(c) Investigation by the District Management Team and above
4.81 To the initiated a nod is as good as a wink. Dr. A's ambiguous letter, together with that from Mr. C and a short report from the Unit Administrator, were considered by the District Management Team on July 1 2th, following which the District Administrator wrote to the Area Administrator giving his team's conclusions. He reported that the Medical Executive Committee had 'received' those documents at its meeting on July 5th and 'felt that it had no further observations to make in this connection as the reports were fulsome replies to the Critique'. He continued "The District Management Team... received the views of the Medical Executive committee and agreed that whilst they did not appreciate the wide circulation of this particular document, they did not object to staff giving their views on the standard Of care of patients. The Team accordingly endorsed the comments made in the letter from the Chairman of the Medical Executive Committee commenting on the Critique and also the further comments of the Chief Nursing Officer and Unit Administrator. It concluded by Stating that it had every confidence in the staff at St. Augustine's Hospital."
4.82 There the matter would have rested if the District Management Team had not been encouraged from above to further action.
4.83 What had been happening elsewhere? It is convenient to start with the Regional Team of Officers. On May 14th, Miss MNO, the Regional Nursing Officer, had a telephone call from Miss POW, the Nursing member of the Regional Advisory Team which had visited the hospital in 1973. She told Miss MNO that the Critique did not surprise her and that she felt some of the allegations had Substance: that the allegation that totally unsuitable nursing staff were in positions of responsibility had some substance due to the implementation of Salmon and the assimilation procedure: that the former Group Secretary had been remote and that there had been a suppression of nursing: that the Consultant Medical Staff had a poor relationship with nursing administration: and that there was a general feeling Of simmering under the surface.
4.84 Miss PQR augmented this by a letter of the sate date. It included the following important passages:-
4.85 "There is no doubt that the 'long stay' Patient is not getting the therapeutic approach of a multidisciplinary team in many of the wards, and, while not wishing to make excuses under any circumstances, the fact remains that too few people (medical, nursing and remedial staff) are trying to cope with far too many patients. In these circumstances, apathy and frustration are the result. The initial enthusiasm With which staff approach their role is replaced by a laissez faire attitude when no—one in particular appears interested in their efforts.
4.86 "The impetus for change and encouragement in development of the therapeutic environment MUST, in the first instance, come from the Consultants. In my opinion, this does not happen at St. Augustine's - the concentration of efforts are limited, in the main, to acute admission wards.
4.87 "The H.A.S. Report was considered, in the main, unfair and biased by former management. Many of the recommendations said to have been put into effect by top management were not apparent. The recommendations in our Report (RAT) on the follow up visit were said to have been implemented. I was not present at this meeting and in fact was not convinced that the recommendations had been implemented with any enthusiasm...
4.88 "I am sure this Report is in essence what appears to the authors valid observations. In my opinion, the points raised should be investigated by an outside body. I would not think it wise to leave too long a gap before an investigation takes place. Does the D.H.S.S. ever ask the Health Commissioner to look into Reports of this nature?"
4.89 Miss MNO told the Regional Administrator about Miss PQR's communication on May 20th. They agreed that "the first step would be to discuss at the earliest opportunity with the Area Team of Officers their proposed action concerning the contents of the Critique" and the need to check on certain matters including the complaints procedure, the incident recording procedure in use, progress in case conferences and the establishment of therapeutic programmes, the extent of custodial care, the introduction of a retirement policy for staff and nurses in particular, and the meeting p where staff participation was allowed.
4.90 Everybody was so busy that no meeting could be arranged until July 22nd. In the meantime the Regional Administrator had obtained the comments of the doctor who had been head of the Regional Advisory Team. He reported of the Critique that "most of the comments are basically true".
4.91 It was the meeting on July 22nd which set the District Management Team off on a further investigation. Although Miss MNO told those present of Miss PQR's views, a copy of her letter was not handed over, and we do not think that the Area or District Administrators were fully informed of or, at least comprehended, the strength of the confirmation for the Critique coming from these two former members of the Regional Advisory Team. It is a great pity that their Report in 1973 did not convey their feelings with sufficient clarity.
4.92 On September 11th the Area Team of Officers considered 'a summary of comments' on the Critique by the District Management Team which was presented to them by the District Nursing Officer. At the request of the Area Team a more detailed report on the Critique was produced by the District Team for a further meeting on 16th September. Both documents formed part of the Agenda for the public part of the Area Health Authority meeting on September 17th.
4.93 The first summary included the following passage:— "The following suggestions are being considered as items on which positive action can be taken at the present time", and there then follows:
(i) Development of In Service Training aimed specifically at long serving senior nursing staff, and the establishment of guidelines for implementation of therapeutic activities at ward level:
(ii) the establishment of a patients bank and the relief of nurses from the distribution of patients cash,
(iii) a report by the Unit Administrator to the Medical Executive Committee on the progress of multidisciplinary ward meetings, and
(iv) the establishment of participative Management groups "which could involve such grades as Nursing Assistants".
4.94 However overworked the District Management Team was, it was regrettable that these steps were still in the 'consideration' stage four—and—a—half months after the circulation of the Critique. The Area Team recommended "that a multidisciplinary executive team comprising for example, the Medical Executive Committee Chairman, the Sector Administrator and the Principal Nursing Officer, should be formed to consider the day to day running of the hospital, and "that there should be a policy of staff retraining in modern psychiatric care for staff with long service at" the hospital.
4.95 The more detailed report on the Critique from the District Management Team left very many unanswered questions. In order to give its flavour and illustrate the questions which should have been asked about it we set out the first two sections.
"1 THERE IS LACK OF POLICY FOR TREATMENT OF LONG STAY PATIENTS Medical staff and nursing staff comment that the declared policy is to get patients back into the community and to reduce the number of patients at the hospital, as far as the limitations in terms of finance and manpower allow. The reduction from 1,314 in August 1972 to 1,032 in July 1974 is an indication of the progress made so far', and represents an extraordinary effort on the part of all concerned with the intensive rehabilitation and discharge of these patients. Nevertheless, much remains to be done for those still regarded as long stay patients.
2 THE MAJORITY OF THE PATIENTS DO NOT RECEIVE THE BENEFIT OF INDIVIDUAL TREATMENT PROGRAMMES Consultant medical staff are prepared to accept that they do not spend enough time with their long—stay patients and are concerned about this, but it is pointed out that each Consultant has responsibility for Populations averaging over 120,000 whereas an acceptable figure would be 60,000 The appointment of additional Consultants has improved the situation to some extent and future appointments are planned in 1975. Nursing staff comments are that although there are facilities for Industrial and Occupational Therapy these need to be greatly extended. Proposals for this development are in the Development Programme."
4.96 The first comment confused policy with objective, and in any event left totally unanswered the question "What is the policy for the long stay patients Who cannot be discharged because of their condition or the lack of hostel accommodation?"
4.97 The second comment left unanswered the question "Do any, and, if so, how many, long stay patients have individual treatment programmes?"
4.98 It does not seem to have occurred to the District Management Team which prepared those comments, or the Area Team or Health Authority members who received them, to ask those elementary questions. Why not? The Area Administrator told us that his team were 'very dissatisfied' with the District Team's comments and asked them to be °a little bit more specific'. The Area Medical Officer, on the other hand, said "My impression was at the time of the Area Health Authority meeting in September that the District Management Team had done as reasonable a job as I would have expected them to do… On the medical side my honest opinion was that there was nothing particularly untoward which I could say, or I could identify, as worthy of further enquiry. I was happy." If the Consultants had been asked at that time how many long stay patients had individual treatment programmes they would have answered, as they answered us, 'none'. The Area Medical Officer said such an answer would not have satisfied him that all was well. He was unable to tell us why that question had not been asked, although he explained that he, too, like the Regional Administrator had to some extent assessed the Critique in the light of the known reputation of the hospital.
06 April 2026
