B. Above Ward Level
1. Nurses
5.22 The performance of Senior Nursing Officers was of variable quality. Most have been promoted from within the Hospital, One, at least, was failing for much the same reasons that some of the Nursing Officers were failing. Another needed help and continuing guidance in some spheres. All are hampered by lack of secretarial help. Agreed policies and standards and suitable in-service training will help them all.
5.23 The Chief Nursing Officer emerged from his evidence to us, and from what we heard about him, as a pleasant quiet man who did not like difficult decisions and failed to give the nursing staff the professional identity and leadership his job required. As we said earlier in this report, and will refer to again later, this is not surprising in view of his personality and long standing position of subservience to Dr. A. and Mr. B. If the Management Committee wished for new ideas and for the nursing staff to be led to a greater independence and responsibility, they should not have appointed him as Chief Nursing Officer. We wondered whether a desire to retain the long standing balance of power in the hospital may not in part have been responsible for his appointment. He was inadequately prepared for his new role, and had been in an acting position for a humiliatingly long period before he was finally appointed Chief Nursing Officer in December 1971. He retired in July 1975.
5.24 This balance of power with the nurses in a subservient position Was not easily disturbed. Mr. CX took up his post as Principal Nursing Officer in September, 1972. He came from St. Wulstan's Hospital, Malvern, and brought with him new ideas and a far from subservient attitude which were badly needed at St. Augustine's. In a short time he made some progress, but he found that he was unable to use his initiative and left in May, 1974. His departure was a. great loss to the hospital.
5.25 Mr. CX told us something of the position of the nurses. "First and foremost the status and accommodation for Nursing Officers was appalling. The SNOs and Nursing Officers all shared one little room with three desks between 15 and 20 people. I thought this was intolerable." He described how a position was achieved where each senior Nursing Officer has a small office and each Nursing Officer has a desk and chair in the central office.
5.26 Another problem was the lack of initiative by Senior Nursing Officers and Nursing Officers. "I came into a position where they did they were told, but never as they felt their right to do". In this They were reflecting the behaviour of their Chief Nursing Officer. In Mr. CX's opinion the Group Secretary ran all but the medical side of the hospital, which was effectively in the control of Dr. A. although he was no longer formally the Medical Superintendent, Mr. C. "saw it not necessarily as his duty, but his need to report to these gentlemen, one every morning and the other quite regularly. This, again, was a source of annoyance to me because I did not see it as absolutely necessary with the nursing administration being a profession on its own and wanting to stand on its own two feet."
5.27 Mr. CX tried to increase the status of the nursing profession in the hospital, asking that he and the Principal Nursing Officer, Education, should attend the Heads of Department meetings, but Mr. B did not agree and the request was turned down. He also suggested that they should attend the Medical Executive Committee meetings to facilitate a free exchange of views between the two professions. This again was turned down, although during his last few months he and the Principal Nursing Officer, Education, were invited into the meetings for 15 minute periods to explain the Salmon structure.
5.28 We were left with the impression that there had been a deliberate closing of the higher ranks in the hospital to prevent this intruder from disturbing the accepted balance of power. We do not doubt that he was regarded as abrasive and 'too big for his boots'.
2. The Doctors
5.29 When the hospital was split into clinical areas in August, 1972, each area formed a psychiatric division. There were three adult psychiatric divisions and one child psychiatric division. Although all disciplines were represented at divisional meetings they were outnumbered by the doctors.
5.30 All the doctors of the hospital belong to the Medical Staff Committee which was formed in 1972 and meets once a week. It is concerned with routine medical matters and reports to the Medical Executive Committee which normally meets monthly and is attended by all the Consultants, the Divisional Nursing Officer, the Senior Psychologist and the Community Physician. Until his retirement the Chief Nursing Officer attended.
5.31 We have already mentioned that staff working in the hospital did not seem to know who was responsible for taking decisions if there was disagreement. Some of the lack of clarity is well demonstrated by the following extracts, from the evidence given by Dr. A and Dr. X, the past and present chairmen of the Medical Executive Committee,
5.32 Dr. A. was asked about his understanding of his role as Chairman of Area 1 Psychiatric Division,
“Q. To whom do you regard yourself as being responsible as Chairman of Division 1?
A. To whom do I regard myself as being responsible? In what sphere? Professionally?Q. For the running of the Division. You are the person who is primarily responsible for Area 1, are you not?
A. Yes. Q. To whom are you responsible? - A. I am responsible to myself.Q. Is there any other area of responsibility than the clinical one?
A. I do not think that T regard myself as responsible medically. I would not use the word 'responsible?. I am obviously responsible to other groups and bodies - the DMT, the Area Health Authority and the Regional Health Authority."
5.33 Dr. X. on the other hand considers that the psychiatric divisions are "accountable to the Medical Executive Committee. They are in a sense sub committees of the Medical Executive Committee as I see it". He explained that the Psychiatric Divisional (Area) meetings and the Medical Executive Committee are concerned with "medical matters basically".
5.34 Of the Medical Executive Committee Dr. A said that "it is concerned with major policy decisions mostly medically based". Efforts were made to clarify the role further:
Q. Does it have responsibility for coordinating the medical and nursing services within the hospital?
A. Very much less the nursing services, but certainly the medical services. It always receives reports from the different divisions and from its own medical staff committee and other sources. It has a coordinating function, yes.Q. Is it in any way concerned with the standard of nursing at ward level.
A. No, I do not think that it would be concerned with the standard of nursing at ward level. It might be concerned with the deployment of nurses or with the functions of nurses; for example, an increase in the number of psychiatric community nurses or a matter of general policy affecting us all, but not necessarily the standard of nursing at ward level.Q. If it were felt by the members of the medical staff that the standard of nursing was unsuitable or inadequate or that the standard of teaching of nurses was inadequate, how would they pursue that point of view?
A. By individual members of the medical staff regarding individual instances?Q. No; in general terms?
A. I suppose that if it was felt on the whole that the nursing of patients was inadequate, it would clearly have to be brought up at the Medical Executive Committee, but I cannot envisage such a thing happening."
5.35 Later on Dr. A. appeared to be indicating that if a. Division (Clinical Area) reported unhappiness about some matter, action might be taken by the Medical Executive Committee, and he was asked "do you regard the medical Executive Committee as having a monitoring function?" Answer: "No."
"Q. You do not? -
A. It is very limited I think.Q. You do not regard it as having a monitoring function?
A. I am sorry, I do regard it as having a, monitoring function of essentially medical performance.Q. Did the Medical Executive Committee have a monitoring function for the care of patients on Heather Ward?
A. No, apart from any information that might have been given about Heather Ward in an area or divisional report to them."
When it was suggested that his answers were hedging and amounted to both 'Yes" and 'No" he disclaimed any such intention.
5.36 When we endeavoured to find out how far the Medical Executive Committee is concerned in divisional (Clinical Area) affairs, Dr. A. said "the Medical Executive Committee was not very much involved in divisional affairs, unless it was being asked to formulate some major hospital policy which might have affected everybody in the hospital. T think divisions very much, perhaps too much, took care of their own affairs."
5.37 Towards the end of his evidence we tried to find out to what extent the Medical Executive Committee regarded itself as responsible for patient care.
“Q. Did the Medical Executive Committee collectively, in your view have an overall responsibility for the care of patients in the hospital?
A. More individually than collectively. As far as policy decisions are concerned, collectively their major decisions influence the care of patients.Q. I do not understand the answer. Is it not capable of a clear answer? Did the Medical Executive Committee have an overall responsibility for the care of patients in the hospital?
A. I am sorry, but I cannot answer that any more clearly. The consultant has responsibility for the care of his patients.Q. I am trying to find out where the buck stops, to use a colloquialism. In your view, who did have responsibility for the overall care of patients in the hospital?
A. If you have got to accept that any body or person has overall responsibility for other consultants' work, then clearly you can say the chairman or the medical secretary of the Medical Executive Committee or the management teams if you like. I do not understand this concept.Q. You do not understand the concept of an overall responsibility for the care of patients in the hospital?
A. Not for clinical cares no.Q. You feed into the phrase "clinical care". Would you define to me where clinical care ends and other care begins?
A. In the overall circumstances which contribute to the patients’ well being and care, obviously the Medical Executive has a large responsibility. What I am trying to get over is that it is not responsible for an individual consultant's treatment of his patients Perhaps I am misunderstanding or being very obtuse, in which case I am sorry.Q. I am sorry if I have not been making myself clear. Suppose a visitor comes to the hospital and asks you, "who or what is responsible for the overall care of patients in the hospital?" Is that capable of an answer which will be meaningful to him?
A. I think it is a difficult question to answer meaningfully, quite honestly.
5.38 When Dr. A. was asked whether as Chairman Of the Medical Executive Committee he could be described as the leader of all the doctors in the hospital, he replied "Not in any clinical sense”.
5.39 Dr. X said that the Medical Executive Committee "should and does receive communications from the divisions and it should consider them and itself make recommendations. These, in the present bureaucratic system, should be passed on to the District Management Team, which should then pass them to the District Medical Committee, and eventually one would hope that some action would be taken. Apart from this the Medical Executive Committee Considers matters of wider medical importance within the hospital and the relationship of medical matters to the nursing, Psychological and administrative areas..." As Chairman of such an important committee, Dr. X seemed strangely ignorant of the nursing hierarchy. Having explained the relationship of the Divisional and Medical Executive Committees to the District Management Team he added that the nurses "have an independent organisation with which I am not familiar". He did not know if there was any comparable structure in the nursing side. This lack of information Must hamper his function as a co ordinator.
5.40 It would have been convenient to have been able to summarise the above answers, but the difficulty in so doing will be clear, and in this lack of definition and clear understanding of function lie many of St. Augustine's past problems. Dr. W. said "The big problem is that the Medical Executive Committee has got no teeth. It makes recommendations, they are minuted and that is that, nothing happens".
5.41 An example of the lack of, or failure to use, teeth occurred when the Medical Executive Committee recommended that subject to the views of Division 1 there should be a swap of two wards as between Clinical Areas 1 and 2. Clinical Area I rejected the recommendation but the Medical Executive did not consider it any further or report the disagreement to the District Management Team, although satisfied that the swap was in the best interest of the Hospital as a whole.
5.42 Other problems on which the Medical Executive Committee had failed to make any real impact by the time we left were the number of beds in Hawthorn ward, how the number of empty beds in the hospital could be utilised to reduce the numbers in overcrowded wards and the correction of the apparent imbalance between the Clinical Areas which we refer to later.
09 February 2025
