| Ashworth Special Hospital: Report of the Committee of Inquiry | |||||||||||||||||||
 The Long Road to Lawrence Ward 198996 continued 2.12.26 In the course of his Judgment, Judge L.J., who agreed with the judgment of Auld L.J., observed:
2.12.27 Later in his Judgment, having dealt with the position of patients admitted under section 3 he said:
2.12.28 It may well be that some RMOs will argue that the Medical Director has no line management control over individual RMOs in so far as clinical matters are concerned, but we have no doubt that this Judicial Review was rightly rejected. In the Special Hospitals there are fundamental requirements of security that must prevail and be seen to prevail. For far too long there has been uncertainty in this important area. We welcome the clarification provided by this Judgment. Visiting 2.12.29 Paragraph 26 of the Code of Practice is concerned with "Visiting patients detained in hospital or registered nursing homes." 2.12.30 In this paragraph, 26.1 states "All detained patients are entitled to maintain contact with and be visited by whomsoever they wish, subject to some carefully limited exceptions." 26.2 is concerned with the grounds for excluding a visitor. There are two principal grounds which may justify the exclusion of a visitor :
2.12.31 On the evidence we have heard, visitors are a potential source of entry of such matters as are mentioned. We take the view, as with searching referred to in paragraph 25, that paragraph 26 must be applied according to the nature of the hospital concerned. There is a vast difference between Special Hospitals and nursing homes for the mentally ill. It must be necessary to have the ability to search visitors and without cause. The only distinction we would make is that visitors do not inhabit the Hospital and there should be no need to search if the visitor refuses to be searched, but it should be clearly understood that the Special Hospitals have a right to refuse entry to the Hospital to a visitor who refuses to be searched.
2.12.33 Paragraph 26.3 of the Code of Practice concerns "facilitation of visiting". One matter it states is that "ordinarily, inadequate staff numbers should not be a deterrent to regular visiting". In the Special Hospitals it is essential to have the power to insist on visits being properly supervised. We have heard a considerable amount of evidence concerning the supervision of visits, whether ward-based or centrally-based. The need for that power is for purposes identical to the need for the power to search. There is inevitably a limitation on the number of staff available to supervise visits. In the Special Hospitals this is usually controlled by ensuring that visits are pre-arranged so that the number of visits occurring at any one time does not result in inadequate staff availability, but we are of the view that, if at any time, there is an inadequate number of staff available properly to supervise visits, there should be a power to refuse a visitor entry to the Hospital. However, this should not normally occur in the case of pre-arranged visits. Telephone and Mail 2.12.34 Paragraph 26.4 of the Code concerns "other forms of communication". It states:
2.12.35 Recommendation 76 of the Blom-Cooper Inquiry recommended "that patients at Ashworth should have a readily accessible personal telephone system like those available in general hospitals and NHS psychiatric hospitals." Yet misuse of telephones by patients has featured in a number of internal inquiries. 2.12.36 It is clear from the evidence before us that the wide interpretation of that recommendation throughout the Hospital led to abuse, significantly affected the security of the Hospital and, in particular, the Personality Disorder Unit.
2.12.38 Relaxation of the inspection and opening of mail and parcels following the work of the Task Force has undoubtedly led to breaches of security and the introduction into the Hospital of prohibited substances and articles. The minutes of the meetings of the Security Managers, to which reference has already been made, illustrate the different approaches that came into being concerning the inspection of mail and packages as well as problems connected with the use of telephones.
2.12.40 We have also examined the use of computers and computer related equipment which has developed in recent years and made recommendations relating to their possession and use by patients. (See paragraph 3.39.0 et seq.) 2.13.0 The Creation of the PDU The Rationale 2.13.1 We turn now to the PDU itself. Dr Higgins, the medical member of the Task Force set up after the Blom-Cooper Report, described the rationale for creating the PDU. He and Mr Rae, the nurse member of the Task Force, had focused their attention on developing multi-disciplinary working within the Hospital. He remarked that there were some areas of the Hospital where effective multi-disciplinary working was in place, others where it was not. At the time some staff were unused and even resistant to the concept of multi-disciplinary working. Professional rivalry was also very evident. And the management structures and policies of the Hospital were not conducive to consistent multi-disciplinary working. 2.13.2 Dr Higgins, in his statement, outlined a number of weaknesses which he and Mr Rae had identified:
2.13.3 The Task Force decided that changes had to be made to improve the poor co-operation between disciplines and the inadequate development of care programmes defined by patient need. Dr Higgins told us that he and his Task Force colleagues did try to engage the different staff groups in developing ideas about the future, but with limited success. The eventual analysis of the problems was largely the Task Force's own. 2.13.4 We have discussed the Task Force's proposed changes in 2.8.0et seq. above. The Task Force produced an initial Report to the SHSA in December 1992 making its observations on the working of the Hospital. The SHSA considered this and commissioned the Task Force to suggest a detailed reorganization of patient groupings to improve the focus of their care and to produce a revised management structure which would better service the changed hospital. 2.13.5 In their original Report to the SHSA the Task Force outlined a number of consider-ations to be borne in mind when planning the reorganization of patient services. They argued that there was a clear distinction between the treatment needs of different groups of patients: adult men with mental illness; adult men and some young men with pure or predominant personality disorder; men with learning disabilities; women with mental illness, personality disorder and learning disabilities; and other small specialist groups. The largest group was men with a mental illness; this group would almost inevitably leave the Hospital via the psychiatric services in their home locality, usually via their local secure unit. It might therefore be wise to manage together such patients from the same region or adjacent regions in a regime where they were not on the same ward as personality disordered patients with whom they were traditionally mixed. Liaison with smaller numbers of receiving and referring units would therefore be made much easier. 2.13.6 The case for a specialist unit for personality disordered patients was, in short, that by developing a specialist unit some of the well-recognized shortcomings in care and treatment of this group might be tackled. At that time there was no guarantee that a patient suffering from personality disorder referred for assessment would be assessed by a consultant working with personality disordered patients. A specialist unit could ensure that consultants who would potentially be working with a patient actually did the assessment. Such a unit could facilitate the development of recognized forms of assessment, treatment, and outcome measures for personality disorder; it might attract staff of all disciplines interested in this form of work; help facilitate the development of audit and research; and enable clearer distinctions to be drawn between those admitted for assessment, those undergoing treatment and those for whom treatment had failed and who required long-term humane containment on grounds of enduring risk. Furthermore, security considerations would presumably be much higher on the agenda than they would be for the patients elsewhere given that experience had shown that it was predominantly the personality disordered patient who presented the most major difficulties within the Hospital. We applaud these principles, but sadly they were not implemented. 2.13.7 Dr Higgins noted that there were some concerns about the establishment of the personality disorders unit, but these concerns were not raised very vigorously. They included clinical issues about patients who might require mental illness and personality disorder facilities at different times or who, despite the diagnosis, might be better placed for rehabilitative and transfer purposes in a unit not specifically designated to their diagnosis. There were comments about the difficulty of attracting the required numbers of interested and suitably qualified staff, but this was not felt to be insurmountable if the unit truly developed as a dynamic successful entity. Some doubted whether agglomerating the most potentially difficult patients would be manageable. Experience with the two existing longstanding personality disorder wards had shown that problems of control and security might occur. These problems might be far greater in a personality disordered unit. However, these objections were not decisive. 2.13.8 After extensive consultation at Ashworth Hospital and on the SHSA Board it was felt that the balance favoured the formation of a discrete personality disorder unit. If it was properly managed; if realistic operational policies were produced; if effective multi-disciplinary working emerged; if greater expertise developed; and if security was always seen as a matter continually under review, then Ashworth Hospital could safety and securely not only manage its personality disordered patients well, but also contribute to the continuing debate about the treatability of those with a severe personality disorder in a secure hospital setting. Dr Higgins in his evidence admitted that there were a large number of "ifs", but argued that nevertheless the proposal was better than leaving matters as they were. 2.13.9 To allow such a clinical reorganization of the Hospital, the Task Force recommended a parallel reorganization of the management structure, with greater autonomy for the new units and a multi-disciplinary management structure. The professional fiefdoms needed to be removed and strong general management introduced, not least to produce a range of operational policies for each unit and to develop multi-disciplinary working. High calibre managers were seen as a crucial feature of the reorganization process. 2.13.10 We have described above the subsequent Task Force Report to the SHSA in February 1993 which outlined a proposed ward reconfiguration and new management structure in considerable detail. This was broadly accepted and then remitted to Ashworth Hospital for further consideration. The Task Force was wound-up shortly afterwards. Mrs Janice Miles, the new General Manager of Ashworth Hospital, attended the SHSA Board Meeting on 16 September 1993, and presented a paper describing the restructuring proposals for her Hospital, proposals which had emerged after further internal discussions at the Hospital and which were slight modifications of the proposals of the Task Force. Her proposals were accepted. 2.13.11 The PDU became functional in December 1993 and formally came into being in April 1994. It consisted of six wards. Two of the six, Lawrence and Owen, changed little as they had both housed a population of largely personality disordered patients for some years, although the population of Owen had to move from Forster Ward. By contrast, Macaulay, Ruskin and Shelley were significantly involved in the clinical restructuring. Firs Ward (later Newman Ward) was on the East Site. 2.13.12 Dr Ian Strickland was the first Clinical Manager; because he still carried a clinical caseload he was supported by a Business Manager, Mr Martin Royal. The six Ward Managers reported to a Clinical Area Nurse Manager, who in turn reported to Dr Strickland. This structure then changed and the Ward Managers reported directly to Dr Strickland, with a Clinical Nurse Manager introduced in an advisory capacity. Was the PDU Ever Viable? 2.13.13 It is appropriate to consider at this point in the history of the PDU whether bringing together more than 100 personality disordered patients into a single unit was a sensible option. The Mental Illness Units/Directorate have been relatively successful, but the PDU has never lived up to the hopes of the Task Force. Was this foreseeable? 2.13.14 At the theoretical level the argument for a discrete specialist unit is sound. We ourselves are convinced of the need to have specialist units. But were the practical issues thought through? Was the Task Force naive? 2.13.15 We heard considerable evidence to the effect that the PDU, in its early days, was in a parlous state. Dr Strickland noted in his statement that after his appointment in December 1993 he was given the task of bringing together all the personality disordered patients onto six wards, in just two or three months. The intention was that Lawrence and Macaulay Wards would be low dependency; Owen Ward medium dependency, Ruskin Ward medium to high dependency, Shelley Ward high dependency and admissions, and Newman Ward a ward for younger patients. But, in practice, patients moved to where there was a bed available. Sometimes patients separated previously for security reasons were brought back together again thanks to the small number of available wards. In evidence Dr Strickland said he had argued for a smaller PDU, with just three wards. 2.13.16 Dr Strickland also argued that 25-bedded wards were too large for this group, preferring 8-bedded wards instead, with a proper assessment process. He told us that the doctors working on the Unit had had no say in its creation. (Dr Sylvester, the former Director of Medical Services and Lead Consultant on the PDU agreed on this point.) Dr Strickland admitted that there was no real treatment model at the start; the priority had been to manage a large group of heterogeneous patients. It is disingenuous of Dr Strickland to say that doctors had no say at all; we accept Dr Higgins' evidence that, despite trying to involve staff in developing the Task Force's proposals, he and his colleagues received little help from the generality of staff. That said, the establishing of the Unit was highly flawed. We agree with Dr Strickland that both the Unit and the Wards were too big, and that there should have been a proper assessment process. 2.13.17 Dr Strickland's successor as Clinical Manager, Mr Tarbuck, confirmed the overall picture presented by Dr Strickland. He described the PDU when he took it over in the summer of 1994 in the wake of the Owen Ward incident thus:
2.13.18 Many of the staff in post did not want to be there. They were generally ill-equipped to deal with these patients all grouped together: "There were lots of good staff there, but quite a sizeable minority were not able to cope with the work they were being able to do." Mr Melia, now a Senior Clinical Nurse within the PDU, confirmed this picture. He told us that when he became Ward Manager of Macaulay Ward in August 1994, 18 patient moves had taken place over the previous nine months as the mentally ill population of the Ward was replaced by personality disordered patients. The staff were totally ill-equipped to deal with the change of patients, lacking as they did knowledge of the nature and treatment of personality disorder. 2.13.19 In evidence Mr Tarbuck elaborated further on the state of the Unit in mid-1994. The management and staff were not really in control of the Unit; patients had got used to crossing boundaries and staff felt demotivated and disempowered. The Unit was under-established as far as nursing staff were concerned; around one in six staff was on sick leave. He approached Mrs Miles and senior colleagues on a number of occasions and made a detailed case for more resources in a paper entitled Benchmarks for Practice in June 1995. His request was turned down. 2.13.20 Like Dr Strickland, Mr Tarbuck thought that the rationale of the Unit and the therapies it was to offer had not been thought through. He and his colleagues spent much time trying to articulate what might or might not work. He noted that, at the start of his tenure, most of the PCTs lacked psychology input and some lacked social work input; in some instances there was no trust and little respect between members; and minutes were sometimes of variable quality. Mr Tarbuck noted tensions in PCT practice in 1994, with people arriving excessively late; reading notes when being spoken to; leaving meetings to answer telephone calls and so forth. Mr Tarbuck felt that he was "firefighting" until mid-1995, coping with crisis after crisis. Staff had allowed patients inappropriately to cross boundaries; certain patients were colluding and needed to be split up. But Lawrence Ward was not seen to be one of the problematic wards:
2.13.21 Mr Tarbuck's successor, Mr James Murphy, thought the Unit had been created too quickly, with inadequate preparation of staff and too little thought given to the nature of the problems created by putting this group of patients together. Some "untreatable" patients were accommodated with patients just coming into the system, undermining the treatment of the latter. Some staff could not cope. 2.13.22 Mrs Miles confirmed the general picture. She admitted that a number of factors militated against the Unit's success, including the questionable competence of some of the consultants. She agreed that the clinical mix was not ideal; that the wards were larger than she and the SHSA would have liked; and that the creation of the Clinical Units made moving patients more difficult, as there was very little spare capacity within the PDU itself. Nevertheless she defended the decision to create the PDU, even with hindsight; it was necessary she argued, to create the other Clinical Units. 2.13.23 What had happened? A radical new change had been made too fast, with inadequate preparation. Many of the Unit's problems should have been foreseen. To take one example: Dr Higgins made it clear that a high quality manager was key to the success of the PDU. Yet Dr Strickland was appointed as the first Clinical Manager, someone who by his own admission lacked management experience and was not up to the job. There were apparently no external candidates for the job. 2.13.24 Such an innovative venture as this required an in-depth consideration of the implications of putting 150 personality disordered patients together. Once this particular decision was made the die was cast and the Hospital had to live with the consequences. 2.13.25 The SHSA was responsible for agreeing the new structure. They should have been aware of the risks and invested heavily in time and effort to ensure that the right quality of managerial and clinical staff were appointed to the Unit. Mr Kaye admitted that the SHSA had not foreseen the potential problems adequately:
2.13.26 Nobody emerges from this with any credit. The risks involved in creating such a large PDU were recognised from the start, but were sharply increased by poor leadership and implementation. As the Chief Executive of the SHSA Mr Kaye must carry the ultimate responsibility, but many others are also blameworthy. This was not just a reasonable risk that went wrong despite the best efforts of all those involved. It was a high risk that was sharply increased by incompetence. 2.14.0 The Owen Ward Report: Report of the Investigation into the Events leading up to the Hostage-Taking Incident on Owen Ward on 8 June 1994 and related matters. We discuss this Report at considerable length, for which we make no apology. The Report formed a vital part of our investigations and its contents were never published. We have speculated that had this Report been published in 1994, the necessary in-depth examination of the PDU at Ashworth Hospital would have taken place some years earlier than our Inquiry. The Reports 2.14.1 We have already referred to this internal Report as being one of the most serious if not the most serious Report in the history of Ashworth Hospital. It is dated 18 July 1994. The Chairman of the Inquiry was Mr Green (then Director of Business Development), and the other members were Dr P. Coorey (a consultant forensic psychiatrist), Mr Ian Paterson (the Security Resources Manager), and Mr George Alan (the Nursing Informatics Manager). The original Report is 59 pages long and, more importantly, attached to it are 385 pages of appendices. The Report itself presents an appalling picture but with the appendices we can only describe it as horrendous. During the course of our Inquiry we felt it right to congratulate Mr Green and his team for presenting a fearlessly thorough Report which makes a significant number of findings concerning the Hospital's failure to create a safe and secure therapeutic environment on Owen Ward. 2.14.2 The first version of the Report we received came from London. It was 19 pages long and without appendices. The first three pages comprise the title page, and a letter from the then General Manager Mrs Miles. The last three pages are a summary by Mrs Miles of the findings of an external advisor she had appointed to look at the work of the Inquiry and to comment on it. She had appointed Mr J. Parry, the Senior Nurse Manager of the Merseyside Regional Forensic Psychiatry Service, because it was being said that the internal Report would be a whitewash. The original Report was certainly not a whitewash, and Mr Parry's Report was not based on any shorter version. He saw the whole Report and the appendices. Despite being a significant abridgement of the original, the 19-page Report made disquieting reading even though, within it, most of the original recommendations had either been omitted or truncated, and criticisms of policies and practices in place or management's failure to formulate or introduce them had been removed. It omits the whole of the 27-page narrative of the original which is based on the appendices and deals with the terms of reference. It reduces the original 20 pages of recommendations to eight pages. From a reading of the 19-page version, it soon became apparent that a fuller Report existed as well as appendices, and those we eventually obtained from Ashworth Hospital. For many months we were under the impression that at least the 19-page version had been circulated, because in a letter attached to it Mrs Miles writes:
We were to discover this was not the case. It was not until we received the statement of Mr Harry Ryan of UNISON that we discovered, appended to that statement, a yet shorter version of the Owen Ward Report. This is the only version which was ever circulated. It is not surprising that its circulation gave rise to serious indignation. Appended to Mr Ryan's submission is a press release condemnatory of the handling of the Owen Ward Report:
2.14.3 On the 31st day of our hearings we received a copy of this third version in a short bundle. The first page is a letter from Mrs Miles addressed to "Dear Colleague" which describes the Report as the "final Report into the investigation following events on Owen Ward", and indicates that "it is not a public document and is not being circulated outside the Hospital". 2.14.4 We deal later with why, in our judgment, this Report and also the Swan Report were concealed. Owen Ward in 1994 2.14.5 Owen Ward has had a chequered history. The killing of Stephen Mallalieu took place on Owen Ward in 1990, that of Derek Williams on Forster Ward the same year. The patient population of Forster Ward later moved to Owen Ward. By 1994 the Ward was in a parlous state. A general description of the Ward is given in paragraph 2 of the full Report:
We discuss the problems of the "post-graduate" Lawrence Ward in Part Three below. The condition of the ward was clear from the Report into a very serious incident on Owen Ward just a month before the hostage-taking, when the bedroom of Mr J. O'Neill had been set on fire, and that incident has been described as an attempted murder. It was, however, not investigated until the full Owen Ward Report had been received, and Mrs Miles ordered an investigation in a letter to Mr Tarbuck dated 4 October 1994. That Report demonstrates that for some months Owen Ward was in a parlous state and out of control. Both patients and staff were fearful for their lives. We must stress at this point that Owen and Lawrence Wards were not the only wards with problems. There were also serious problems in 1995 and 1996 on other wards in the PDU. We deal below with the investigation into the activities of Stephen Braund on Ruskin Ward, formerly Macaulay Ward, and the investigation of the possessions of Stephen Finney (whose death, after being taken to hospital gave rise to some suspicion as to its cause) found in his room on Shelly Ward in June 1996. These events point inexorably to the conclusion that the conception of the PDU was wrong. Incident followed incident, without effective policies and structures being established and put in place. The simple fact is that it is impossible effectively to manage many patients in this group in the absence of a basic immutable security structure. For them a structured environment providing an appropriate degree of control and security is essential. This was never achieved.
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