7. The Reaction to and the investigation of the Critique
4.56 The opinion is widely held in St. Augustine's that if the investigation into the first part of the Critique had been better handled there would have been no Second part, and no long, disrupting and expensive Enquiry. Before we look at the main steps that were taken it will be helpful to indicate in broad terms the circumstances and attitudes which did much to shape the pattern of events.
4.57 (i) Both within and without the hospital many people, while doing their best to adopt a responsible attitude to criticism much of which they must have known was well founded, nevertheless felt distaste for the authors. The basis for this distaste is not easy to distil. It had much to do with 'bad form' and 'disloyalty'. They were seen as two young and inexperienced men who did not know their 'station'. The hierarchy had been treated with disdain. Didn't they appreciate that the matters of which they were complaining were inherent in an under financed and understaffed National Health Service? Why pillory St. Augustine's when it was better than many other hospitals?
4.58 We have no doubt that Dr. Ankers sensed the resentment and criticism close beneath the surface of the formal invitations to talk, and that this contributed to his over—reaction.
4.59 (ii) The first part of the Critique was received in April, 1974. within about two weeks of the take over by the new National Health Service administration. Members of the Regional Team of Officers and their supporting staff had worked for the Regional Hospital Board and, with their knowledge and previous contacts, were probably the team most suited and qualified to investigate the allegations in the Critique. However, on 1st April two administrative tiers had appeared between them and St. Augustine's and the investigation had to be left to them, although it was realised that they were hopelessly overstretched in manpower and resources and that the District Management Team contained no member with any psychiatric knowledge or experience. In those circumstances the Area Health Authority would have been wise to accept the Region's offer of help.
4.60 (iii) The Regional Administrator, who had been Secretary to the Regional Hospital Board since 1968, told us that St. Augustine's had not been regarded as a problem hospital in the Region: the Management Committee had been regarded as good and was known to have a high regard for its officers: moreover the performance indicators of press cuttings and complaints indicated no serious trouble, and there had been no complaints from any voluntary organisation. In his opinion the Reports of the Hospital Advisory Service and the Regional Advisory Team, although critical, were far less so than of other hospitals in the Region. A member of the Regional Hospital Board, who he regarded as the best informed in the mental health field, and who had served at the same time on the Group Management Committee, believed St. Augustine's and St. Martins to be the best hospitals in the Region. We are confident that this assessment of St. Augustine's permeated down from the Region to both Area and District.
4.61 We now pass to look at the manner in which the Critique was investigated at various levels and the attitudes of some of the people involved. Where possible we keep to the chronological order of events.
(a) Investigation by the Nursing Administration within the Hospital
4.62 Within a very few days of receiving the Critique, Mr. C the Chief Nursing Officer, on April 24th wrote short but polite letters to the two authors thanking them for sending him a copy, assuring them that the points they made would be considered in detail by the senior nursing staff, and concluding that he would then "like to convene a meeting which I hope you will be able to attend, when the Critique can be discussed and you could then elaborate the points raised."
4.63 Dr. Ankers had a long friendly talk with Mr. C lasting one and three quarter hours on May 2nd. Mr. C asked why he had not brought the grievances to him. Dr. Ankers replied that he had taken them to the Nursing Officer, the Senior Nursing Officer and the Principal Nursing Officer without result and had then decided to adopt other means. Mr. C tried to impress on him the progress already made in the hospital and described the Critique as a "lump of half truths". When Dr. Ankers gave a few examples of Mrs. Z's behaviour in order to illustrate what he meant by mistreatment and malpractice, Mr. C said he thought that they were rather extreme examples and explained that it was difficult to do anything about unsuitable staff because of the power of the Unions.'
4.64 Following this interview, and having heard views expressed within the hospital that they were just two young inexperienced voices crying in the wilderness, the authors began to approach members of the staff to sign a document stating "We, the undersigned, being members of the staff of St. Augustine's Hospital, Chartham Down, Canterbury, endorse in general terms the substance of the Critique Regarding Policy by W.B. Ankers and 0. Etsello of April 1974 relating to St. Augustine's Hospital". It is significant that 33 out of the 34 signatories were nurses. 13 were trained nurses, including four Ward Sisters or Charge Nurses, 16 were either student of pupil nurses, and 4 were untrained Nursing Assistants. In addition to the nurses there was one occupational therapist.
4.65 On May 15th Dr. Ankers had another long talk with Mr. C who asked him not to precipitate a split between young and old attitudes by asking student nurses to sign the document. He added that any Charge Nurse who signed it would be indicting himself. At the end of this meeting Dr. Ankers explained that if there were to be any meetings to discuss the contents of the Critique Mr. Weston must be present. (It will be recalled that he had left the hospital on April 30th.)
4.66 On May 16th Mr. C again saw Dr. Ankers for two and a half hours in the course of which he tried to persuade him to meet the District Nursing Officer and others on May 20th to discuss the Critique. Dr. Ankers said he would do so if Mr. Weston's expenses could be paid so that he could also attend, Mr. C replied that he could not authorise payment of those expenses and asked him to give, particulars of the mistreatment and malpractice. Dr. Ankers declined to give these details as he did not wish for a witch hunt after individuals when he and Mr. Weston were concerned with lack of policy.
4.67 On May 20th Dr. Ankers met the District Nursing Officer in private and she tried to persuade him to attend the meeting that had been arranged, but he repeated his objection to attending without Mr. Weston. She accepted that this was reasonable, but said that she could not authorise reimbursement of Mr. Weston's fares as this was a matter for the District Treasurer.
4.68 There the matter rested and no further invitation to meet the health authorities was extended to Dr. Ankers and Mr. Weston until the end of September. The District Nursing Officer told us that she did not ask the District Treasurer to authorise this expenditure.
4.69 On May 20th Mr. C handed the District Nursing Officer a memorandum of 19th May prepared by Mr. L and in which he sought to set out the views on the Critique expressed by Senior Nursing, Officers and Nursing Officers at a meeting held on the instructions of the Principal Nursing Officer. This paper is full of the two way look we have already described. It included these two sentences:— "It was generally agreed that the Critique had fulfilled a function in reviving the stimulus to overcome shortcomings. The hospital was actively defended against these criticisms." It pointed out that the policy of the hospital was "to get patients back into the community as far as the limitations in terms of finance and manpower allow and that it was probably wise to concentrate on the return of the short term patients. After stating that there was an obligation on staff to use their initiative the memorandum continued "A paper written by a Staff Nurse of many years experience concerning the Critique was unanimously accepted as being the answer to the situation." (our underlining). That paper ridiculed the Critique. Two passages convey its flavour. "My next reaction was that this was sour grapes. A case of the modern trend of student bodies 'doing their thing'. Sit-ins - kick the Admin - Up the Fuzz etc. etc. I felt I wanted to reply in a humourous ridiculous type of vein 'with apologies to Abbott and Costello’, but then I felt that ridicule would be out of place this Critique was ridiculous enough." Then later on: "Only constructive criticism is any good, any bloody fool can read various pamphlets and pick out passages that do not ring true to the existing regime. You may think that that is what I am doing now but I offer the authors constructive criticism if you don't wish people to know you are foolish then don't open your mouth and prove it."
4.70 That this kind of document should have been universally accepted by the Senior Nursing Officers and Nursing Officers as the "answer to the situation" is deeply disturbing. It reveals an attitude of derision beneath the surface of respectability and responsibility in the upper nursing echelons. The District Nursing Officer sent the document to the Area Nursing Officer. It is in our view significant that neither of these officers, nor indeed the Chief nor Principal Nursing Officers, thought it right to meet Senior Nursing Officers and Nursing Officers in an endeavour to lead them to a more constructive response.
4.71 The Principal Nursing Officer's written comments of May 14th were restrained but gave no indication as to whether he regarded the contents of the Critique as well founded. He wrote "I know Dr. Ankers to be a well intentioned and caring young man who I am sure has taken this line of action for best intentions. Mr. Etsello, however, I feel I would have to question his motives. The document is well written — it is bound to have a good effect on the hospital in the long run — my one concern however is that Dr. Ankers is only referring to Heather Ward when, in fact, he quotes the hospital." He then supports what his officers have said.
4.72 On June 5th, Mr. C wrote to the District Nursing Officer expressing his views on the Critique "in relation to the areas where it affects nursing". It is a classic non—answer. First he says that criticism has always been welcomed and encouraged by nursing staff "providing it is constructive and informed and well intentioned", but he continues that he finds the Critique very hard to answer. "Whilst I accept that the criticism is basically well—intentioned it has been developed without a thorough knowledge of many situations here which has resulted in a number of what I can only call half truths being expressed and these are always difficult to answer without going into a great deal of detail". He went on that there were areas needing improvement, but the "nursing administration are very aware of this and are doing their best within the resources, manpower and financial, that are allotted to us".
4.73 Nobody in authority, however, made any enquiries among the student nurses and pupils. It was important to find out whether they agreed with the Critique. If they did, it would surely mean, at least, that such policy as was claimed by authority to exist was not understood by an important part of the caring staff. The fact that they were not consulted confirms our firm view that, whatever the outward veneer, the views of, junior staff were not really welcome, particularly if critical.
09 February 2025
