This patient was admitted to St. Augustine's in January, 1974 when he was 62 years old. He died on February 14th, 1975 and the second part of the Critique is dedicated to his memory. The manner of his admission to the hospital and his management thereafter, further illustrate the need for a true multi-disciplinary approach, and the problems that can arise when this does not occur.
Towards the end of 1973 Dr. W very much wanted to arrange for patient GT to be transferred from Heather Ward to Broadmoor Hospital. Unfortunately Broadmoor would only agree to accept GT if Dr. W would agree to accept patient EV in return. This kind of exchange between the special hospitals and the General psychiatric hospitals seems quite wrong in principle.
Patient EV had a long history of mental illness since 1950. He had been admitted to St. Augustine's in 1954 and 1955, following threats of stabbing and of attacking his general practitioner with a knife and a red hot poker. He was then diagnosed as suffering from paranoia, and was described as feeling very persecuted and preparing legal action against various people. He was twice discharged into the care of his wife, but in July 1955 he was convicted of murder. Following a reprieve he served ten years in prison before being transferred in October, 1965, to Broadmoor where he was diagnosed as suffering from paranoid schizophrenia and brain damage with epilepsy.
Efforts by Broadmoor to persuade Dr. Q, the Consultant in whose care EV had been in 1954 and 1955, to accept him at St. Augustine's failed. He was therefore transferred to Hellingly Hospital in July, 1969, where he remained until he was conditionally discharged in November, 1970. He was readmitted to Broadmoor in January, 1971, following a quarrel involving a knife.
In the summer of 1973 the Department of Health asked the Senior Administrative Medical Officer of the South East Metropolitan Regional Hospital Board if a vacancy for EV could be found in a hospital in the region. Hellingly was approached, but declined. The letter sent to the Board by a Consultant from that hospital in July, 1973, only came to light after we had concluded the hearing of oral evidence. We quote from it, however, because in our view it contains an excellent summary of the case.
"We do not feel that Hellingly can really offer this patient anything at all, and we are doubtful if in fact a psychiatric hospital is either appropriate or necessary. It must be appreciated that very considerable efforts were made to rehabilitate this patient. Those efforts in fact failed and we can see no way of ensuring that they would not fail again - in fact we feel confident that they would. This would be damaging to both the patient and to the hospital." After suggesting that if he is to leave Broadmoor a hostel under Broadmoor's direct supervision might be appropriate, the letter continues "Transfer to a peripheral hospital seems to us to offer no solution in any direction apart from giving Broadmoor a vacancy. Dr. MO clearly states that he thinks this man is deteriorating so we would not presumably be accepting him with a view to rehabilitation. We know and everybody else knows, that he is extremely manipulative, that he has ample experience of psychiatric hospitals where staffing is difficult and at times precarious, and that he is an ideal manipulator, particularly of comparatively inexperienced staff... We must stress that a person like this has been shown to be inappropriately placed in the conventional type hospital, he does not fit into and is not appropriately classified as requiring acute admission ward care, he himself does not regard himself as a chronic patient and does not identify with long stay patients in long stay wards, and in any case expectations of and for him are utterly different. This means he is very much on his own in every sort of way."
The decision to admit Mr. EV to St. Augustine's was that of Dr. W alone. It was not discussed at either the Medical Executive Committee or the Area 2 Divisional meeting. If, as Dr. W told us There were some informal discussions with Nursing Officers, we are satisfied that the matter was not gone into in any detail. He discussed the matter with Dr. Q, who had already refused to accept him, and who told him that EV was a most disreputable character. Dr. W's predicament was that he felt he had to get Mr. GT to Broadmoor. He had assaulted two members of the staff quite seriously and was, in the opinion of Dr. W, a potential murderer. Dr. MO at Broadmoor would not accept him except as a swap for Mr. EV. Dr. W discussed the position with Dr. MO and the Nursing staff at Broadmoor and decided to accept him, even though he had no suitable ward for him, and he knew the swap to be hazardous.
Dr. W would never have contemplated accepting Mr. EV if he had not wanted to get rid of Mr. GT. In our view swaps of this kind are wrong in principle and should never be the responsibility of the Consultant alone. The risks are great and the repercussions on other patients and staff may be considerable. There should have been formal discussions involving all the disciplines, and the decision should have been taken in this case by the Hospital Management Committee. In future such decisions should be taken by the Hospital Management Team (see Section 6).
Dr. X, the Divisional Chairman, and now Chairman of the Medical Executive Committee, told us, and we accept, that he was not consulted about the swap. His view was that it was not a matter for decision by the Division. "This is the responsibility of the Consultant concerned, and I would not wish to interfere, and could not interfere, in his clinical work." With that view we disagree profoundly, and after some further questioning Dr. X modified his view to the extent of accepting that there should have been consultation with the other Consultants and nursing staff.
By accepting Mr. EV, Dr. W said "I committed myself to his rehabilitation." We are very doubtful if he thought out what rehabilitation he could provide. A realistic assessment was probably that all that could be done was to say to NT. EV "Keep yourself out of trouble for the next 12 months, and we will try to get you some work outside the hospital." Rehabilitation in any other sense was not viable bearing in mind past attempts and the unsuitability of the wards. If this was Dr. W's intention the position needed to be explained clearly to the staff so that they understood the difficulties and the strictly limited objective. We are satisfied that no clear guidance was in fact given.
After a few days in an admission ward Mr. EV was transferred to Heather, which with its mix of patients, overcrowding and understaffing, already had more than enough problems. Staff understood from Dr. W that Mr. EV had come there "for rehabilitation". From the start they and the Ward Medical Officer made it plain to Dr. W that they regarded the ward as unsuitable. Mr. EV told Mr. AZ that "they promised him that he would be rehabilitated and leave the hospital within a year".
Although Mr. EV was given a single room, he started complaining almost immediately at being in Heather. The Ward Medical Officer, who had already expressed to Dr. W her view that the ward was unsuitable, recorded in the case notes on February 22nd, 1974, "He feels that he should be with people who are less disturbed and with people he can communicate with". In spite of this, his behaviour was acceptable to begin with. He bought clothes and sold them to the patients, he took an active part in patients meetings, and formed an Increasingly close link with Dr. Ankers who proved a ready victim for his powers of manipulation.
Although he was offered work in the Industrial Therapy Unit and the hospital kitchen, he chose to work in the ward kitchen. In time his behaviour started to deteriorate, his complaints became more vociferous and he commenced to return from outings the worse for drink. Dr. Ankers attributed this to the lack of a rehabilitation programme and an unsuitable environment. A student nurse also told us that there did not seem to be any useful policy for treating Mr. EV, and that he was left alone by most of the staff. Dr. Ankers became more and more emotionally involved on behalf of a man who he felt had already paid his debt to society. He received no counselling from anyone to help him. Mr. AZ warned him that he must not forget that he was a murderer, but this we feel only increased Dr. Ankers' conviction that Mr. EV, was being discarded because of his past, and that nobody really cared.
Mr. EV needed help in letter writing. On June 8th Mr. V asked Dr. Ankers to help him write a letter to his Member of Parliament. At. Mr. EV's dictation Dr. Ankers wrote a letter in which he complained of the unsuitability of the ward, and made serious allegations about members of the staff, including Mrs. Z. Mr. EV handed this letter to Miss BY a week later and an investigation followed in which it was decided that the allegations were unfounded. Shortly afterwards Mrs. Z was moved for her own safety, and Mr. V and Dr. Ankers were shifted to other wards. The letter was eventually handed back to Mr. EV, who did not despatch it to his M.P.
09 February 2025
