied that no reliance should be put upon it.
3.51 If a patient's life is in immediate danger the therapeutic team should go ahead and administer E.C.T. if satisfied that this is appropriate treatment, but they will have to justify their action if objections are subsequently raised.
3.52 In all other cases, however, the same procedures should be followed as set out above under "Refusal to give Consent".
Unwillingness to receive E.C.T. after consent given
3.53 Nobody suggested that a written consent for E.C.T. is valid consent to a course of E.C.T. other than the course for which it is given. If, for example, it was given before the commencement of a course of treatment it does not apply to a fresh course begun, say, six months later. In such circumstances a further written consent should be obtained.
3.54 A patient who has given his consent to a course of E.C.T. is entitled to withdraw that consent at any time, and if the therapeutic team is satisfied that he intended to withdraw his consent they must go through the procedure under "Refusal to give consent" before completing the treatment. It is, however, often difficult to judge whether a patient has really Withdrawn his consent. If a patient who has given his consent to a course of E.C.T. behaves in a way which would certainly indicate to any lay person that he is objecting to, and trying to avoid, any particular treatment, can and should the therapeutic team give him that treatment on the basis that his consent is still operative? Indecision and frequent changes of mind are sometimes significant symptoms in mental illness. S omehow a sensible and, of necessity, bold path must be found between, on the one side, an overcautious response to signs of reluctance by a patient to receive treatment for which he has already given his consent, and, on the other side, refusal to accept that a patient has clearly withdrawn his consent to a treatment, even where the withdrawal is a result of his illness. We consider later in this Report two examples of this dilemma at St. Augustine's, and how it was met. If a patient withdraws his consent to E.C.T., either before a course has begun or in the middle, no further E.C.T. must be given. If he Cannot be persuaded to renew his consent and such treatment is essential to his health, an order must be obtained under Section 30 and then under Section 26.
3.55 Throughout this section we have referred to decisions and action by the therapeutic team. There may be one team concerned with the decision whether E.C.T. is the right treatment for a patient, and another with its administration. We develop the concept of these teams later in this Report. We emphasise at this stage, however, that each patient and situation is unique. New situations may develop quite rapidly, and, if misunderstandings are to be avoided and the right decisions made, it is essential that the members of each team discuss and agree their policies and attitudes well in advance. If two teams are involved there should be close co-operation.
3.56 We proceed now to the consideration of Incidents 6, 11, 5 and 67.
Incident 6
3.57 The information in this incident was given by Mr. Weston. We find that it is accurate, and that the incident described occurred in about 1972. The patient concerned was a Mr. GHI, an informal patient in his late 60's who suffered from chronic depression and had received E.C.T. on many occasions. The Charge Nurse told us that he frequently had to be carried to the treatment, sometimes pleading not to have it, and was then held down on the bed. We do not doubt that all concerned in the administration of the E.C.T. were satisfied that it was the right treatment for him. His attitude was described as negative towards all aspects of his care. That may well be so, but it did not justify the action taken on the occasion described in the incident or on the other occasions.
3.58 Examination of Mr. GHI's case notes revealed a disturbing state of affairs. There was an entry of February 7th, 1972 "E.C.T. was to be given but patient protested so violently that it was impossible to administer the anaesthetic. As patient injured attempt discontinued. Possibly he could be sedated prior to the next attempt”.
3.59 These notes also disclose, as Dr. Q agreed, that on August 25th, 1971, he directed that Mr. GHI should have a course of six treatments at the rate of two per week. They started on August 26th and without any further written instructions he received 13 treatments. On November 22nd, 1971, Dr. Q directed that they were "to continue once weekly until clinically recovered". His treatments continued at the rate of one or two a week until he had received 20. In January, 1972, Dr. Q interviewed Mr. GHI's relatives and wrote 'No further E.C.T.' Without any further written directions E.C.T. started again in February and continued until Mr. GHI had had 30 treatments since August 26th. Later in 1972 Dr. R found that Mr. GHI was showing signs of organic cerebral deficit or dementia. Excessive use of E.C.T. can be a cause of, or contribute to, this condition. Dr. Q agreed that it was unusual to give 30 E.C.Ts. He was then asked whether he thought there was any connection between those treatments and the development of the organic deficit. He replied "I should not have thought we should have pressed the E.C.T. to that extent. I think the original six would have been adequate. I think it should have ended at that time". Any comment by us is superfluous.
3.60 Another occurrence took place in Ash Ward in May 1975 when a female patient was brought to the ward for E.C.T. She was an informal patient who was known to resist E.C.T. on occasions. She was brought forcibly into the room by the Nursing Officer and held on the bed. The Charge Nurse in charge of the E.C.T. team declined to participate further and there were protests from some of the student nurses. The Nursing Officer afterwards explained to the nurses that the patient had been in a "deeply negativistic state" and they thereupon signed statements that they were content. In some cases, however, their concern remained. The Nursing Officer agreed that this patient was physically resisting E.C.T., but because she resisted everything else as well, and usually gave in at the end, he "did not consider that (the patient) was being forcibly compelled to have E.C.T."
3.61 These incidents show how unreal a patient's supposed consent often is, and how tortuous are some of the arguments resorted to in order to avoid facing reality. It is no wonder that there have been unhappiness and misunderstandings in some staff, particularly the younger ones. We are satisfied that a degree of force that exceeds any legitimate persuasion has been used to administer E.C.T. to unwilling informal patients on many occasions. Indeed, it has attracted a jargon of its own. Dr. Q informed us "We do not refer to 'force' but 'support' when assisting a patient to a ward where he is to receive E.C.T." Some doctors boldly take the stand that in their patients interests they have to take professional risks. The team of nurses that forcibly applies the E.C.T. may, however, be less able to assess the situation and may unknowingly become involved in a criminal assault. There must be clear multidisciplinary discussions, leading to agreed multidisciplinary policies and procedures. When these have been a agreed the 'nursing procedure.' leaflet on E.C.T. will need redrafting.
Incident 11
3.62 We accept this as accurate.
Incident 57
3.63 We are not satisfied that E.C.T. has been used as a punitive measure The forcible application of E.C.T. in circumstances such as we have been considering can, however, too easily lead to a belief that it is used for that purpose, and intimations that a patient will require E.C.T. if his disturbed behaviour continues can be interpreted as threats.
Incident 67
3.64 Mrs. JKL had been both inpatient and outpatient at St. Augustine's for about 20 years. She was a chronic schizophrenic and had required E.C.T. on several occasions. Her Consultant was Dr. Q.
3.65 In October, 1973, Mrs. JKL, who was then in her mid 50's, complained to her General Practitioner of pain in her back following an accident two months earlier. She was X-rayed at the Royal Victoria Hospital, Folkestone, and the X-ray report sent to her General Practitioner referred to 'moderate degenerative changes at all levels in the dorsal and lumbar spine'. No other lesions were seen. In November, 1973 while an inpatient at St. Augustine's, Mrs. JKL had a left mastectomy for carcinoma. In May, 1974, Mrs. JKL was still complaining of central lumbar back pain so her General Practitioner arranged for further X-rays at the Royal Victoria Hospital. He received the X-ray report on May 29th. It said that there was some compression of the body of L3 and that the appearance could be due to metastatic deposits. This indicated that there might well be a cancerous tumour present in that area.
3.66 Subsequently Mrs. JKL was readmitted to St. Augustine's as an inpatient because of her mental illness. On about July 24th she was examined by the Surgical Registrar who found that she had local secondary tumours at the site of the operation, Otherwise her physical condition was satisfactory. Dr. Q saw her on July 28th and found her mental condition 'pretty fair', but he did not examine her physically. She was discharged on that day.
3.67 On July 29th Mrs. JKL's General Practitioner found her in a state of depression and feeling very shaky. He does not recall that she said she had fallen. The following day he telephoned the hospital and spoke to Dr. Q whose recollection of the conversation was that the General Practitioner had told him that Mrs. JKL had fallen down the stairs and was suffering from depression., He told us that he had agreed with her doctor to readmit her as an inpatient for E.C.T. but that he had told him that as far as the fall downstairs was concerned, St. Augustine's was not the hospital for admission for physical injuries and asked him to arrange that she should be sent to the Royal Victoria Hospital for a full examination to exclude bony injury. He explained to us that he had in mind that she would be X-rayed there. The General Practitioner did not recall any reference to the physical examination, and arranged for an ambulance to take Mrs. JKL straight to St. Augustine's on the same day. On the way she complained of abdominal pain and was taken to the Royal Victoria where she was given an abdominal examination in the Accident Department and sent on to St. Augustine's with a diagnosis of "? constipation".
3.68 On arrival at St. Augustine's Mrs. JKL was examined by a Medical Assistant who was the Duty Admission Officer for the day. She had no information as to why the patient was being readmitted. She gave her a physical examination and noted a history of her having fallen and injured her elbow. She found no abnormalities. If she had known Mrs. JKL's recent history she might have looked for evidence of further secondaries.
3.69 Mrs. JKL walked to her ward and was observed in the ward walking satisfactorily to and from the toilet. Later that evening the Duty Admission Officer was told that the patient had slipped on the floor in the toilet but there were no bruises or signs of injury. The doctor a sked the nurses to keep the patient under observation.
3.70 The following morning Dr. Q walked through the ward. As he passed Mrs. JKL she said "good morning" to him. On his own evidence that was the only contact he had with her before authorising a course of five E.C.Ts.
3.71 There was evidence that Mrs. JKL, after signing the form of consent referred to in the next paragraph, fell or slipped to the ground as she was getting out of bed prior to going for E.C.T., and that thereafter she said that she was unable or unwilling to walk. There was also evidence that Dr. Q was told of this and said that E.C.T. shou1d proceed as arranged, Dr. Q denies that he was told of any such incident by the bed or that Mrs. JKL was, or might be, unable to walk. Dr. Q's version was that he was told that Mrs. JKL was not prepared to get out of bed to walk upstairs to ECT, and that he thereupon gave instructions that she should be carried upstairs. This required four people as she weighed 15 to 16 stone.
3.72 When Dr. Q gave the form for consent to E.C.T.to the Sister so that she could obtain Mrs. JKL's signature he had already signed the declaration "I confirm that I have explained to the patient the nature and effect of this treatment" and had given written instructions for "5 E.C.Ts at 2 per week from Wednesday 31.7.74." Moreover, the form required a signature by Mrs. JKL to the effect “I (Mrs. JKL) hereby consent to undergo the administration of electroplexy the nature and effect of which have been explained to me by Dr./M '. When the form was brought back with Mrs. JKL's signature no name had been inserted. Dr. Q says that he was told at that time by the Sister that Mrs. JKL was complaining of a pain in the leg.
3.73 Dr. Q told us that although he would normally have seen the patient and explained the position, he did not do do on this occasion because he was afraid that his presence might cause her to say 'yes' to E.C.T. when she really wanted to say 'no'. "I deliberately avoided seeing her. I felt that if I went to see this woman I might influence her into having it. I wanted her to have a free choice." He told us that he felt she could more readily say 'no' to a nurse. Very shortly after this he gave some answers which were totally irreconcilable with that explanation for falling to carry out his normal practice. He referred to Mrs. JKL's complaint of pain in her leg and said that he had decided before ordering her to be carried upstairs for E.C.T. that she had invented the pain to avoid E.C.T. He then had to agree that he had ordered her to be carried upstairs to be given E.C.T. at a time when he believed that she did not want to have it. She was an informal patient.
3.74 After she had received E.C.T. Mrs. JKL complained of pain in her back. The Duty Doctor was summoned and she was immediately sent to the Kent and Canterbury Hospital, from which she was transferred to Brook Hospital, woolwich, where she died on August 5th. It Was not disputed that the information given by Dr. Q to a Sister in St. Augustin was accurate, namely that Mrs. JKL died from a combination of a tumour of the corda equinal metastases and two collapsed vertebrae.
3.75 What was the state of Dr. Q'S knowledge when he authorised E.C.T., why did he fail to examine her?'
3.76 Dr. Q told us that he had no knowledge of the X-ray taken in May, 1974 or the findings based on it. We proceed on that basis. However, he admitted that he knew:
(i) that Mrs. JKL had local secondaries where the left breast had, been removed, and that secondary tumours in the bones from cancers in the breast are Common;
(ii) that contrary to his advice no physical examination had been made at the Royal Victoria ,Hospital and no X-rays taken;
(iii) that on the morning he authorised E.C.T. she was complaining of pain in her leg and was unwilling to walk, and that she was a woman who had not previously behaved in this way.
3.77 We have no doubt that the exercise of reasonable care by Dr. Q demanded that he should satisfy himself
(i) that Mrs. JKL required E.C.T and
(ii) that she was physically fit for such treatment.
3.78 On the question of whether she needed E.C.T. he agreed that he had discharged her four or five days earlier as fit to go home on medication, and that her General Practitioner's' view that she required more E.C.T. might be wrong. He further agreed that he was the Consultant Psychiatrist whose duty it was to decide whether or not to administer E.C.T. Dr. Q sought at that point in his evidence to justify his failure to see her to decide whether E.C.T. was required by telling us that he had shortly before this read an article that E.C.T. can help in the treatment of cancer and he thought that Mrs'. JKL would be a suitable patient on whom to experiment. That in. our view made it even more necessary to examine her before commencing such an experiment and explain the treatment fully to her. He told no-one, and made no note, that one of the reasons for giving E.C.T. was to see whether it would help treat her cancer. Later in his evidence he said the real need for E.C.T. was fear that she might commit suicide in the future. None of these explanations begin to excuse Dr. Q's failure to examine Mrs. JKL to make up his mind about her mental state before authorising the further course of E.C.T.
3.79 Dr. Q tried to excuse his failure to check Mrs. JKL's physical condition by relying on the physical examination carried out by the Medical Assistant the day before, but he had clearly had in mind something very much more thorough than that when he requested her General Practitioner to have her examined at the Royal Victoria Hospital, otherwise there would have been no point in sending her there. He had also had in mind that she would be X-rayed at the Royal Victoria, but he knew that had not been done. If there were local secondaries from breast cancer he knew that bones could be affected and that X-ray and/or blood tests were advisable to reveal this. Any weakening of bones could lead to serious damage from E.C.T. Moreover he knew that Mrs. JKL was that morning complaining of a pain in the leg, but he says that he concluded that it was an invention without even seeing her and enquiring from her and the nurses when it had first been felt and whether she had had any accident which might account for it. Dr. Q knew that Mrs. JKL had local secondaries. He also knew of complaints from Mrs. JKL within the past 24 hours of pains in the abdomen, elbow and leg, and that she had fallen at home. This history of pain in the limbs and abdomen, and of falling, should have alerted him to the possibility of further widespread secondaries, and we are satisfied that he should have undertaken far more extensive investigation of Mrs. JKL's physical state by examination, X-ray and blood tests before prescribing the course of E.C.T. Secondary metastatic disease in tile bones does not necessarily mean that E.C.T. should not be given, but it calls for large doses of muscle relaxant to reduce the risk of fracture of bones.
3.80 As we have said, he not only failed to make any examination of her mental condition, without which he was in no position to justify E.C.T., but he also failed to explain to her the experimental nature of the E.C.T. and what he hoped it would achieve. He should also have warned her of the increased risk if there was any metastatic disease of the bones.
3.81 When the second part of the Critique was received the Medical Staff Committee met and went through the incidents, seeking to identify them. The following note was taken of the explanation that Dr. Q then gave of Incident 67. "Patient with long chronic history (1955). E.C.T. ordered as usually giving good results on patients having had Mastectomy. The patient was very depressed as well as suffering from carcinoma with metastases. After a fall she had been X-rayed - with a negative result at the RVH Folkestone. Dr. Q would have no hesitation in prescribing the same treatment again."
3.82 Our criticisms of Dr. Q have been based on his own evidence. His casual approach to E.C.T. on this occasion, and the large number of treatments given to Mr. GHI disturb us deeply. Neither are we at all happy about his use of E.C.T. as a diagnostic measure to distinguish between depression and dementia. Dr. Q estimated that he used E.C.T. for this purpose about once a month, although accepting that in some forms of dementia it would involve increased risk to the patient. We understand that Dr. Q, although retired, has facilities to treat patients at St. Augustine's Hospital. The Regional Health Authority should consider this Report before extending these facilities.
09 February 2025
