4.1 At the end of the second part of the Critique, Dr. Ankers and Mr. Weston indicted the 'Medical and Administrative Bodies' for 'creating a climate in this hospital which discourages open, free discussion, and discourages patients and staff from publicly making criticisms and complaints'. It was because they had found the 'normal channels' of criticism so frustrating that they produced the first part of the Critique.
4.2 In this section we look at various incidents and procedures which throw light upon attitudes at various times and levels in the hierarchy, and which have led us to the conclusion that there were good grounds for their frustration.
1. The ‘J’ Enquiry
4.3 In August, 1971, Miss J, a student nurse, made written complaints about events in Bay Ward. They can be summarised thus:
(i) Two patients were on occasions locked in the clinical room, toilets and linen room.
(ii) Another patient was not given sufficient fluid as a punishment for scratching her legs.
(iii) Another patient was left unnecessarily long in a urine saturated bed.
(iv) Another patient was shaken and had her hair pulled by a Sister.
(v) A Sister came on duty at 5.00 a.m., and started getting up patients requiring more intensive care.
4.4 This was a ward containing 35 female patients, many of whom were disturbed. Sometimes there would only be one or two members of staff on duty. One of the Sisters concerned was in her late 60’s with years of hard work and many kindnesses to patients behind her. We can understand the wishes of all to support staff working long hours in difficult circumstances: nevertheless, the following respects in which the complaints were handled suggest that criticism was resented, and that hospital loyalties were too heavily on the side of its long—serving members.
4.5 (a) When the matter came to the attention of the Group Secretary his actions are best described in his letter of August 23rd, 1971, to the Department of Health. "I arranged for Miss J to be interviewed by two members of the Hospital Management Committee immediately in the presence of the Physician Superintendent and Principal Nursing Officer. She withdrew the allegation concerning a nurse coming on duty at 5.00 a.m. as this was outside the scope of her personal experience, but she persists with her other allegations and the Hospital Management Committee decided to enquire into this officially."
4.6 At the commencement of the enquiry that followed Miss J withdrew the allegation about the withholding of fluid because she had been told by the two Management Committee members that the drink withheld was not one of the standard meal time drinks and the patient was, therefore, not officially entitled to it. Although the members of that Committee of Enquiry had before them written information that the patient had told Dr. A that drink was temporarily withheld if she scratched her ankle, and that in the Ward Medical Officer's opinion there was no medical reason for withholding fluid from her, they did not investigate this allegation any further.
4.7 In our view both these matters should have been investigated. The preliminary meeting with the two Management Committee members could well have given Miss J and others the impression that the authorities did not wish to investigate a complaint unless there was no other escape.
4.8 (b) It was accepted before the hospital Enquiry that the two patients had on occasions been locked in the lavatory and clinical room in order to prevent them disturbing other patients, or other, patients disturbing them. The clinical room door could not be opened from the inside when it was shut, and these rooms were used because the side room doors could not be locked. There was a written statement from the Ward Medical Officer saying that she had not given permission for this and knew nothing about it. The nurses against whom the allegation was made agreed that they had not informed any doctors. Miss J said one of the things that concerned her was that she believed a patient could only be locked in a room with 'a doctor's approval.
4.9 In a note prepared by Dr. A for that Committee of Enquiry, he pointed out that prior to 1959 the power to lock a person in a single room could only be authorised by a doctor and that there had then been a statutory obligation to record the time for which he was secluded in a book. He continued "there is no similar provision made in the Mental Health Act, and there is now not, so far as I am aware, any medico—legal reason why a patient should not be confined in a room. At the same time the doctors would prefer to know of and authorise in advance any such occasions and should also be given the opportunity to instigate alternative procedures such as appropriate medication or a temporary transfer of ward". His oral evidence or advice given to that Committee was more positive. The proceedings were recorded and we had a transcription of the tapes. At one point he said that since 1959 a patient could be locked up 'at the discretion of the Nurse in Charge', and later he added "I was just going to mention again this question of seclusion, if we can use that word. There is no reason why a Sister or Charge Nurse should not confine a patient to a single room if she feels that it is in the interest of the patient, or in the interests of other patients to do so. She might like to discuss this with the doctor — I do not know. You see, no other patient was concerned."
4.10 Unfortunately, however, Dr. A's evidence to that committee differed materially from what he said to us. He told us that since 1959 "the policy has been that you do not lock patients up without reporting the fact". He amplified that later, saying "There was no change when the 1959 Act came in. I sent a short summary of that Act to the Nursing Administration and pointed out that there would be no change in our procedure with regard to seclusion. It was no longer a legal necessity to through this. This as far as I know, and I hope, is still on the nurses procedure file. Certainly a reminder was sent to all nurses not so long ago by the Chief Nursing Officer about it - that you cannot shut a patient up without a doctor's permission. You can if it is an emergency but no more. It has to be recorded both in the nurses summary, setting out the times and who authorised it and it has to be recorded in the patients case sheet." He said that had always been the position and his understanding of it.
4.11 The summary of the Act to which Dr. A referred stated "While the keeping of a Register of Seclusion ... will no longer be a statutory obligation, there will not, at present, be any alteration in the present procedure". No instructions to alter this were ever issued.
4.12 The Chief Nursing Officer confirmed.mhat Dr. A had told us. He amplified it slightly, saying that if nurses "secluded in an emergency, then they would inform the ward doctor immediately. That was my understanding and that was based on advice given by Dr. A." He, like Dr. A, attended the Miss J enquiry. He heard what Dr. A said there, but never suggested that it was wrong, although taking part in the deliberations of that Committee which were also recorded and transcribed.
4.13 The Hospital Committee found none of the complaints they investigated proved. The nurses who had locked the patients in the clinical room and toilet were not criticised in any way. We have no doubt that the evidence of Dr. A played its part in bringing about that outcome on that particular complaint. No-one had suggested that the patients had been confined for cruel or vindictive reasons.
4.14 This is a good example of how ranks close in the face of criticism. We are satisfied that the procedure for shutting patients into rooms so that they cannot get out has always required that the doctor must be told afterwards if there has not been time to get his authority beforehand, and that the period of seclusion must be recorded in writing. The information given by Dr. A to the Committee enquiring into Miss J's allegations did less than justice to her complaint on that matter and was unduly favourable to those she criticised.
2. Absence of clear complaints procedure for staff
4.15 There has been confusion about whether there is a written complaints form for staff and whether there is any definite procedure.
4.16 On December 18th, 1973, an Assistant Secretary at the South East Metropolitan Regional Hospital Board wrote to Mr. B sending at his request an extract from a report of a recent Committee of Enquiry set up by the Board, relating to recommendations on complaints procedure". The extract included the following recommendation. "There should be one clearly defined written procedure for dealing with staff complaints verbal or written. This procedure should be made known to all staff who should be told at which level their complaint was being dealt with and they should be made aware of the action taken". Confusion crept in because those in authority at St. Augustine's and subsequently at District level, did not distinguish between 'complaints by or on behalf of patients', for which there was a written form, and complaints by staff for which there was none unless the complaint was made by or on behalf of a patient. When we commenced to hear evidence we asked for the staff complaints procedure and were given that appropriate for complaints by or on behalf of patients. There was a covering note from the Sector Administrator stating that that procedure "is applicable to complaints by staff as well as patients. This is generally accepted and understood". There is however, no written instruction to that effect and we were told that the choice as to whether or not to follow that procedure would probably be governed by the gravity of the complaint. This absence of one clearly defined written procedure for staff is not conducive to making complaints 'respectable', or facilitating their presentation. This matter must be dealt with.
4.17 It became apparent during the course of the Enquiry that there is no recognised national procedure for dealing with complaints by staff about other staff, although, as referred to in the last paragraph, the Region had issued advice to their own hospitals, including St, Augustine's. We consider that the Department of Health and Social Security should have produced guidelines on a procedure which could be nationally adopted, and we recommend that immediate consideration be given to this.
3. The complaint against Mr. IN
4.18 During 1973 three students made complaints against Mr. IN, who has already been referred to in this Report in connection with Incident 3. The complaints included allegations which, if true, were criminal assaults, and allegations involving bad nursing. They were promptly referred to the police who decided to take no action on the alleged criminal assaults. The Hospital should without doubt have then proceeded to investigate the other matters, but failed to do so. It will not be profitable to set out in detail why this was not done. It is sufficient to say that the decision by the police not to prosecute was received within a very short time of the take over by the new administration in April, 1974, and those who should have taken the decision were not informed of what had gone before and were too busy to go into the matter as fully as they should. Such failure, however, does not encourage others to complain about bad nursing procedures. Too easily the apathetic or cynical 'what's the point?' defeats the sense of duty.
4. Other impediments to criticism
4.19 (i) The widespread belief that no action will be taken on a complaint unless there are two witnesses.
(ii) The inept procedures too often followed when complaints were made, for example' in Ash, Hazel, Elm and Heather.
(iii) The failure of too many of such complaints as were made to produce any change. Examples are the failure to investigate properly, or take adequate action on, the complaints about Mrs. Z, Mrs. UG, and Miss OA, and the failure to get sufficient reduction of beds on Hawthorn.
09 February 2025
