The Daggett allegations continued

3.4.16 It was not until 21 February that Mr Bingley, the Chief Executive of the Commission, learned that the My Concerns document had in fact been received some two months previously. He immediately informed the Secretary of State's Private Office. Subsequently an internal inquiry was held which concluded that the Commission had failed to undertake fully all its responsibilities in relation to its dealings with Mr Daggett, and in particular had missed an opportunity to alert Ministers to the nature of Mr Daggett's allegations before they entered the public domain. The Commission's Visiting Policies were amended to make it clear to all Commissioners the importance of bringing any matters involving allegations of criminal activity to the notice of more senior colleagues including, if necessary, the Chief Executive. Mr Bingley accepted, when he gave evidence, that mistakes had been made and admitted that the policies setting out what Commissioners should do in such circumstances, had been insufficiently clear.

3.4.17 The Daily Express reported on the search of Lawrence Ward on Wednesday 22 January. The story referred to Mr Daggett, and claimed that in the search knives, a grappling hook, drugs and child pornography had been found. It also claimed that a fertilizer bomb had been discovered in the garden. The Hospital briefed the HSPSCT that there was no substance to the stories. The Sunday Express ran a further story on 26 January, quoting Mr Corrigan, the nurse who had been dismissed for gross misconduct. Ashworth denied the story and Mrs Miles wrote letters to the Press Complaints Commission and to Express Newspapers complaining about the stories in the Express papers.

3.4.18 At about this time a reporter contacted the Hospital, saying that he had access to the My Concerns document. He asked whether Child A had been abused. The evidence of Mrs Miles was that she had instructed Ms Hocking, her Communications Manager, to tell the reporter that there was no firm evidence to confirm or deny this. Ms Hocking confirmed in a written document setting out the sequence of events that she had maintained the strictly factual line that there was no decisive evidence on this point, and that the child had been supervised throughout her visits by her father. She was however, uncomfortable with the circumstantial evidence emerging to suggest the child might have been at risk. During this time she was in close contact with Ms Kate Hardy, the Communications Manager at the HSPSCT. Ms Hocking, stated that she explained to Ms Hardy the line she was taking with the media. Ms Hardy, however, maintained that Ms Hocking had given her a categorical denial that the child was abused. Mr Rowden stated that Mrs Miles had also made such a denial.

3.4.19 The HSPSCT appear to think Ashworth had given a categorical denial, and having regard to other matters which were concealed we are inclined to believe that Ashworth Hospital made that denial.

3.4.20 The Police were informed of suspicions about possible paedophile activity on the ward on 28 January. On 29 January Mrs Miles briefed Mr Tinston, the Regional Director. On Thursday 30 January Mr Rowden was told by Dr Jones that she had received a copy of the Daggett Dossier whilst on a visit at Rampton. That evening Mr Murphy contacted Mr Rowden. This call led to Mr Rowden visiting Mr Murphy, although there is a dispute over who initiated the visit. During that call Mr Murphy said that the Daggett allegations were "90 per cent true". Mrs Miles later briefed Mr Rowden that the police would be raiding the house of the ex-patient whose daughter was visiting the Hospital. It appears that the same day the Home Office had received the Daggett Dossier via Alice Mahon MP.

3.4.21 The following day there was a case conference in Bradford concerning the child. That evening she was taken into care. The same day police raided the house of her father in Bradford and removed some 150 videotapes and other items. It emerged that in 1992 there had been a previous case conference concerning the child; Ashworth had been asked to send Reports on the father but the then Medical Director, Dr Sylvester, had failed to answer the letter. Having read the Daggett dossier, Mr Rowden telephoned Mrs Miles and expressed concern over inadequate briefing.

3.4.22 On 3 February Mrs Miles discussed matters with Mr Tinston and Mr Rowden. Mr Rowden asked Mrs Miles why the HSPSCT were not informed of Mr Daggett's real whereabouts and why the HSPSCT had been told the child was supervised at all times. He described Mrs Miles as defensive; she had said that the father was supervising the child at all times. Mr Rowden said that this would not do. That evening, without the knowledge of Mrs Miles, Mr Rowden had dinner with Mr Murphy and several other senior staff. Mr Murphy expressed concerns about the Hospital and the Executive Directors. He said that he had received a copy of a transcript of an interview in August 1996 between a patient, Mr Finney, and his solicitor, in which Steven Finney complained about life on the PDU. This letter corroborated much of the Daggett Dossier. Mr Murphy had said that Mrs Miles had insisted that data from the January search should not be reported to the HSPSCT. He expressed his lack of confidence in the abilities of the RMOs in the PDU. Mr Rowden then briefed Mr Kerr and Mrs Nelson about his concerns. Sir Alan Langlands, the Chief Executive of the NHS Executive, was aware that Mr Rowden had met Mr Murphy.

3.4.23 On 4 February Mrs Miles and Mr Tinston agreed that there should be an independent inquiry into the management of Lawrence Ward. The Police had agreed to investigate the allegations concerning the child. Mrs Miles and senior colleagues had discussed suspending Dr Strickland but felt that this should await the result of the inquiry. Mr Rowden briefed Mr Kerr and Mrs Nelson on his return from Liverpool.

3.4.24 On 6 February officials met The Rt Hon Steven Dorrell, the then Secretary of State, to discuss the allegations. The following day Mr Dorrell announced the establishment of our Inquiry.

3.4.25 The chronology outlined above raises a number of important issues, which we deal with below.

3.5.0 The Delay in Informing the Police

3.5.1 Inspector Marsden told us that the delay in bringing in the police until February was harmful to the investigation. By that time the Lawrence Ward garden had been levelled and patients had erased their videotapes. He commented:

"Certainly I feel if we had been called in at an earlier stage, some of the evidence that was there we would have been able to obtain and we would have been looking at a very different picture today."

3.5.2 The police should have been called in earlier, and we criticize Mrs Miles for not involving them earlier.

3.6.0 Communication

3.6.1 Whilst a number of aspects of the detailed chronology of events remain disputed, one thing is clear: Ashworth Hospital never passed Mr Daggett's document to the Department of Health. The result was that officials were always to some extent kept in the dark. Mr Rowden noted in evidence that he had been given the impression that all was under control:

"When I realized the nature of what Mr Daggett was actually suggesting . . . which was that a child had been into this high secure environment, an eight year old child, the daughter of a known paedophile, to a ward where there were known paedophiles, that pornography caches were there in some substantial quantities, that the financial regimes in Lawrence Ward and possibly elsewhere had been severely compromised, that drugs were available, that staff collusion might have been on the cards, this was a rather, if I may say, more serious picture than the one I think I was being advised on up to the time I saw Steven Daggett's document myself."

3.6.2 Mr Rowden also noted that the HSPSCT had been briefed to the effect that the child had been properly supervised at all times. Ministers had been briefed to the effect that all was being properly handled; he felt that he and Ministers were thereby misled as to the true nature of events on Lawrence Ward. He thought the senior management team had been in danger of losing its grip, still confident that matters could be kept under control.

3.6.3 Mr Rowden in his evidence was surprised that a copy of My Concerns was not sent to the HSPSCT. For her part, Mrs Miles said that she treated the document as a patient complaint:

". . . Because we were already investigating, because Mr Rowden had had by this time the Report into the absconsion, I really did not see this document as being anything other than confirmation of what we were already dealing with, and it was not normal procedure to send patients' complaints to the Commissioning Board".

3.6.4 We think it was wholly unreasonable to regard this as a normal patient's complaint. It was a substantial and complex document referring to extremely serious matters within the PDU. Much of what Mr Daggett had said had been confirmed as being largely true. Mrs Miles admitted the Hospital could not be sure whether or not Child A had been abused. Mr Murphy had made it clear to her that he had grave doubts about the clinical environment of the ward.

3.6.5 Mrs Miles was quite properly briefing the police on her concerns about a possible paedophile ring and was briefing the North West Regional Office and the Commissioning Team. There was such sensitivity on the part of Mrs Miles that it coloured her judgment about how much information she should share. The briefing she was giving clearly did not give senior colleagues the information they needed effectively to assess the real situation. Quite simply, the allegation about Child A being unsupervised in the company of known paedophiles should have leapt from the page and allowed the Commissioning Team to question the Hospital about what was going on. It would have also enabled the Team to keep Ministers properly informed. Mrs Miles told us that one reason for maintaining such tight security was a worry on her part that a very senior member of staff might be involved in a paedophile ring. She disclosed the name to the Panel in strict confidence. We heard no evidence that would support such a suspicion and judge that her fears were wholly unfounded.

3.6.6 Mrs Miles expressed the view that Mr Rowden was in part to blame for the way in which events had progressed to a Public Inquiry. Leaving aside the question as to whether an Inquiry was needed (we are in no doubt that it was), Mrs Miles has only herself to blame for the failure to keep the Department of Health fully informed. Had she not been economical with the truth events might indeed have taken a different course.

3.6.7 To be fair to Mrs Miles, communication problems were not all one-way. Our attention was drawn to a letter to Mr Rowden from a patient, Mr Steven Finney, who subsequently died in February 1997. This letter alleged that nurses had given him illicit drugs, that staff brought in drugs and alcohol and that this was the tip of the iceberg. Mr Rowden took a month to forward this to the Hospital, for which he apologized.

3.6.8 Mrs Miles' failure to pass on the My Concerns document and Mr Rowden's failure to respond quickly to a very serious letter reflect what appears to have been a somewhat dysfunctional relationship between the Hospital and the Board. It is not within our terms of reference to attribute blame for this, and the NHS Executive has acted to clarify matters. We hope matters will have been considerably improved by the new arrangements.

3.6.9 Neither failure should have occurred if a simple two way system of communicating all matters affecting security had been established, but the failures are different in that Mrs Miles' failure involved concealing an embarrassing state of affairs. Her attempt to protect the Hospital from criticism and press censure was misjudged.

3.7.0 The Delay in Searching Lawrence Ward

3.7.1 Mr Murphy had raised his concerns about Lawrence Ward in May 1996. By August and September he and Mrs Miles were convinced that the PCT on the Ward was inadequate and that Hospital procedures had been seriously compromised. In September Mr Daggett absconded and a few days later a find of hardcore pornographic videos was made. Then Mr Daggett raised his concerns about the ward with Mr Murphy and others on 29 October. However, no major search occurred until January 1997. We are bound to ask why the delay occurred?

3.7.2 What is more, a two week "amnesty" was declared in the first part of October 1996 for patients to hand over illicit material. Mr Cannon, a Team Leader, told us he was not sure who declared this amnesty. Mr Arnold, the Ward Manager, told us that Mr Murphy had met the Ward Managers of the PDU as a group shortly after the videotape find and told them to make patients aware that they should hand in any illicit videotapes. However, this was not an amnesty as such, as any clinical issues raised by any videotapes handed over would be dealt with by clinical teams.

3.7.3 We asked a number of patients and staff about the delay in searching the ward. All expressed surprise. Mr Cannon accepted that a large-scale search would require bringing in extra staff, but said that his experience at Broadmoor led him to expect a large search fairly quickly. He told us that one member of staff even complained to the Security Department about the lack of action in around November that year. Mr Foster, the current Ward Manager, denied that the Ward was in any sense out of control in the weeks and months before the big search. He could not understand the delay. He confirmed that the patients had been expecting a big search for a long time.

3.7.4 We asked Mr Arnold about the delay and why he had not carried out a full search immediately. He told us that a full search of all 25 bedrooms was, in his view, beyond his authority; he would have wanted senior backing before taking such a potentially explosive step. He also did not have the staff to do it, nor was there anywhere to put the patients whilst a full search was carried out.

3.7.5 We regard these excuses as inadequate. He should have sought the necessary authority and support to do so. His rather laid back attitude in seeking assistance, if he required it, is important in this regard.

3.7.6 For her part, Mrs Miles explained that she and Mr Murphy were concentrating on managing the absconsion first and foremost before deciding how to manage the situation on the ward. The delay in searching was to allow Mr Murphy to gain more information about the precise situation and to assess what level of support he had in the PDU to do what he thought necessary. She was advised against tightening up procedures on Lawrence Ward by one of the consultants in early November 1996, but ignored that advice. (It was suggested that it was Dr Crispin who had advised against carrying out a search of Lawrence Ward in November 1996. Dr Crispin had no recollection of so doing.) Mrs Miles was, however, concerned about carrying out the search before Christmas, the Christmas period being a time of tension in a High Security Hospital, and so it was delayed until Mr Murphy was back from leave.

3.7.7 Mr Gardner told us that around this time a number of changes were being made to tighten up security, such as the reintroduction of central inspection of mail and central checking of videos. There was talk about independent search teams being introduced. There was concern that a full search at that time might have been seen as provocative. He accepted that such a search might have uncovered far more.

3.7.8 Mr Murphy, in his evidence, appeared to blame Mrs Miles for delaying a search which he was ready to carry out in December, although he noted that staff appeared to have been warned that a search was in the offing and he wished to keep an element of surprise. In the event the search on the 17th of January revealed that a large number of videotapes had been recorded over by Ceefax. Patient Q told us he had personally wiped around fifty videos in anticipation of a search. Patient H confirmed that patients were busily wiping their videotapes.

3.7.9 Mrs Miles thought that the situation needed to be approached carefully:

" . . . in a crisis I tend to deal with things calmly, coolly and collectedly, and I think in that sort of Hospital that is the way you deal with a crisis. You do not run around like a headless chicken making a drama out of events. You have to deal with them calmly and coolly and the fact that was how I was dealing with it, I am afraid must have been interpreted by Mr Rowden ­ but he certainly did not ask me at the time ­ as me not dealing with the issues in the way that he thought I should".

Mrs Miles accepted the situation was serious, but she disputed that the Hospital was out of control.

3.7.10 We believe that Mrs Miles' delay left a potentially dangerous situation longer than necessary. We see no reason why Lawrence Ward could not have been searched very early in October at the latest. We share Inspector Marsden's view that had it taken place then much more would have been found. The totality of the evidence points to Ashworth Hospital wanting to take as much sting as possible out of a Report of the findings of the search. For this, as Chief Executive, Mrs Miles must bear the main responsibility, but others could have counselled her to act more urgently had there been a feeling that a search should have been made regardless of the consequences resulting from the findings.

3.8.0 Monitoring

3.8.1 The delay in searching so as to be sure of her ground leads one to ask why was Mrs Miles not better informed about the problems on Lawrence Ward? Mrs Miles told us that all the information she was getting back, both in terms of monitoring Reports and verbal briefings, was telling her that Lawrence Ward was stable and not a problem. It was not until Mr Murphy arrived that she realized that things were not as they should be. But this does suggest she did not have her finger on the pulse of this part of the Hospital.

3.8.2 We asked her why she had not been more visible on that particular ward. Mrs Miles admitted that she did not visit the ward, even though by September she had identified it as a potentially serious problem. She and Mr Murphy had agreed that he, as Clinical Director, should front activities within the PDU.

3.8.3 Mrs Miles can also justifiably be criticized for failing to grasp this situation more quickly. She commented to us that the procedures and processes of monitoring were in place, but that people let her down. This may be true up to a point. But it does suggest an over-readiness to accept those comforting monitoring Reports and a failure to question those in charge of the PDU more thoroughly. The record of poor performance of Dr Strickland when in charge of the Owen Ward PCT should surely have suggested the need for close monitoring by the senior management team.

3.8.4 We asked Mr Keown, author of the Report into Events on Lawrence Ward, whether Mr Murphy should have known more of what had been going on. He thought not; Lawrence Ward was going on in its traditional way, and ward staff were familiar with the way it was run. They did not see anything out of the ordinary to report upwards.

3.8.5 But Mr Keown did think that the situation on Lawrence Ward, which we discuss at length below, should have been picked up by the PCT and members of the PDU management team. The problems posed by the garden should have been obvious; the way in which the shop was operating; the practice of allowing Mr Corrigan to run his own shop; the frequent trips to buy stock for the shop were all obvious enough. The problem was that the development of such practices on Lawrence Ward had been insidious over a number of years, so people on the ward had not seen the wood for the trees. Even so, sight must not be lost of the fact that the Lawrence Ward PCT, as had the Owen Ward PCT before it, had been instrumental in thrusting matters of security into the background.

3.8.6 The Hospital management had missed what was happening over a period of years.

3.9.0 Management Culture

3.9.1 One of the most curious aspects of this affair is the dinner at Mr Murphy's house, because it involved several senior managers of Ashworth Hospital meeting the Director of the HSPSCT in private. Mr Rowden clearly saw this as a highly unusual event, a briefing outside the management line by a senior manager who was concerned that he could not take these issues to his Chief Executive. He accordingly ensured that his Chairman and line manager were aware of, and approved, his action in going to meet Mr Murphy.

3.9.2 But Mr Murphy in his evidence presented it as a normal enough occurrence to have a meeting with a purchaser. Mrs Miles was aware of the issues; he had what he described as an open relationship with members of the HSPSCT. He saw the impetus for the meeting as coming as much from Mr Rowden as from him. However, he did not tell Mrs Miles about the meeting (contrast Mr Rowden's actions in informing his senior colleagues).

3.9.3 Mrs Miles told us she was extremely surprised that Mr Murphy had chosen to go outside the management line. He had come to her in May 1996 speaking of his concerns about Lawrence Ward and she had been working with him closely. She could not understand why he should wish to go outside the line at that point. We believe that her procrastination in taking action played a significant part in his doing so.

3.9.4 A further disputed point is whether Mr Murphy had stated that he and his colleagues had no confidence in Mrs Miles and her top team of directors. Mr Murphy agreed that he had expressed concerns about the management culture of the Hospital and thought the management team were not appreciating the seriousness of the position. But he denied that he and colleagues had said they had no faith in Mrs Miles. He did not feel she was well-advised.

3.9.5 Mr Michael Bateson, a Principal Social Worker, was also at the dinner. He told us that he expressed his concern to Mr Rowden that a child had been put at risk. He denied he had expressed any lack of confidence in Mrs Miles, whom he thought was taking matters seriously; his concerns were about the attitude of Mr Dale, whom he thought was underplaying the seriousness of the situation and putting the interests of Ashworth above those of the child.

3.9.6 This meeting between a senior manager of a provider hospital and one of his purchasing opposite numbers cannot be regarded as a perfectly normal meeting. Mr Rowden clearly did not understand it in this light and he was right not to do so. The action he took to brief his senior colleagues and to ensure that they understood and approved of what he was doing was, in our view, very sensible. This was a very important meeting from Mr Rowden's point of view, and whatever may have been in Mr Murphy's mind, we believe that the impressions Mr Rowden took back with him and of which he told us were a genuine distillation of the meeting. We accept Mr Rowden's overall version of events.

3.9.7 Whatever the precise circumstances of the meeting the mere fact it took place reflects poorly on the secretive management culture of Ashworth Hospital. If Mrs Miles had been briefing Mr Rowden fully, what Mr Murphy said to him that night would not have been news.

3.9.8 If Mr Murphy had concerns about the senior managers around Mrs Miles, so too did she, judging by the fact that she did not fully brief all her senior management team about the January search before it happened. She also did not trust her head social worker enough to involve him in liaising with Bradford Social Services.

3.9.9 The impression we gained was of a beleaguered Chief Executive working very hard to control an unwieldy organization, but hampered by a senior management team riven by very serious divisions. This was compounded by a relationship with the Commissioning Team at the centre of government which was characterized by distrust and secrecy, and a new freedom for action granted by Special Health Authority status that encouraged the senior management team in their belief that they could and should do it all alone.We turn now to discuss Mr Daggett's allegations in detail.

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.

3.10.1 We have described how the allegations made by Mr Daggett in his 24-page document My Concerns came to light. We invited Mr Daggett to give evidence to the Inquiry to expand on those allegations. A number of other patients who were resident on Lawrence Ward at the relevant time also gave evidence. In addition, we called the key members of the Patient Care Team on Lawrence Ward, as well as more junior staff.

3.10.2 The allegations made by Mr Daggett are graphic and shocking.But we are well aware that personality disordered patients are quite capable of making malicious complaints and accusations. In assessing the truth or otherwise of what Mr Daggett said we have also had the benefit of the Hospital's internal inquiry into Mr Daggett's absconsion (The Kendrick Report), the inquiry into financial irregularities and other matters on Lawrence Ward (The Keown Report) and the inquiry into Child Care Issues at Ashworth Hospital Authority ("IR2"). We were also privy to the witness statements taken by Merseyside Police, and the conclusions of their investigations. The IR2 Report was later withdrawn by the Hospital on the grounds that it was deeply flawed by its lack of expertise and independence. We were told that the Hospital had withdrawn the Report in a letter from the Acting Chief Executive dated 30 September 1998. When we first saw the IR2 Report we had noted those weaknesses and placed no reliance on it except in so far as it referred to matters, for example documents, which were not so stigmatised. We deal with this matter more fully at paragraph 3.23.3 et seq. below.

3.10.3 Mr Keown and his team were asked to investigate financial irregularities referred to in the Kendrick Report on the absconsion of Mr Daggett, to review and comment on relevant guidelines and policies on patients' financial dealings, to consider any other matters related to the above and to make recommendations. Mr Keown and his team concentrated on events between January and October 1996. In the event, the focus of the Inquiry broadened as new issues came to light. The result is a Report which covers much, if not all, of the ground which we were asked to review.

3.10.4 Mr Keown made the point, which we echo, that the findings of his team's inquiry were very similar to that of the Owen Ward Report and the investigation into patient S. Braund. Ashworth Hospital had failed to learn the lessons from the previous inquiries and found itself faced with the same problems of patients subverting systems for their own ends.

3.10.5 We would like to say at the outset that there were deficiencies with Mr Keown's Report. He and his team only interviewed one member of the PCT, namely Mr Arnold, and other interviewees were not given the opportunity to respond to allegations made by patients or staff. The conclusions were at times based wholly on patient reports. Several patients complained of coercion, complaints that in one case at least were partially upheld. The Report did not always amass sufficient evidence for its conclusions. In many ways it was a pity the team saw fit to range over the whole gamut of Mr Daggett's allegations. But these shortcomings do not nullify the whole investigation. The circumstances were clearly such that fuller investigations would merely have confirmed the findings.

3.10.6 Below we discuss at length the allegations made by Mr Daggett, as well as other areas of concern, such as patient access to cash cards, which emerged during our Inquiry.

3.11.0 The Allegations

3.11.1 The allegations concern the misuse of both prescribed and proscribed drugs; a trade in pornography, at least some of it involving children; poor standards of security; poor standards of clinical care, in Mr Daggett's and others' cases; financial irregularities; and possible paedophile activity.

3.11.2 By far the most serious allegations concern the possible abuse of a little girl, Child A, who over a period of years was visiting two patients on Lawrence Ward, Mr Corrigan and Mr Hemming. We feel it is important for the readers of this Report to have some impression of what sort of men these patients were. We reproduce the graphic words of Leading Counsel to the Inquiry, Mr John Royce QC, at Knutsford:

"The first man, Mr Peter Hemming, had a very substantial history of paedophile activity with young girls. Back in 1972 he indecently assaulted a nine year old girl and then three days later he tricked a seven year old girl and a nine year old to go with him to a secluded place, where he forced the nine year old to perform oral sex. He was sent to prison. In 1975, he impersonated a police officer and in the process persuaded a 12 year old girl to allow him to search her physically, and he fondled her genitalia in the process. In 1977 he accosted a 11 year old girl in an alley. When she resisted, he banged her head against the wall. In 1978 he enticed a 11 year old boy into a building, he threatened him with a knife, forced him to strip, he committed acts of gross indecency with him, he then tied him up and kept him until the following morning, when he repeated those acts of gross indecency with that young boy. He was sentenced to six years' imprisonment, of which he served four. Five days after his release from that prison sentence, he stopped two young girls of about nine and ten. Again he pretended to be a policeman. He enticed them to an area where they were out of sight, he made them strip at knife-point, he used tape to bind and gag the younger girl. He then forced the older girl to have oral sex with him, he then started to strangle her until she lost consciousness. He then hit her head against a concrete step. When she had recovered to some extent, he bound her with tape, and stuffed a sock in her mouth. He then forced the younger girl to have oral sex with him and when the first girl managed to escape from this terrifying ordeal, he himself fled. He was convicted of indecent assault, actual bodily harm and attempted rape. It was that offence that led him to being given a hospital order unrestricted in time and that led to him coming to Ashworth Hospital.

"The other man, Paul Corrigan, had a severe, serious history of abduction and buggery of young boys, and served various sentences of imprisonment. But the offence which led him in due course to come to Ashworth is breathtaking in its awfulness. In November 1981, a 13 year old newspaper boy used to make his way across a park to deliver his newspapers. Corrigan had been released from
prison early that year, but in November, he saw this lad and he hatched a plot. He plotted to kidnap him, to bind him with chains, to gag him and to cover his head with darkened goggles so that he could not see where he was going, and indeed that is what he did three weeks later with the help initially of another man. He
chained him, put the goggles over his head, he forced him at knife-point back to his flat. At the flat, he was subjected, that boy, to a catalogue of torture, of sexual acts, and other activity which was so foul and degrading that it was all part of the humiliating and horrific ordeal that young man had to undergo at the hands of Paul Corrigan. Eventually he was taken out into the country, where Corrigan used the knife on that boy in a way that almost defies belief. He cut off or partially cut off his genitals; he inflicted about 100 wounds upon him, and finally he cut open his stomach and left him in a ditch to die. The body was found by three schoolboys the next day."

3.11.3 These crimes are sickening. It is against this backdrop that one must ask why this child was allowed to visit these men, frequently unsupervised, at all, let alone on any ward, but particularly on this ward housing patients with serious personality disorders, all of whom had serious criminal histories, including murder, rape and sexual assaults against children.

3.12.0 Lawrence Ward: A Ward Apart

3.12.1 Child A visited Lawrence Ward literally hundreds of times. How could such a thing happen? One needs to understand the historical background. We heard from various sources that Lawrence Ward was regarded by patients and staff alike as a bit different: a ward where patients were trusted, where there were very few incidents, a ward which largely ran itself. It had relatively low staffing levels, levels which surprised nurses like Ms Edge coming from higher dependency wards. It was the ward to which official visitors were taken, a "flagship" ward. The now notorious garden was featured in a national gardening magazine. As Mr Moran, who was Ward Manager from October 1993 to June 1994, put it in the context of searching:

"Lawrence Ward was a highly trusted and highly privileged set of individuals. It was like no other ward in the Hospital."

". . . You aspired to go to Lawrence Ward, you earned the right to go on Lawrence Ward, because it was operated on low staffing. They have wine and cheese parties. It was a slow insidious process that the invasiveness of such things as searching ceased."

Mr Moran agreed with the suggestion of Dr Strickland and Dr Crispin's Counsel that the relaxed regime of Lawrence Ward was well-known throughout the Hospital. Both staff and patients believed Lawrence Ward was different from other wards in the Hospital.

3.12.2 And indeed in some ways it was. The Hospital provided us with a breakdown of serious incidents on the PDU between 1 July 1994 and 31 August 1997. Only 1.6% were on Lawrence Ward, compared to 41.9% on Shelley Ward and 29.3% on Ruskin. This is not to say that the ward was completely without incident: Patient E described how on his first day on Lawrence Ward in 1993 a female visitor was attacked whilst visiting a patient's room. The patient concerned was moved off the ward within half an hour. But such events were very rare. Mr Paterson the Deputy Security Manager indicated that other wards in the PDU, notably Shelley and Macaulay Wards, were of far greater concern than Lawrence Ward.
Mr Day, the first Security Liaison Officer for the PDU, missed many PCT meetings on Lawrence Ward because they clashed with the PCT meeting on Macaulay, which was far more of a "problem ward". Lawrence Ward was not a priority for the Security Department.

Ward Philosophy

3.12.3 The philosophy of the ward was enshrined in the Lawrence Ward Information Booklet, subtitled A Fine Wind is Blowing the New Direction of Time (a quote from D.H. Lawrence). This was revised in 1993. The Mission Statement of the ward was as follows:

"Lawrence Ward is a democratic community of individuals brought together to improve interpersonal relationships, promote personal growth and provide insight through the use of group processes and individual therapies, the ultimate aim of which is their return to society with appropriate continued support to enable the probability of success to be maximised."

3.12.4 Dr Strickland was asked to explain the philosophy of the ward. He admitted that running a therapeutic community in a high security setting was in one sense impossible, given that the patients were detained. The paramount importance of security was also a barrier to developing such a community. But they did try to develop trust between staff and patients:

". . . to work in a collaborative way together, both in terms of designing their treatment programmes and carrying that forward. Also, in terms of the way that security was handled . . . if there was someone who offended against those rules they were moved off that ward."

3.12.5 This is a topic we return to later. If a patient is moved off the ward for offending against its rules, it results in the ward rules themselves never being questioned for this group of patients. The basis of the "therapeutic community" is agreement or consent, a factor usually absent, or at least fragile, in a high security setting. It follows that Dr Strickland's view that a therapeutic community was an impossible concept is almost certainly valid in this setting. As will be seen in Part Six, Dr Snowden makes the point that many of his colleagues asked to provide evidence did not fully come to terms with the problems presented by the severe end of the personality disordered group. A number of facilities which specialize in the treatment of personality disorder such as Henderson Hospital, and Grendon prison can and do funnel their intake in two ways:

a. they only accept those who want to co-operate and change, and

b. they reject those who subsequently fail to co-operate fully.

The High Security Hospitals do not have the freedom to select and reject. In dealing as they do with the very severe end of the spectrum of personality disorder, the procedures such as those at Henderson Hospital would be inappropriate. We return to this topic in Part Six.

3.12.6 Dr Strickland told us that he and his colleagues tried to look at patients' offending behaviour and their general relationships with others, to see how their behaviour could be modified, taking into account the patients' own backgrounds, which were often marked by abusive relationships. Patients would be invited into case conferences to hear what was being said about them, to try to persuade them to confront their problems. His fellow RMO on Lawrence Ward, Dr Crispin, agreed; she stressed the importance of looking at the way in which the personality disorder manifested itself, both in general behaviour and in relation to the index offences. The problem was that many patients were controlled within the confines of Ashworth but were still highly dangerous, because they had as yet not been fully assessed and their offending behaviour addressed.

3.12.7 It is an indictment of the system that patients were in Ashworth and on long-stay wards, without being fully assessed, and consequently without fully developed treatment plans. At least two of the serious events on wards which we have considered in this Report involved such patients.