4.35 The Chief Nursing Officer commented to the Management Committee that it was not accepted that access to case notes was severely restricted and that student nurses could obtain access to them when required "in accordance with the recommendations of the Medical Defence Union." He did not, however, say that that recommendation did not accord with that in the Report. He went on 'We feel that there should be more ward conferences dependent on availability of doctors (who are at present in short supply)". No comments were received from the Medical Superintendent or the Group Secretary. Mr. C's observations ‘on the table' sad "The more access to records' the less informative they will have to become. There should be more ward conferences and with more medical staff this could happen." The Management Committee endorsed the Chief Nursing Officer's comments after deleting the sentence about the need for more ward conferences.
4.36 There has been a Continuing argument at St. Augustine's about access to patients case notes • The Consultants have in our view adopted an unduly restrictive attitude (see paragraphs. 6.36- 41).
4.37 Paragraph 96 included the important statement "Many nurses felt that they would like to extend their nursing roles realising that nursing care at St. Augustine's is too frequently custodial, the exceptions between Redwood House and Oak House where nurses are encouraged to accept more therapeutic roles". Once again the Medical Superintendent and Group Secretary made no comment. Dr. R recorded "Really!" The Chief Nursing Officer stated "To some extent this is true.” The Management Committee endorsed that comment but no investigations seem to have followed as to why care was "too frequently custodial" Or what could be done about it. That kind of questioning regrettably had to wait for the arrival Of Dr. Ankers and Mr. Weston.
4.38 Paragraphs 98 and 99 reported "Regular ward meetings exist on some wards where multidisciplinary team work is more evident such as Oak House and Acacia. These meetings are an essential art of patient care. The absence of ward meetings on other wards makes it difficult for nurses to contribute to policies directly relating to patient care." There followed the advice Multidisciplinary ward meetings should be established on all wards, weekly where possible and otherwise monthly". There were no comments from the Medical Superintendent or Group Secretary. Dr. R stated "We have been over this topic many times and have been unable to implement". The Management Committee adopted the Chief Nursing Officer's contribution:, "Multidisciplinary meetings are taking place on some wards and some areas and this will be developed further in the future." There the matter rested with no further investigation.
4.39 Paragraphs 116 and 117 dealt with 'Disturbed wards' and stated that these were provided separately for males and females and were locked. “The regime is essentially custodial rather than therapeutic.” The advice was "A multidisciplinary team should consider the policy for disturbed patients and review the need for any disturbed wards. If still considered necessary such a ward should provide intensive treatment, a high Staff/patient ratio, and preferably be open, mixed and of fewer than 30 beds," Neither the Medical Superintendent nor the Chief Nursing Officer nor the Group Secretary commented. Dr. R said "Abolition already agreed under team system." The Management Committee reported "The use of closed wards will be discontinued." Its members had apparently equate a disturbed ward with a closed ward, and had overlooked the advice that if a disturbed ward was found necessary it should be open. The advice that a multidisciplinary team should consider the policy for disturbed patients was not followed.
4.40 We have already described the situation in Heather Ward and the problems caused by its high proportion of disturbed patients. No policy had been discussed or formulated. It provided neither intensive treatment nor a high staff/patient ratio. Dr. W described Heather Ward to us as a disturbed ward, yet when the District Management Team later reported to the Area Health Authority on Dr. Ankers' assertion that these and other paragraphs in the Report had not been fully implemented, they said "It is reported that there are no disturbed wards at St. Augustine's now that the scheme for 'clinical areas' has been implemented." Denial of a problem does not mean that it will go away.
4.41 The Report also recommended that nursing staff should visit the wards at Fulbourn Hospital and see the management of 'disturbed patients'. The Management Committee endorsed the Chief Nursing Officer's. comment that this would be done. A team of nurses visited Fulbourn in May, 1972, and the Nursing Officer who led the party wrote a report on what they had seen. Unfortunately, however, it contained no suggestions as to whether anything they had seen or heard could helpfully be applied in St. Augustine's, and the report was filed until the first part of the Critique pointed out that this paragraph of the Hospital Advisory Service Report, amongst others, had not been implemented. The District Management Team then commented "A party visited Fulbourn Hospital and it is reported they received the impression that conditions were worse than at St. Augustine's." The Hospital's response to this and much of the Hospital Advisory Service Report, including these paragraphs, was negative and defensive.
4.42 Paragraphs 124 and 125.2 pointed out that many of the patients in the psychogeriatric wards had no psychiatric involvement and were primarily geriatric patients, yet the wards were not equipped to nurse geriatric patients. It recommended that they should be properly equipped after advice from a geriatrician. Nobody commented on this, and it was only in late 1974 and 1975 that any appreciable progress was made in carrying out this recommendation.
4.43 Paragraph 125.1 repeated the advice given in paragraphs 71 and 72 that all patients over 65 should be assessed and treated in the first place at St. Martins Hospital. The Chief Nursing Officer had commented "A mixed psychogeriatric assessment/screening unit at St. Martins would be a good thing and welcomed by nursing staff". The Medical Superintendent, however, differed and said it would be a very retrograde step, and suggested an alternative. The Management Committee in their comment to the Regional Hospital Board endorsed the Medical Superintendent's view but failed to indicate that the Chief Nursing Officer had supported the HAS advice. In September, 1974, after Part I of the Critique had pointed out that this and other paragraphs of the Report remained unimplemented, the District Management Team supported the Hospital Advisory Service advice, stating "It is agreed that action is still required to assess and treat all patients over 65 at St. Martins Hospital but lack of resources have so far prevented this." In the Autumn of 1975, St. Martins still presented a picture of a neglected backwater for geriatrics, When visited at 6.00 p.m. one evening patients were being put to bed for lack of any evening activity.
4.44 In its conclusions the Report referred again to the many areas in which custodial care could be found and the "urgent need for a multidisciplinary review of many activities, particularly the formation of teams, the admission policy, mixed sex wards, and the reduction in numbers of the large wards." It added "Nevertheless, there is a considerable fund of goodwill and latent energy waiting to be released." It is significant that many of the items which were not commented on in the notes submitted to the Management Committee related to this need for a multidisciplinary approach. It must have been clear to the Hospital Advisory Service Team that the development of the concept of multidisciplinary teams and the division of the catchment area into sections related to teams working within the hospital would require a great deal of work, and that the Group Secretary would have to provide a major back-up service by collating information, working out areas of the hospital and ensuring that the changeover went as smoothly as possible by getting the right equipment to the right wards. For example, supplies of the correct clothing had to reach wards which changed from female to male and vice versa. This must have been one of the reasons for the advice that he should give up his multiple role, delegate his responsibilities and develop the personnel services. We heard of many problems which arose at the time of, or as a result of, 'areaization', and in our view some, at least, would have been avoided if the Group Secretary had given more time to policy and overall direction instead of continuing to concentrate on the detail which should have been delegated to others.
4.45 We have dealt in some detail with the ways in which the recommendation of the Hospital Advisory Service were treated because a comparison between what we found in the wards and those recommendations makes it clear that if they had been fully discussed and implemented there would have been no Critique. Instead the Report was treated with something approaching a patronising disdain.
4.46 The first part of the Critique was correct in asserting that the paragraphs there referred to had not been fully implemented. The authors could have added many more.
4.47 There should have been full multidisciplinary discussions on the Hospital Advisory Service Report at ward, clinical area and Management Committee level. Only when this had been done could the Management Committee make its report to the Regional Hospital Board. Instead, part of a Management Committee meeting was devoted to the consideration of the individual comments of four individuals, several of whom had failed to comment on matters profoundly affecting or affected by their disciplines.
4.48 Early in 1973 St. Augustine's was visited by the Regional Advisory Team which had been formed by the Regional Hospital Board to follow up visits by the Hospital Advisory Service and to monitor standards generally, The Team's visit was lengthy and involved discussions with a great many people of all disciplines. It was most Unfortunate that its Report nowhere sets out the progress made in implementing the advice contained in the Hospital Advisory Service Report. Moreover, the Team's report was concerned in the main with the long term and did not tackle or refer to the most urgent problems in the long-stay wards: it appeared to concentrate on material needs rather than attitudes and the standard of care provided. We can well understand anybody reading that report coming to the conclusion that there was nothing to cause serious concern at St. Augustine's.
4.49 It is of great significance that, having signed a report in those terms, the doctor who led the Team should have reported to the Regional Administrator following the publication of the first part of the Critique that "most of the comments are basically true", and that the nursing member should have telephoned and written to the Regional Nursing Officer in the terms set out in paragraphs 4.83-88 of our Report.
4.50 We have no doubt that the explanation for the discrepancy between the terms of the Regional Advisory Team's report and the reaction of those two members to the Critique is that that team was over anxious to avoid its Report being received with the same resentment occasioned by the Hospital Advisory Service Report. This exposes the difficulty of having an Advisory Team which is too close to those whom it is advising. The realisation that they all have to work together in the future may, as here, lead to their Report omitting important matters of concern that have come to their attention and of which the Regional Hospital Board should undoubtedly have been informed.
4.51 We recommend that all future follow up visits to Hospital Advisory Service Reports should result in reports which detail •the progress made on each recommendation. Where it is not intended to implement a recommendation, or where implementation has been postponed or delayed, full reasons should be given. If a Hospital Advisory Service Report comments, for example, that care in certain wards is largely custodial and that there is an absence of multidisciplinary working, the follow up report, no matter who it is produced by, should state whether that is still the position and, if so, what is being done about it.
06 April 2026
