In December Mr. EV attacked another patient and threatened a student nurse with a knife. Application was therefore made to return him to Broadmoor. Dr. Ankers had continued to see a lot of Mr. EV, and on January 12th he and Mr. Weston, who had both resigned from the hospital staff by this time, wrote to the Canterbury and Thanet Health District, the Kent Area Health Authority, the Regional Health Authority, the Community Health Council for the District, the Home Office, Dr. MO and the Health Service Commissioner for England, saying that Mr. EV had been sent to the hospital for rehabilitation, but that he had been placed on an unsuitable ward, and that there had been no treatment programme and no rehabilitation. They summarised their letter thus "We are writing this letter because Mr. [EV] has been denied what he came to St. Augustine's for. Instead he has been offered nothing but custodial care."
The District Management Team obtained reports from Dr. W and the Chief Nursing Officer which they sent to the Area Health Authority whose Administrator replied to the District Administrator "I should guess that Etsello (Weston) and Ankers, while perhaps having to accept the medical evidence in the Consultant's reports, may nevertheless say that the hospital offered no rehabilitation to him on Heather Ward, and that care was custodial with the minimum of treatment. In other words I am not at all sure that the reports answer the points they made in their letter of January 12th, 1975. Have you any views on this yourself?" No reply was received, but the District Management Team sent a message for all staff at the hospital: "The Team did not accept there was any foundation in the allegations contained in the letter [of January 12th] which contained a large number of inaccuracies and uninformed observation."
In his report the Chief Nursing Officer described how Mr. EV had appeared to enjoy organising and participating in ward activities. He continued: "He, however, became associated with Nursing Assistant Mr. Ankers and for a short while with Staff Nurse Mr. Etsello (Weston), both of whom were critical and, indeed, at times hostile towards any form of authority (I understand both belong to an organisation which does not accept any form of authority) Both of these nurses were apparently not prepared to accept any other opinion than their own as regards treatment prescribed for patients. I think it is fair to say that any disharmony that existed in that ward emanated from the attitude of these two staff members."
It will be apparent from what we have already said how misleading this statement was. Mr. Weston had left the hospital in April, 1974, and it is worth contrasting what the Chief Nursing Officer said in January, 1975, with a reference he had given on him in confidence in June, 1974, to the Senior Nursing Officer (Education) of the Tynemouth School of Nursing. "Mr. Etsello is an intelligent but rather solitary young man with a highly developed social conscience. During the course of his training his ward reports were above average and since completing his training he has worked as a Staff Nurse on a long stay ward where he displayed an interest in the patients' welfare, coupled with a flair for organisation. His health record and time keeping were reasonable and I think he is motivated by a genuine desire for improvement and would recommend him for further training."
One of those documents is thoroughly misleading. That of January, 1975 not only contributed to the District Management Team's rejection of the allegations in Dr. Ankers' and Mr. Weston's letter of January 12th; 1975 but was also the cause of the Regional Medical Officer, who had no first hand knowledge, writing of Mr. EV on February 12th, 1975, "In my view this patient has probably suffered as a result of the influence and contact with Mr. Ankers and Mr. Etsello."
On February 12th, Mr. EV was informed that he would be transferred to Wormwood Scrubs on February 14th. He received 48 hours warning because he had a considerable amount of property which would require packing. On the afternoon of February 13th he saw Dr. W, who formed the opinion that he had been drinking. Dr. W did not say anything to the nursing staff about this, or suggest any modification of his medication.
That evening Mr. EV was visited by Dr. Ankers, who observed that he was pouring a strong mixture of whisky, gin and orange from bottles in his room. He had seen him drinking earlier that day and knew that it was dangerous for him to mix excessive drink with his medication. Mr. EV spoke of committing suicide if things did not work out. Dr. Ankers did not ask the staff if it was wise for Mr. EV to drink more, and he did not report the presence of the alcohol because "I did not want Alex to think that I would report him. Alex was a friend of mine, and I tried to offer him respect within that friendship, and to trust his own judgement."
Dr. Ankers and some friends who had accompanied him left the hospital about 11.15 and warned the nurse on night duty to keep an eye on Mr. EV as they were afraid he might do something to himself, by which the nurse understood they were afraid he might commit suicide. In the early hours of the morning Mr. EV was found dead by his bed. Dr. W in a report prepared for the Inquest said "I assume that he probably killed himself but I do not know."
The post mortem revealed that he had had more than his normal dose of Amylobarbitone and that death was caused by anoxia due to epilepsy and alcohol ingestion. The Coroner's jury returned a verdict of death by natural causes, and added that they did not wish to add a rider as they understood that an enquiry was to be held at the hospital. It is unnecessary for us to question that verdict. It may be that Mr. EV was taking a deliberate risk in the hope of drawing attention to the injustices which he was convinced that he had suffered at the hospital.
Although Dr. W visited the ward about once a fortnight for brief visits, he did not ensure that staff understood what he was trying to achieve with Mr. EV or why. If he had done so we feel that Dr. Ankers might not have got so emotionally involved, but even so Dr. Ankers was at fault in not drawing to the attention of the night nurse Mr. EV's heavy drinking on February 13th, and the presence of the partly consumed half bottles of gin and whisky.
This brings us to the question of hospital policy, or lack of policy, on the consumption of alcohol by patients. In view of his medication it was dangerous for Mr. EV to have more than a double measure of spirits. Dr. W claimed to have told the ward staff that he was not to have any alcohol, other than an occasional light ale on the ward. If this be so, it is hard to understand why he said nothing to the ward staff on February 13th when he suspected Mr. EV had been drinking. He said he relied on word of month for this information to reach all staff, including night staff. He made no entry in the case notes about alcohol because "I have the basic assumption that every patient in the hospital is not allowed to drink spirits, alcohol, so I do not in a sense feel that it needs to be highlighted in each patient's notes". Dr. W modified this and said that he thought that he had been told when coming to the Hospital in November, 1972, that it had been laid down that if a patient was found drunk, the fact should be reported to the doctor.
Examination of the minutes of the Medical Staff Committee in 1972 revealed that the question of drink by patients had been considered at the request of the Chief Nursing Officer. The Medical Staff Committee had replied that patient 'under the influence of drink or drugs' should be reported to the Nurse in Charge and Medical Officer. There was no suggestion that patients should not drink any spirits, although a reminder was issued "of the advisability of warning patients of the possible dangers of combining alcohol with any drugs they are taking. Each individual Consultant will determine his policy towards any individual case."
Although we accept that Dr. W told Mr. Elf that he should not drink any spirits, we do not think that this was sufficiently conveyed to all nursing staff This was the joint responsibility of Dr. W and the Charge Nurses.
In August of 1975 the Medical Executive Committee further considered the question of drink. They stated "There is no objection in principle to patients drinking alcohol socially and in moderation. Indeed this may sometimes be therapeutic. Patients are warned not to mix alcohol with certain drugs, and with one group of drugs in particular they are told (in writing) that alcohol is expressly forbidden."
We consider that there should be a clearly laid down procedure for ensuring that all ward staff are informed of the names of the patients who have been warned not to mix drink with their drugs, and what steps they should take if a patient disregards this advice.
06 April 2026
