Contents

Letter to the Secretary of State

Membership of the Inquiry panel

Acknowledgements

Timetable of Key Events

Abbreviations and Glossary

Part 1 ­ Background to the Inquiry

1.1.0 The Establishment of the Inquiry

1.2.0 Composition of the Committee and Terms of Reference

1.3.0 Gathering Material

1.4.0 The Nature of an Inquiry

1.5.0 The Criminal Investigations

1.6.0 Taking of Evidence on Oath

1.7.0 Salmon Letters

1.8.0 Representation of Parties

1.9.0 Handling of Statements

1.10.0 Hearings

1.11.0 Cross-Examination

1.12.0 Credibility of Witnesses

1.13.0 Use of LiveNote

1.14.0 Disclosure of Documents

1.15.0 Assessment of the Personality Disorder Unit

1.16.0 Visits to Other Services

1.17.0 Terminology

1.18.0 The Special Hospitals: a Short History

1.19.0 The Problems of the Special Hospitals

1.20.0 The Broadmoor External Management Review

1.21.0 The History of Ashworth Hospital

1.22.0 Ashworth Hospital Today

1.23.0 The Personality Disorder Unit

1.24.0 A Snapshot of the PDU, 12 February 1997

1.25.0 The Patients' Evidence

1.26.0 The Local Community

1.27.0 The Mental Health Act Commission

1.28.0 The Commission and the Impact of the Blom-Cooper Inquiry

1.29.0 The Commission and the Personality Disorder Unit

1.30.0 The Commission: Conclusions

1.31.0 Mental Health Review Tribunals

1.32.0 Social Services Inspectorate

1.33.0 Ashworth Hospital and the Criminal Justice System

1.34.0 Personality Disordered Prisoners within the Prison System

1.35.0 The Services

1.36.0 The Role of the Home Office Mental Health Unit

1.37.0 The Use of Hospitals as "Quasi-Prisons"

1.38.0 Directing Prisoners to Unwilling Hospitals

1.39.0 Recall to Hospital

1.40.0 Detention versus Rehabilitation

1.41.0 Leave of Absence

1.42.0 Interim Transfer Directions

1.43.0 The Hospital Direction

1.44.0 The Advisory Board on Restricted Patients

1.45.0 The Parole Board

1.46.0 The Probation Service

1.47.0 Care Programme Approach and Post-Discharge Arrangements

Part 2 ­ The Long Road to Lawrence Ward 1989­1996

2.0.0 Introduction

2.1.0 The Establishment of the Special Hospitals Service Authority

2.2.0 The Creation of Ashworth

2.3.0 The New Hospital's Structure

2.4.0 The Report into the Death of Patient Stephen Mallalieu

2.5.0 The Rowe Report

2.6.0 Miss Kinsley's Security Audits

2.7.0 The Blom-Cooper Report

2.8.0 The Task Force

2.9.0 The New Structure

2.10.0 The Implementation of the Blom-Cooper Recommendations

2.11.0 The Swan Report: A Review of The Services for Women at Ashworth Hospital (July 1993)

2.12.0 The Code of Practice (August 1993)

2.13.0 The Creation of the PDU

2.14.0 The Owen Ward Report

2.15.0 The Health Advisory Service Visit and With Care In Mind Secure

2.16.0 Management Matters

2.17.0 The Braund Report

2.18.0 The Finney Report: Investigation into Documents found in Patient Stephen Finney's Belongings

2.19.0 The SHSA and the Hospitals

2.20.0 Security Managers' Meetings

2.21.0 Security and the Security Department

2.22.0 Use of Telephones by Patients

2.23.0 Searching Patients' Possessions

2.24.0 Devolution and Multi-disciplinary Working

2.25.0 The Policy-Making Process

2.26.0 The Dissemination of Policies

2.27.0 Formal and Informal Monitoring

2.28.0 "Visibility"

2.29.0 Patients' Rights

2.30.0 Patient Care Teams

2.31.0 An Operations Manager and Control of Policies

2.32.0 Clinical Arrogance

2.33.0 Inquiryitis

2.34.0 SHSA to SHAs

2.35.0 The SHSA ­ A Balance Sheet

2.36.0 A Special Health Authority

2.37.0 The High Security Psychiatric Services Commissioning Board (HSPSCB)

2.38.0 The Position of the Regional Offices (ROs)

2.39.0 The National Picture: Conclusions

2.40.0 The End of the Road

Part 3 ­ The Daggett Allegations

3.1.0 Steven Daggett

3.2.0 Evaluating the Allegations

3.3.0 Inquiry into the Circumstances Leading to the Absconding of SD and a Review of the Current Leave of Absence Procedure

3.4.0 Events Leading up to the Inquiry

3.5.0 The Delay in Informing the Police

3.6.0 Communication

3.7.0 The Delay in Searching Lawrence Ward

3.8.0 Monitoring

3.9.0 Management Culture

3.10.0 The Allegations about Misuse of Drugs and Alcohol, Financial Irregularities, Possible Paedophile Activity and the Availability of Pornographic Material within the Personality Disorder Unit

3.11.0 The Allegations

3.12.0 Lawrence Ward: A Ward Apart

3.13.0 Clinical Care

3.14.0 The Lawrence Ward Environment

3.15.0 Drugs

3.16.0 Financial Irregularities

3.17.0 The Lawrence Ward Shop

3.18.0 Mr Corrigan's Shop

3.19.0 Cash Cards

3.20.0 Pornography

3.21.0 Garden Projects

3.22.0 Alcohol

3.23.0 Inappropriate Behaviour with a Visiting Child

3.24.0 Visiting Policy: the Context

3.25.0 Hospital Policy on Visiting

3.26.0 The Lawrence Ward Policy

3.27.0 Supervision of Visits

3.28.0 The Reaction of the Patient Care Team

3.29.0 Leave of Absence Trips to Bradford and the Social Worker's Role

3.30.0 Liaison with Outside Bodies

3.31.0 The Approach to Childcare Issues

3.32.0 Room Searching

3.33.0 Leave of Absence Trips

3.34.0 Use of Ward Computer

3.35.0 Computers

3.36.0 The Patient Care Team

3.37.0 The Investigation by Merseyside Police

3.38.0 Conclusion

3.39.0 Computers in the Future.

Part 4 ­ The Professions

4.1.0 Introduction

4.2.0 The Assessment Visit

4.3.0 Professor Sines' Assessment Visit

4.4.0 The Doctors

4.5.0 The Role of the RMO

4.6.0 The Medical Director

4.7.0 The Nurses

4.8.0 The Social Workers

4.9.0 The Pyschologists

4.10.0 Multi-disciplinary Working

4.11.0 Social Therapy ­ Time for a New Profession?

Part 5 ­ Accountability and Responsibilities

5.1.0 Accountability

5.2.0 Comments on Individuals and Organizations

5.3.0 Department of Health Ministers

5.4.0 Mrs Anne-Marie Nelson

5.5.0 Mr Charles Kaye

5.6.0 Professor Pamela Taylor

5.7.0 Mr Paul Lever

5.8.0 Mrs Janice Miles

5.9.0 Mr Peter Green

5.10.0 Mr Colin Dale

5.11.0 Mr Thomas Maxwell

5.12.0 Mr James Gardner

5.13.0 Mr Paul Tarbuck

5.14.0 Mr James Murphy

5.15.0 Dr Joseph Sylvester

5.16.0 Dr Girish Shetty

5.17.0 Dr Ian Strickland

5.18.0 Dr Zona Crispin

5.19.0 Mr Richard Backhouse

5.20.0 Mr Michael Bateson

5.21.0 Dr Mark Stowell-Smith

5.22.0 Mrs Pamela Day

5.23.0 Mr Michael Berry

5.24.0 Mr Alan Arnold

5.25.0 Nurse Paul Boocock

5.26.0 Enrolled Nurse James Corrigan

5.27.0 Father of Child A

Part 6 ­ Personality Disorder

6.1.0 Personality Disorder ­ A Short History

6.2.0 Psychopathic Disorder and Personality Disorder

6.3.0 The "Lottery"

6.4.0 Terminology and Diagnosis of Personality Disorder

6.5.0 Conclusions

6.6.0 Treatment and Management

6.7.0 The Size of the Problem

6.8.0 The Treatment and Management of Personality Disorder

6.9.0 Personality Disorder and Dangerousness

6.10.0 General Conclusions

Part 7 ­ Time for Change

7.1.0 The Problems

7.2.0 A New Model

7.3.0 A Regional Network

7.4.0 The Management of Personality Disorder within the Forensic Network

7.5.0 The New Legal Framework

7.6.0 The Rationale for Change

7.7.0 Other Consequential Amendments

7.8.0 The Reviewable Sentence ­ the Process

7.9.0 The Management of Sentenced Offenders with Personality Disorder

7.10.0 Assessment

7.11.0 Specialist Units

7.12.0 A Third Way?

Flow Charts

Part 8 ­ Recommendations

Ashworth Hospital

The Personality Disorder Unit

Future Services

Prison Service

Monitoring and Inspection

Accountability in the NHS

Mental Health Legislation

Policies

Child Protection

Social Work Department

Physical Security

Searching

Patients' Mail

Security Intelligence Unit

Community Card/Parole

Telephones

Video Cassette Recorders

Internal Inquiries

The Professions

Computers and IT Security

Ethnic Minorities

Appendix 1 ­ The Establishment of the Inquiry

Appendix 2 ­ The Inquiry Process

Appendix 3 ­ Parties and their Representatives before the Inquiry

Appendix 4 ­ Oral Witnesses

Appendix 5 ­ Statements and Submissions Disclosed to all Parties

Appendix 6 ­ Bibliography

Appendix 7 ­ Forensic Psychiatry ­ Secure Units

Appendix 8 ­ Visits

Appendix 9 ­ Amendments to the Mental Health Act 1983