| Ashworth Special Hospital: Report of the Committee of Inquiry | ||||
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PART 1 Background to the Inquiry 1.1.0 The Establishment of the Inquiry 1.1.1 On 7 February 1997 the Right Honourable Stephen Dorrell MP, then Secretary of State for Health, established a statutory inquiry under section 84 of the National Health Service Act 1977 to investigate serious allegations made by Mr Steven Daggett, a former patient of the Personality Disorder Unit (PDU) at Ashworth High Security Hospital. The allegations concerned possible paedophile activity on one of the wards of the PDU, the availability of pornography, drugs and alcohol, and financial irregularities. At the same time, the then Chief Executive, Mrs Janice Miles, was suspended and Mr Erville Millar was appointed as Acting Chief Executive. 1.1.2 Dr Hilary Hodge was appointed as substantive Chief Executive in October 1997. Her appointment was not a success and she left the Hospital in June 1998, with Mr Peter Clarke, Chief Executive of Mental Health Services of Salford NHS Trust, taking over as Acting Chief Executive. 1.1.3 We deal with the events leading up to the establishment of this Inquiry in greater detail below. 1.2.0 Composition of the Committee and Terms of Reference 1.2.1 The Chairman was appointed on 7 February 1997 and the other members of the Committee of Inquiry shortly thereafter. Our membership reflects a broad range of experience and expertise in the law, forensic psychiatric services and health service management. 1.2.2 We were asked to work to the following terms of reference:
1.2.3 In his statement to the House of Commons (see Appendix 1), The Rt Hon Stephen Dorrell MP, made clear that the inquiry should focus on the policies, clinical care and management of the PDU, as this was where problems had emerged. But he noted that the inquiry would wish to follow up any wider questions necessary to a proper consideration of the issues. Mr Dorrell's successor, the Rt Hon Frank Dobson MP, also encouraged us to look more widely than our relatively narrow brief to focus on matters of broad policy interest. 1.2.4 We have indeed used that freedom where we thought it necessary. Thus we have not limited ourselves to a narrow focus on the events alleged and, in many cases, proved to have taken place on Lawrence Ward in and around 1995 and 1996. To do so would have ignored the context within which those events took place. First, Lawrence Ward was not the only ward within the PDU to have suffered very major problems since the Unit's inception (we are thinking here in particular of the Owen Ward hostage-taking in June 1994, of which much more below). Second, we could not discuss the various security weaknesses of Lawrence Ward without examining the overall security failures of the Hospital. Third, this Inquiry follows the earlier Blom-Cooper Inquiry of 1991/2, which quite rightly launched a radical change in the nature of the Hospital. But the implementation of its recommendations was fatally flawed as far as the Hospital's personality disordered patients were concerned. To understand the troubled history of the PDU one needs to understand the aftermath of the Blom-Cooper Inquiry. 1.2.5 At the same time we were aware that we needed to give our work clear chronological limits. We decided it would be sensible to go back in time as far as 1989, the year management transferred from the Department of Health to the new Special Hospitals Service Authority and to continue up to October 1996, when Mr Daggett returned from his absconsion. For obvious reasons we have concentrated in particular on the years 19931996, but there was an inevitable drift into 1997. 1.2.6 We have also taken the view that to tackle the second part of our remit sensibly we had to examine in detail the controversies surrounding the diagnosis, treatment and treatability of personality disorder and the right services for individuals with personality disorder. In this we concentrated our attention on the severe end of the spectrum of personality disorders, on the sorts of offender who have found themselves in Ashworth Hospital's PDU. We therefore devoted some two weeks of hearings to evidence from some of the acknowledged experts in personality disorder. We have published their expert submissions as a separate volume. We are very grateful to the experts who generously gave their time. We have been much helped by their thoughts. 1.2.7 Furthermore, although the holding of seminars by public committees of inquiry has not always proved worthwhile, we decided to hold three - one on the management of this difficult group of patients, the second on matters of accountability within the National Health Service and the third on legal issues which appeared to require to be considered. We held all the seminars after we had heard all the evidence with the object of testing preliminary views which we had formed. Because we were testing preliminary views we decided not to hold the seminars in public, and we invited prominent experts to assist us in these sounding board exercises. This enabled us to hear from a wider range of people with appropriate expertise than we could possibly have invited to give evidence. 1.2.8 The seminar which looked at the management of severely personality disordered individuals was attended by some 50 clinicians, managers and others. The third, which focused on the legal issues raised by severely personality disordered offenders, was attended by a small group of judges, academic lawyers, forensic psychiatrists, civil servants and others. The second which we organized concerned accountability. Any inquiry such as ours focuses on serious problems and inevitably judgements have to be made about where responsibility for any errors lies and who should be accountable to the outside world for the effective running of a service. It is also important to judge individuals in the context of the system in place during their time. A defective system within which individuals have to work can contribute substantially to personal failure. To help us refine our views on what principles of accountability are appropriate for a service such as the NHS we invited a small group of interested parties to discuss a number of the relevant issues. 1.2.9 We are extremely grateful to all those who attended these sessions. We found them extremely helpful in challenging and refining our thinking. 1.2.10 We turn now to the nuts and bolts of the inquiry process. 1.3.0 Gathering Material 1.3.1 For some months after the Inquiry was established a steady stream of papers emerged, largely, but not wholly, from the Hospital. Initially, in order to decide the main routes to be explored, the Chairman, Secretary and Solicitor to the Inquiry in various combinations met a number of people with in-depth knowledge of Ashworth Hospital and indeed of the High Security Hospitals in general. We received much helpful information and assistance, for which we are most grateful. 1.3.2 In the meantime the Hospital set up a small team led by Mr Peter Green who rendered us much assistance in identifying relevant material. Having been at Ashworth for some years he was well placed to coordinate the production of potentially relevant documents. We are grateful to Mr Green and his team, who at all times have responded to our requests to the very best of their ability. As will be seen, he and his team did not enjoy the same level of cooperation from within the Hospital and in particular the PDU. 1.3.3 By the time we started to hear evidence in November 1997 we had amassed a formidable quantity of documents, with many thousands of pages being disclosed to parties to the Inquiry, although we had sifted out many more. We were confident we had received more or less all of the potentially relevant material. However, during the first session of hearings it emerged that this was not the case. At a very late stage large quantities of documents were served relating to serious incidents. One particular set of documents related to very serious allegations made by a personality disordered patient who later died. This late service of documents greatly inconvenienced us and other parties to the Inquiry. Mr Green gave evidence on a number of different days, but just before his final appearance, for some reason he had been relieved of his duties at Ashworth Hospital. We lost a valuable assistant at a critical time. 1.3.4 Mr Green's last appearance came about because we recalled him to explain these problems. He told us that the vast amount of information that was sent to the Inquiry did not emanate from the PDU, which had been obstructive from the beginning of the Inquiry. It got to the stage where he had written to the Acting Chief Executive expressing his frustration at the PDU's lack of support. Things did not improve greatly thereafter. From time to time we felt that the flow of documents later disclosed, and which could have been disclosed much earlier, was being controlled so as to inhibit their thorough digestion. 1.3.5 We are quite satisfied that Mr Green and his team fulfilled their duties diligently and honestly. Unfortunately some members of the PDU appear to have been less than cooperative, for whatever reason. 1.3.6 This episode also reflects the lack of a central information system within the Hospital itself, which would have given the Inquiry ready access to much of the information which emerged so late. There was no reason why any of the material we were given late in November 1997 could not have been in our hands in March or April. 1.4.0 The Nature of an Inquiry 1.4.1 Unlike Sir Louis Blom-Cooper's Inquiry into Ashworth Hospital in 19912,1 this Inquiry was given statutory powers from the outset. The effect of section 84 of the National Health Service Act 1977 is to give an inquiry powers to compel persons to give evidence or to produce papers; and to take evidence on oath or affirmation. 1.4.2 A public Inquiry such as this is not like a civil or criminal trial which are adversarial in nature. A public inquiry which is inquisitorial, is aimed primarily at establishing the truth rather than proving guilt or innocence. In Paragraph 28 of the Royal Commission on Tribunals of Inquiry, Cmnd 3121 (1966) (chaired by the Rt Hon Lord Justice Salmon) Lord Justice Salmon points out that it is the Committee's responsibility, as an inquisitorial tribunal:
The Inquiry has the freedom to conduct its operations as it sees fit; to decide what documents it needs to see; whom to call as witnesses; and how to proceed, in order to discharge its responsibility to the public to arrive at the truth. There is some guidance available, particularly in the six principles set out in Lord Salmon's Report. These are:
[Paragraph 32.] The thread that runs through those principles is that an Inquiry should be both fair and thorough. However, a limited adoption of some adversarial practices can assist in the process. 1.4.3 Committees of Inquiry have considerable freedom to pursue their enquiries as they see fit. It is a freedom with a mixed blessing. Unlike a judge in a civil or criminal trial, the panel does not receive papers which have already been prepared by lawyers. In paragraph 30 of the 1966 Royal Commission it is said:
1.4.4 Preparation is therefore a Committee of Inquiry's first task, and we touched on that in 1.3.15 above. Members of the public may be surprised when a committee set up as a matter of urgency does not immediately begin to hear evidence. It cannot do so. The oral and documentary evidence is "out there somewhere", but it has to be found, considered and sifted for relevance. Additionally an appropriate scheme for dealing with relevant evidence at hearings has to be devised. 1.4.5 Each judicial inquiry is different, and has its own particular issues of process to address. We discuss below the major procedural issues facing us and how we have addressed them, and outline other important aspects of our approach to our remit. At Appendix 2 are copies of Press Notices we issued on 28 July 1997 and 17 October 1997. 1.5.0 The Criminal Investigations 1.5.1 Firstly, we have always had to bear in mind that ours was not the only investigation into aspects of these allegations. Merseyside Police have investigated very thoroughly the suggestions that a child visitor may have been abused within Lawrence Ward and we have been careful throughout not to interfere with the progress of their investigations. For their part, Merseyside Police have been extremely helpful to us and we are grateful to them. 1.5.2 The existence of these investigations, and the possibility of criminal charges, have had serious implications for how we tackled our remit. Early on it became clear that the best way to avoid any interference with the criminal investigations was to reverse the order in which we handled its two main parts, tackling the more general part of our remit first. We anxiously considered whether such a decision would "put the cart before the horse". Part One of our remit involves a fact-finding exercise concerning what happened on Lawrence Ward. Part Two involves considering how things happened, why they could have been allowed to happen and what needs to change. Part Two also involves the wider consideration of the policies, clinical care and procedures of the Personality Disorder Unit and its security arrangements. Additionally we were charged with considering the management arrangements for securing effective clinical care and appropriate security needs of patients. 1.5.3 The two parts are not separated by water-tight bulkheads, but there was no disadvantage in tackling Part Two first. On the contrary there was a positive value to be gained. The more we learned about the management, care and treatment of personality disordered patients, the better able we were to appraise the management, clinical care, security and other arrangements prevalent at the time with which Part One of our remit is concerned. 1.5.4 From another point of view the decision to deal with Part Two first was fortuitous. The investigation by Merseyside Police took some months longer than expected. As a result the Crown Prosecution Service did not receive papers until September 1997. Had we opted to deal with Part One first we may have had to delay the November hearings. In the event the Crown Prosecution Service did not decide whether any prosecutions should be brought until about four weeks after our hearings had commenced. 1.6.0 Taking of Evidence on Oath 1.6.1 A second issue was whether or not to take evidence on oath or affirmation. There are arguments on both sides. Asking each witness to swear an oath or to affirm may give the inquiry more of an adversarial court-room air than is desired and affords no protection against a witness determined to mislead. Yet by taking evidence on oath one can give witnesses who have unpalatable evidence some measure of protection, by in effect forcing them to reveal the truth on pain of perjury. Also if one feels that would be helpful in some cases, it would be best to apply it in all, so that all witnesses are subject to the same process. We decided to ask all witnesses to give evidence on oath or affirmation. 1.7.1 A third thorny problem was that of the issue of these documents, so-called "Salmon letters". The Royal Commission had recommended their issue as a result of their historical review of inquisitorial processes. From the middle of the seventeenth century until 1921 the investigation of events giving rise to public concern had been by Select Parliamentary Committee or Commission of Inquiry. By 1921 this type of inquiry was entirely discredited and the Tribunals of Inquiry (Evidence) Act 1921 was passed. The 1921 Act had its defects and the Royal Commission was set up to examine whether it should be abolished or kept in its then, or amended, form. It was concluded that certain matters which gave rise to public concern could not be dealt with by ordinary civil or criminal proceedings. Although the inquisitorial procedure was "alien to the concept of justice generally accepted in the United Kingdom", it must be used "to preserve the purity and integrity of our public life without which a successful democracy is impossible". 1.7.2 Having recognized defects in the 1921 Act Lord Salmon recommended six cardinal principles to remove the difficulties and injustices with which people involved in an inquiry may be faced. These are quoted in paragraph 1.4.2 above. The issue of Salmon letters was recommended to implement the second of those cardinal principles. 1.7.3 Lord Salmon recognized that the form of the document disclosing to the witness the substance of the case against him must be left in each case to the discretion of the tribunal. The point is this: the six cardinal principles introduce into the inquisitorial process limited elements of the adversarial system so that the Tribunal is as fair as possible to the witnesses it calls. What has to be remembered is that the inquisitorial process has none of the formality of the adversarial process, as Lord Salmon recognized (Paragraph 30). 1.7.4 In their Report into Complaints at Ashworth Hospital Sir Louis Blom-Cooper and his team warn against the tendency to interpret the Salmon letter process too rigidly. We agree. There is a lack of precision in the machinery of an inquisitorial inquiry. If this were not so the raison d'être for its use would be defeated. 1.7.5 We would also note in passing that all of the six Salmon principles are recommendations, rather than rules. As Sir Richard Scott, Vice Chancellor, said in the context of his own Inquiry:
Our general procedure, however, was different from that adopted by Sir Richard Scott. 1.7.6 In this spirit it must be understood that a Salmon letter is not a precise document. It is intended to help a witness who may be criticized to understand what he may have to address when he gives evidence. It does not however circumscribe permitted questioning of a witness, and any attempt by legal representatives to seek to treat it as a quasi-pleading must be resisted. 1.7.7 In this Inquiry we were conscious that a large number of individuals could potentially be subject to Salmon letters in relation to relatively minor criticisms. It seemed more appropriate to restrict the use of Salmon letters to more central figures. 1.7.8 We adopted a policy of sending those individuals who were judged to be at risk of serious criticism a letter setting out the main areas where the Committee requested their assistance. These letters made clear that further issues might arise during the course of the Inquiry to which individuals would have to respond. We tried to draw these letters as a series of issues or questions. (An example is found in Appendix 2.) 1.8.0 Representation of Parties 1.8.1 One of the issues that arise in an inquiry such as ours is the representation of parties, and in particular, who should be represented at public expense. With regard to the latter point there is a well-known rule of thumb to the effect that the public purse will meet the reasonable costs of any necessary party to an inquiry or tribunal who would be prejudiced in seeking representation were he or she in any doubt about funding. However, the costs of substantial bodies are generally not met from public funds unless there are special circumstances. 1.8.2 We granted representation at public expense to the patients within the PDU and a number of individuals connected with the events in the PDU. Apart from the patients on the PDU, we sought to restrict representation strictly to those parts of the hearings which touched upon an individual's own interest. 1.8.3 With regard to the patients within the PDU we followed the eminently sensible precedent of Sir Louis Blom-Cooper's Inquiry by selecting a single firm to represent all patients, thereby avoiding a multiplicity of representation. Pannone and Partners was selected after a tendering exercise. We did grant separate representation for the Liverpool hearings to Mr Steven Daggett, whose original dossier of complaints made allegations against a number of patients. It was felt that any one firm would face a conflict of interests in representing both Mr Daggett and the other patients within the PDU. 1.8.4 Appendix 3 lists the parties represented at the Inquiry. 1.9.0 Handling of Statements 1.9.1 We took the view that witness statements should be kept confidential and not circulated to parties until decisions had been taken on which witnesses to call and until we could judge with reasonable accuracy the extent to which particular parties needed access to the statements of particular witnesses. 1.9.2 This is another area where the distinction between inquisitorial and an adversarial proceedings becomes apparent. It is the Committee which is inquiring. Other witnesses are only "cross-examined" by parties with the permission of the Committee, and not as of right. As a matter of fairness, if a witness testifies adversely to a party, then it is right that such a party should be enabled to challenge such a witness, but when the witness' evidence in no way affects another party there is no need for that party to have the witness statement or to cross-examine. 1.9.3 Lord Salmon, suggested that even those to whom Salmon letters are sent need only be given the substance of the evidence against them. Thus in making witness statements available at a reasonable time before the hearing we took the view that we were being as fair as possible. 1.10.0 Hearings 1.10.1 We were determined to hold as many of the hearings as possible in public, whilst recognising that some evidence might need to be heard in camera. On several occasions we had discussions over whether or not to allow names to come into the public domain. For the most part we took the view that names should be revealed. On some occasions we deemed it right to use a coded procedure. 1.10.2 We held two preliminary hearings, on Thursday 7 August and Friday 10 October 1997. These hearings provided an opportunity to establish clearly the procedures of the Inquiry and to clarify any questions, as well as to identify the parties to the Inquiry. 1.10.3 The main hearings began on Monday 3 November 1997 at the Great Western Royal Hotel London and continued, sitting Monday to Thursday, until Thursday 11 December. The hearings resumed on Monday 2 February 1998 in Ashworth Hospital itself, where we took evidence from a number of patient witnesses. On Thursday 5 February we held a special session at Maghull Town Hall, to give local councillors the opportunity to put their views directly to the Committee of Inquiry. The hearings continued in London from 10 February until 19 March, first at the Great Western Royal Hotel, and latterly at the New Connaught Rooms, Holborn. 1.10.4 The final set of hearings started on Monday 27 April 1998 at Knutsford Crown Court, where we sat to facilitate the hearing of more patient witnesses. After two weeks in Knutsford we moved to the Adelphi Hotel in Liverpool for the final two weeks, where we finished hearing evidence on Thursday 21 May. A final hearing took place in London on 6th July to hear final submissions from the parties. In all we sat on 69 days. 1.10.5 A word should be said about the location of the hearings. We decided that the hearings concerned with the second part of our remit, namely the general policies of the PDU as opposed to the specific allegations about events on Lawrence Ward, should be heard in London rather than Liverpool. The reason for this was the convenience of potential witnesses. We had decided that in order to tackle this part of our remit appropriately we would have to consider very general issues concerning personality disorder. We therefore intended to invite a large number of people to give evidence from different parts of the country and duly picked London as the most convenient point to meet. But when the focus of attention was firmly on the PDU, and in particular on Lawrence Ward, we heard evidence in the North West. 1.11.0 Cross-Examination 1.11.1 We were concerned to ensure that legal representatives kept their cross-examination relevant and reasonably brief. In the event we found that in order to keep to our timetable we had to guillotine cross-examination time. This was with hindsight a very important step. It forced representatives to focus on their key points in cross-examination and enabled us to get through a very large amount of evidence. From time to time within his discretion, the Chairman allowed counsel a little more than their allotted time. Having allocated time on a guillotine basis it was important that parties were allowed their full allotment if they needed it. To ensure this a chess match dual clock was acquired. One clock was marked panel and the other marked party. When members of the panel asked questions counsel's clock was stopped and only re-started when counsel recommenced questioning. We are very grateful to all parties for their cooperation. 1.12.0 Credibility of Witnesses 1.12.1 As far as the credibility of witnesses is concerned Sir Louis Blom-Cooper's Report contains an interesting and instructive chapter. Sir Louis and his team state:
1.12.2 We agree that personality disordered patients can give reliable evidence. However, the more manipulative they are, and many of the patients we were concerned with were not only manipulative but also intelligent, the greater is the need for care in evaluating their evidence. If, for example, they can spend years creating an aura of respectability and trustworthiness so as to gain privileged status, so they can be selective with the truth. We took the view that our hearings should not be delayed by wrangles over the credibility of individual patient witnesses. Of greater importance in judging the credibility of the patient witnesses is that we had an abundance of other evidence. 1.13.0 Use of LiveNote 1.13.1 We made the decision early on to use the LiveNote Computer-aided transcription system which the Chairman had used extensively in court. This system, which gives users a highly accurate, virtually "real time" running transcript, is widely used in courts both in the UK and overseas, and has been tried and tested in a number of public inquiries. It was used by Sir Richard Scott VC in his Inquiry and by the Terminal 5 Inquiry at Heathrow. The Chairman's experience had been that the system saved considerable amounts of time in court (approximately 20 per cent of the usual time) and afterwards in analysing material and producing judgements. As a Panel we would concur. We found the system extremely helpful and are very grateful to our highly efficient stenographers. 1.13.2 We also took the decision to scan disclosed documents and statements on to CD-ROM, both in "read-only" and searchable form. This meant that we could display relevant documents during the hearings, both for our benefit and that of witnesses, which reduced lengthy and tedious delays spent searching for hard copies to a minimum. 1.13.3 The searchable text of the documents has been invaluable during writing this report. 1.13.4 Copies of "read-only" CD-ROMs were made available free of charge to parties. 1.14.0 Disclosure of Documents 1.14.1 A large number of documents were disclosed to parties to the Inquiry, a number of them highly sensitive documents containing patient confidential information. In deciding to disclose these documents we were conscious that disclosure might conceivably result in such confidential information reaching unsuitable hands. At the same time, we were determined that all parties should have the opportunity to see relevant documentation and were unconvinced that editing documents would have been a satisfactory alternative. We took the precaution of insisting that all parties sign written undertakings not to use the documents for other purposes and to return the documents at the close of the Inquiry. Parties were also bound to seek our permission before copying the documents to any third party, eg for an expert opinion. We insisted that any such third party should likewise sign the written undertaking (see Appendix 2). 1.14.2 We are aware of no instance when our trust has been abused and we are very grateful to all parties for their cooperation in this matter. 1.15.0 Assessment of the Personality Disorder Unit 1.15.1 Part of our remit was to review the clinical care provided by the PDU. In order to help us carry this out we commissioned an assessment of the PDU as it now appeared from a small expert team, comprising Dr Adrian Grounds, from the Institute of Criminology at Cambridge University; Mr Tony Hillis, Director of Nursing at the Reaside Clinic, Birmingham; and Ms Lyn Suddards of the Henderson Hospital in Surrey. 1.15.2 The remit of the team was to spend several days within the Unit, observing practice, studying clinical notes and talking to staff, before reporting their findings. We particularly asked the team to examine the care plans and cross-check them against what was actually happening to patients during the time of the visit; to examine records of serious incidents; to review the medication regimes of patients; to find out the views of staff on the leadership of the PDU and its philosophy of care; and to examine staffing levels and skill mix and the training available. 1.15.3 We heard evidence from Dr Grounds and Ms Suddards and have incorporated their findings into our report. We are most grateful to them for their hard work. 1.16.0 Visits to Other Services 1.16.1 We are very conscious that we have been asked to investigate only one part of one of the three Special Hospitals. But we did not believe we could do our job properly without at least some familiarity with the other British High Security Hospitals, and indeed other services which have to manage severely personality disordered individuals. 1.16.2 We have therefore visited a number of services at home and in Europe over the course of the Inquiry, either as a Panel or in smaller groups, including the other Special Hospitals and the State Hospital at Carstairs; prisons, including Grendon, the Max Glatt Centre at Wormwood Scrubs and the Close Supervision Centre at Woodhill; medium secure units; and facilities in Holland, Germany and Switzerland. A full list is included at Appendix 8. We are most grateful for the hospitality of staff at all these institutions, who gave freely of their time and offered stimulating but occasionally depressing advice. 1.17.0 Terminology 1.17.1 It is important to be clear about terminology. Where we talk about psychopathic disorder this refers to the legal classification under the Mental Health Act 1983. It is not in itself a clinical diagnosis. We discuss at length below some of the difficulties surrounding clinical diagnosis, definition and terminology in this area. The reader should be aware that we use the term "severe personality disorder" to refer to a relatively small group comprising individuals who both suffer from a personality disorder or disorders, one of which will generally be anti-social personality disorder, and who pose a risk of causing serious harm to others. Most, if not all, of the men housed within the PDU at Ashworth can be described as suffering from severe personality disorder. 1.17.2 The term "Special Hospital" has not yet been universally replaced by "High Security Hospital". We use both interchangeably through this report. 1.17.3 We turn now to the history of the Special Hospitals. 1 Sir Louis Blom-Cooper QC, Martin Brown, Dr Robert Dolan and Professor Elaine Murphy, Report of the Committee of Inquiry into Complaints about Ashworth Hospital (London: HMSO, 1992), Cmnd 2028. 2 In paragraph 50 of Lord Salmon's Report it is said: "As soon as possible after he [a witness from whom a statement has been taken] has given his statement, and certainly well in advance, usually not less than seven days before he gives evidence, he should be supplied with a document setting out the allegations against him and the substance of the evidence in support of those allegations". Such documents became known as Salmon letters. 3 Scott, Sir Richard, (1996) Report of the Inquiry into the Export of Defence Equipment and Dual-Use Goods to Iraq and related Prosecutions. Paragraph B2.31, volume 1, p.39. London: The Stationery Office.
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