Chapter 5 of Report on Ely Hospital

The Male Wards by Night.

162. This aspect of conditions at Ely came before us for two principal reasons:

(a)A former Staff Nurse at the hospital, “T”, volunteered to give evidence before us, having heard of the Inquiry in consequence of radio publicity given to our appointment;

(b)Former Staff Nurse “B” (one of the witnesses originally named by XY), when he did eventually come before us, made allegations which were almost entirely concerned with conditions by night— which was when he was invariably on duty.

It became apparent that the allegations made by both these witnesses centred very largely round the conduct of “U”, who had been, since 1954, the Night Charge Nurse responsible for all four male wards. During the early part of Our Inquiry, it was understood that “U” was represented before us by one of the trade union officials appearing. This later ceased to be the position, since “U”was no longer a member of the union concerned.

163. For this reason, amongst others, there were a number of unsatisfactory features about the way in which we were able to conclude our investigation of these allegations. Our principal difficulties were as follows :

(a) It was not possible for “T” to be cross-examined, when he first gave evidence before us, since his allegations necessarily (in the absence of any preliminary statement taken from him by a solicitor) took the representatives by surprise. When eventually he did return for cross-examination, other witnesses (from patients’ families) were then before us and “T”, having spent some hours waiting to give evidence, was not thereafter able to return on a subsequent occasion. This kind of contretemps was, we found, virtually unavoidable without the assistance of a solicitor in the presentation, and organisation, of the case which we were trying to investigate;

(b) It was only when “B” appeared before us that it became apparent that ” U” was no longer represented by anyone then before us. Since we had already experienced the utmost difficulty in securing the attendance of “‘B” at all (we had to hold a special late evening sitting in order to accommodate him), it was not, at that stage, possible, at such short notice, to organise the presence of “U”, so that he might personally hear the evidence against himself. We had, therefore, no option but to settle for the less satisfactory alter­ native of permitting ” U”—before he himself gave evidence—to see the transcript of evidence already given by “B”. “B” was not, therefore, exposed to cross-examination by or on behalf of “U”;

(c) Since it was not possible, in the absence of any person representing “U”, to arrange for his attendance throughout, several other witnesses in course of dealing with much more general matters, found out there being any possibility of cross-examination on “U”‘s behalf) about such allegations;

(d) A number of possible witnesses to the matters spoken about by “T” and “B” either would not—or could not—appear before us to give evidence.

164 Notwithstanding these difficulties, we have felt it to be our duty to reach conclusions about all these matters, since they have, in our opinion, an important bearing on the state of affairs which we were investigating. Although our method of Inquiry could not, for the reasons stated, match up to the strict requirements for a disciplinary investigation, we feel confident that we were able, notwithstanding the difficulties, to reach clear conclusions about whose validity we have no doubt. We should, however, make it plain (specifically in connection with the complaints made by ” T “) that we deliberately did not re-open the investigation made into his original allegations, since these were some four years old. What we did concern ourselves with, as being of much wider importance, was the way in which ” T’s ” complaint, as well as that later made by ” B “, was investigated and dealt with. Since ” T’s ” complaint was made at a time before the constitution of the present HMC and at a time when the posts of Hospital Secretary and Secretary of the HMC were held by their previous holders, we considered the conduct only of those officers who are now still in post.

165 This means that we did not hear evidence from the former Hospital Secretary, nor from the Secretary to the former HMC. These were the people in post at the time of “T’s” complaint. No such difficulty arose, of course, in connection with “B’s” complaint, since all the present officers were in post at that time.

The “T” Affair

166.”T”, who was born in 1910, is a Registered Mental Nurse. He had been nursing for at least 12 years before he came to Ely, in the spring of 1962. His home was in Aberdare, some 25 miles away. At the time of his appointment, it was plainly understood by the Chief Male Nurse, and generally at the hospital, that (apparently for reasons connected with his travel to and from work) it was inconvenient for him to be employed except on night duty. He was, therefore, appointed to the night staff and, plainly, throughout his time at the hospital, employed upon that basis. Until he resigned from the staff (in circumstances discussed below) in January, 1964, his conduct and performance as a nurse had been without reproach. Our own impression of him as a kind and conscientious man entirely coincided with the Physician Superintendent’s description of him as “reliable and diligent”. He was held in the same high regard by the Chief Male Nurse. His professional organisation was the Royal College of Nursing.

167 On 22nd January, 1964, he wrote a letter tp the Physician Superintendent, in which he alleged that Night Charge Nurse “U” had ill-treated a patient and, subsequently, offered violence to himself. In this letter, State Enrolled Nurse “V” was identified as a witness at least to the concluding together with the then Hospital Secretary, investigated the complaint by inter­viewing “T” and “U” and examining the patient said to have been concerned. Nothing was then discovered to confirm or disprove the allegation, which was denied by “U”. The witness “V” does not appear to have been seen. The Chief Male Nurse appears scarcely to have been involved in the investigation of the complaint at that or any other stage. The complaint was accordingly reported. In due course, a special meeting of the HMC was arranged for 13th February, 1964, to investigate the complaint.

168. Before this meeting of the HMC took place, the daughter of the patient concerned in the alleged incident received an anonymous letter, telling her about it—and alleging that “nothing has been done about it”. Solicitors instructed by the patient’s mother communicated with the Legal Adviser of the RHB, so that the text of the anonymous letter became available. Save, however, upon conditions which were not regarded as acceptable, the solicitors were not prepared to make the original (nor apparently a photocopy) of the letter available, so that its authorship could not be further investigated—either by the HMC or by ourselves. It was not suggested to us that “T” was the author of this letter (he first became aware of its existence when he was challenged about it in cross-examination before the HMC); nor is there any reason whatever for supposing that he had anything to do with its authorship. The Legal Adviser to the RHB, eight days before the HMC had sat to investigate the allegation made by “T” against “U”, wrote to the solicitors acting for the patient’s mother to the effect that:

“the person against whom the allegation was made has categorically denied the allegation, and preliminary enquiries indicate that the allegation is completely untrue”. We do not feel ourselves called upon to consider whether or not it was wise for the matter to be dealt with in quite those terms at that early stage of the investigation.

169. The HMC held a long meeting to consider the complaint on the appointed day. Both “T” and “U” were invited, if they wished, to bring a trade union representative with them to this meeting. “U” was represented in this way. “T” was advised, however, by the Royal College of Nursing that was no need for him to be so represented since no complaint had been about him. The procedure followed at the HMC’s meeting was set out a letter which we saw. From this it appears that the Physician Superintendent in a role analogous to that of prosecuting counsel, making a report at the start of the proceedings, being then himself exposed to cross-examination thereafter “calling his witnesses”. No full record of the proceedings was to us. The Chief Male Nurse was not invited to attend before or upon the committee. Nor was the witness “V” (identified in “Ts ” original letter of complaint) called before the Committee.

The Committee’s conclusion was recorded as follows: “After careful consideration the Committee find the allegations not proven.”A rough handwritten note, jotted down by someone (perhaps the then Secretary of the HMC) at the end of the hearing also recorded the following: ” Case not proved, clash of personalities, keep men apart.” “U” was told by the HMC that if in future there was the slightest evidence of any similar conduct on his part, the HMC would deal with him severely because they were very disturbed about the gravity of the allegations. No further steps appear to have been taken to investigate the origin or authorship of the anonymous letter to which we have referred—nor to identify the circumstances which might have caused such a letter to be written.

170 On the Monday following the HMC’s meeting, 17th February, 1964, the Chief Male Nurse discussed the matter with the Hospital Secretary and Physician Superintendent. He claims not to have been told the result of the HMCs deliberations, save to the extent that he appreciated that ” things were going “U”‘s way”. In consequence of these discussions, agreement certainly appears to have been reached that the only way of dealing with the ” difficult personal relationships ” between “T” and “U” was for “T” to be asked to give up night duty. Later that day the Chief Male Nurse did speak to “T” along these lines. Before doing so, however, he had already told “U” what was in the air and “U” took the view that the suggestion which was going to be put to “T” was “obviously tantamount to asking him to resign”.

171.The Chief Male Nurse certainly appreciated that the upshot of what he had been told by the Hospital Secretary was that “U” would remain on and that it “looked as if ‘T’ might have to go”. He agreed that, in view of “Ts” plainly understood preference for night work, the request for him to change to day duty was “tantamount to securing his departure” and that “T’s”resignation was “the object of the exercise”.

172.In the upshot, “T”, having explained to the Chief Male Nurse when the matter was discussed with him that it was not possible for him to change to day duty, did tender his resignation. He was thereupon told to finish working at the hospital on the following Thursday, 20th February, 1964. He did in fact leave the hospital on that day and, although he wrote at the time to the local representative of the Royal College of Nursing that “the officials are doing everything to prevent a scandal by forcing upon me my resignation “, he took the matter no further—and in due course, obtained employment as an “attendant” at an Old People’s Home nearer to his home.

173.The Chief Male Nurse told us that, at the time of these matters, he had already received a number of complaints from other members of the night staff about “U’s ” manner of dealing with them and of dealing with patients. These were to the effect that “U” was inclined to be quick-tempered, loud-mouthed and aggressive. We were not able to investigate these in detail—but they were consistent with other allegations which we did investigate with “U” himself, and to which we refer below. It is right to say that the Physician Superintendent does not appear to have taken the Chief Male Nurse closely into his confidence about the details of the complaint made at this time by “T”. Equally, it is right to say that the Physician Superintendent was not, .at this time, aware of the earlier complaints about “U” which had come to the notice of the Chief Male Nurse.

174. At the end of the day however there is no doubt at all about the sorry conclusion of all these matters. At a time when the Chief Male Nurse, as he told us, was “not at all happy” about the manner in which the Night Charge Nurse dealt with patients and with staff, a complaint was made against the Night Charge Nurse by a conscientious and competent Staff Nurse which had as its only consequence the effective removal from Ely of the Staff Nurse who had had the temerity to complain. No-one in authority at or over the Hospital appears, at the time or subsequently, to have regarded this conclusion as one which called for any special consideration whatever.

175. For our part, we feel bound to regard the story of “T’s” “resignation” from Ely—even although it took place some years ago—as symptomatic of a situation in which members of the nursing staff who were genuinely concerned about conditions in the hospital must have come to feel that it was almost more than their professional life was worth for them to voice any feelings of concern. We return to consider this topic, in a wider sense, in Chapter 7 below.

the “B” Story

176. A former Staff Nurse at Ely, “B” was named by XY as a potential supporting witness. When approached on our behalf during December, , M&I, he indicated that he was unwilling to give evidence. However, on 10th ‘ .February, 1968 (after he had been dismissed from employment at the hospital in circumstances which we discuss below), he wrote to our Secretary, making certain allegations; and he was eventually prevailed upon to give evidence before us. As a result of the evidence which we heard, we felt it right to communicate to the RHB our own feeling that his appeal to the RHB against his dismissal deserved to be considered. We understand that the RHB has now considered his appeal and that he has, in consequence, been re-instated in the hospital service in Wales, away from Ely.

177.” B” was born in Nigeria in November, 1941. He had spent three years mental nursing at a teaching hospital in Nigeria before coming to England 61. He was employed as a student psychiatric nurse at St. George’s Hospital, Stafford, from March, 1962, to October, 1964, when he successfully completed his course of training and qualified as a Registered Mental Nurse. left that hospital in December, 1964 and shortly afterwards joined the sing staff at Whitchurch Hospital, Cardiff. By the time he gave evidence us, he was doing two courses of study, apart from nursing: a part-time oma course (of three years’ duration) in social science at Cardiff University; a full-time course at the School of Occupational Therapy also in Cardiff. was dismissed from Whitchurch Hospital—for two reasons: he had been Jong a bath while on night duty and it had not been possible for him ?p given tours of night duty, which would conveniently permit his attendance, Blag the day, at his social science classes.

178. “B” joined the staff at Ely on 8th November, 1965, as a Staff Nurse. Male Nurse learnt, at the time of “B’s” appointment, about the extension of his studies.

179. “B’s” own record, while at Ely, was not unblemished. In November, 1966, he was accused, by Deputy Charge Nurse “W”, of being asleep on duty and of “insolence”. “B” at that time made counter-accusations against “W”. These matters were investigated by the Chief Male Nurse, who reprimanded “B” and this matter appears to have been satisfactorily disposed of at the time. Apart from certain later incidents, involving Night Charge Nurse “U”, which must be separately considered, there was thereafter no complaint of “B’s” behaviour, either personally or in connection with his performance of his nursing duties. Apparently, he was criticised on more than one occasion for his tendency to read on duty. But this was investigated with him by the Chief Male Nurse, who knew, of course, of “B’s” studies, and, understandably, assured him that there was no objection to his reading during the night, so long as he was not thereby distracted from his nursing duties. After the original complaint, in November, 1966, both the Chief Male Nurse and Deputy Charge Nurse “W” found “B” to be “alert and observant” and entirely satisfactory in the performance of his nursing duties. Indeed, during the few weeks immediately preceding his dismissal in the early part of this year, “B” was regularly acting as Night Nurse in Charge of all four male wards.

180. We obtained from the Director of Nursing, St. George’s Hospital, Stafford, an assessment of “B’s” character and qualities. In forming our own view of “B”, we bore this assessment in mind, as also the point which was urged upon us by one of the legal representatives, to the effect that we should beware of regarding “B” as a ” blue-eyed boy”. He may have had something of a “chip on his shoulder”, being inclined at times to be sullen and unfriendly. There must have been occasions when he was not the easiest of colleagues. But he was plainly ambitious and hard working, being concerned—with a wife (herself a nurse) and young child to support—to acquire additional qualifications. Although he was occasionally naive, we came to regard him as an intelligent and truthful witness; everyone at St. George’s Hospital, Stafford, agreed that he was “very attentive and kind towards the patients in his care”; and we likewise considered him a gentle person, with the attributes of a good, modern nurse—and genuinely concerned for his patients. The whole tenor of his evidence, even after we had given it the most sceptical consideration, fitted in too closely with much else that we had heard for us to be able to regard “B” as other than an essentially truthful witness.

181. Before we turn to consider in detail the allegations made by “B”, we should observe that they seemed to us to be important not so much because of the light which they cast upon the actual, day-to-day conduct of Night Charge Nurse “U”, but because:

(a) They afford a useful insight into the shortcomings, when the matter is looked at from a general point of view, of the method adopted for investigating complaints by one member of the. nursing staff against another; and

(b) They go some way to explain and justify the allegations made to us by “B” that: — “Many honest staff in the past years, at this hospital, have been terminated because they spoke out bitterly against the action of ‘U’ towards the patients.”

The “go home!” incident

182. “B” was concerned in one incident in which Night Charge Nurse “U” plaved no part. It is of no importance in itself. But it forms part of the back-ground to one of the allegations later made against “B” by “U”; and the details of the incident coincide with the account of it that we heard from XY— and so tend to confirm his reliability as a witness. (See Paragraph 103).

183. On one evening, when “B” was due on night duty on Ward 23, he arrived several minutes late because, he said, the bus had broken down. This upset Assistant Chief Male Nurse “A”, whom “B” was due to relieve, and led to a brisk exchange of words between them. The following morning it was “A’s” turn to relieve “B “; “A” arrived correspondingly late and made no great haste to leave his car to proceed to the ward, where “B” was awaiting him. Once again there was a cross exchange of words. And, as “B” made his way away from the ward, “A” shouted after him abusively, and loudly enough to attract the attention of other members of the staff. Amongst other things, “A” told “B” (in strong language) to “get back to his own country” (Nigeria). “B” wrote a letter (which has not survived) reporting the matter to the Chief Male Nurse, who interviewed both “A” and “B” and restored reasonably civil relationships between them. In the absence of the letter written by “B”,we do not feel able to reach any conclusion about his further allegation that conduct, in the morning, involved a degree of rough treatment in getting of the patients into the open and out of Ward 23.

“Rossetti” incident

184 At about 10 p.m. on an evening during the autumn of 1966, “B” was on duty in Ward 21. A dumb patient called Rossetti became involved in an incident with another patient because his nightshirt had disappeared. “B” the dispute by finding another nightshirt and giving to each patient a cup of tea to drink, while each sat on the edge of his bed. When Night Charge ‘U” arrived in the ward, he appeared to have taken exception to this of affairs and to have demanded that the patient should immediately and get into bed, without being allowed to finish his tea. When the declined to comply, “U” took him into the adjacent dayroom and t forcibly to remove his day clothing. It was not, said “U”, his intention at the time to “give him a thoroughly good hammering”. But a five or six minute struggle ensued, at the end of which the patient was in tears on the floor as “U” put it ” clutching his knees in an attitude of supplication “.

185. “U” claimed that he had acted in this way not for the reason given because, when the patient came rushing up to him ” in a state of to be very dirty. ” In fact”” said ” U “, ” he stank, having him right under my nose I tried to persuade him to some of his muck and rubbish “. “U” claimed that it was necessary to handle the patient so firmiy because, wnen he rcauucu has imuu nuu u^ patient’s pocket, he found a “glutinous mess . . . impregnated with cigarette ends, tobacco and . . . three rusty razor blades”. “B”, claimed “U”, was unwilling to help him remove the patient’s clothes, even when informed of what “U” had found.

186 Even on “U’s” account of the incident (which we cannot accept), we cannot see how his manner of treating the patient can be regarded as justified. In fact, we prefer ” B’s ” evidence to the effect that the rough treatment of the patient was unprovoked and that, even if “U” did not set about him, in “B’s” graphic phrase “as though he was going to kill a snake”, “U’s” attitude on this occasion cannot possibly be justified.

187. At the end of the incident “B” became very upset and told “U” that he would report him to the Chief Male Nurse. “U’s” reply, according to “B”, was to the effect that if he, “B”, did report him, then he would “not last long on night duty”. “U” agreed that he might possibly have retorted in this way. We are satisfied that he did.

The “Masefield” incident

188.On one night during the autumn of 1967,”B” was on duty in Ward 23. The patient, Masefield (referred to in Paragraphs 109-113 above) was in a very restless state, notwithstanding the fact that Night Charge Nurse “U” had already attended once during the night to administer a sedative. After about an hour had elapsed, “B” again requested the assistance of “U” with the patient who remained very restless. “U”, understandably enough, was reluctant, after so short a time had elapsed to administer a further sedative. Accordingly, “U” tried to force the patient to lie down in his bed, holding him down and covering him up so that the sedation might take effect. When this had failed, “U” pulled the patient from the dormitory into the dayroom. “B” complained, and we have no doubt that his complaint is well founded, that in course of this treatment, “U” offered undue violence to the patient.

170.On this occasion too, “B” complained to “U” of his conduct suggesting that “U” would not, if he was in Nigeria, be allowed inside a hospital. “U” was thereby provoked to tell “B” to ” go back to “his own country. “B” then told “U” that he would report him, only to evoke (for the second time) the retort from “U” that he would make it sure that” B ” left night duty.

171.After the date of this incident, according to “B”, he “never had peace ” when he was on duty at the same time as “U”, who began thereafter to find “faults at random” in ” B’s” conduct.

The night report book

191. There were several other brushes between “B” and “U”, including one on the night of 2nd/3rd November, 1967 which led “U” to make a brief, generalised written complaint about “B” to the Chief Male Nurse. This was investigated and disposed of, apparently satisfactorily, by the Chief Male Nurse. Together with the other, more or less trivial, incidents, it does not appear to call for detailed consideration.

192.The incident involving the ward night report book for lst/2nd December, 1967, does, however, call for consideration. On that night, “B” was on duty in Ward 21. The man in overall charge of the four male wards on the night in question was not “U” but Deputy Charge Nurse “W”. When “B” came on duty, he found that the ward day staff had failed to leave available the necessary linen and equipment, which would be required during the night; in particular, there was only one clean nightshirt and one clean sheet available. Since the night staff did not have access to the keys of the linen cupboard, this shortage could not be remedied during the night. This was not the first occasion on which the night staff had found themselves similarly short of materials.

193 “B” reported this state of affairs to “W”, when he made his first visit to the ward on that night, it was then agreed between them that “B” should report the matter in the ward report book and that “W” would countersign such report, when the time came for him to do so on the following morning. When “W” re-visited the ward on his last round on the following morning, he read and signed the report which ” B ” had made, which read as follows:

“Routine attention to incontinent patients was made impossible by the day staff, who for reasons best known to them had not supplied the necessary night staff requirements—sheets, drawsheets and shirts. Neither soap nor towels were left out for the patients and this again hampered the normal morning routine procedure—giving patients a wash. The patients had a fairly comfortable night.”

194. This critical report naturally attracted the attention of the Chief Male Nurse, as well as the Physician Superintendent. It was investigated by the Chief Male Nurse. He told us, as Deputy Charge Nurse “W” had also done, that it was in his view ” the right report to make ” in the circumstances, as a means of drawing attention to the matter complained of. Both “W” and the Chief Male Nurse agreed that the making of this report appeared to have “done the trick”. There has been, since “B” made the report referred to, no repetition of their error by the day staff.

195. There, it might be thought, the matter would have ended. Night Charge Nurse “U”, however, took a very different view. In his own words, he regarded “B’s” report as “the most damning castigation of the day staff of 21 Block” and found it hard to believe his eyes when reading it. (He had shown himself particularly concerned to prevent any such “disloyalty” at a time when our Inquiry was proceeding). When he discovered that his Deputy, “W”, had actually seen the report and approved it, “U” told “W” that if he, “U”, had been on duty such a report “would have been torn up” -and that “B” was ” simply asking for and causing trouble “. He was apparently unimpressed by “W’s ” reply that he had specifically approved of and agreed with the report, since he “W”, ” was getting rather fed-up with hearing these complaints”. Moreover, ‘”W” told “, the report appeared to have “paid off “.

196. “U” made a point of discussing the report with “B”, when he next saw him on 7th December, 1967, and told him that he ” deprecated the substance and the wording of the report”. “U ” alleged that “B” then sought to justify the report by explaining that it was written because he wanted to ” get his own back and to cause trouble for Charge Nurse “M'” (the Day Charge Nurse for the ward in question). This suggestion appears to us to be wholly inconsistent with the careful circumstances in which ” B ” had prepared the report in question, in close consultation with Deputy Charge Nurse ” W”. Nor did there appear to us to be any reason why “B” should have wished to “get his own back ” on Charge Nurse “M”. We cannot, therefore, accept what ” U” told us about this interview with “B”. Some unfavourable light is, however, cast upon ” U’s ” attitude towards “B” by the fact that the interview took place at all, as well as by “U’s” suggestion that he subsequently made a point of seeing Charge Nurse “M”, in order to express his regret that the report had been written at all.

197. “U’s” own inclination, as he reiterated before us, would have been to remove the “offending” page from the report book. Such an attitude is, in itself, regrettable; and its fulfilment would be rendered unattainable if the pages of ward report books were consecutively numbered, as we think they should be, in a manner similar to the pages of a minute book.

21st December, 1967

198 The next significant incident occurred on this night, when “B” was in charge of Ward 17A. There is no need to analyse in detail the large volume of evidence which we heard about it. The essential facts may be shortly summarised.

199. At about 9.30 p.m., “U” made his second visit to the ward (where State Enrolled Nurse “X” was on duty in addition to ” B “) and commenced to criticise ” B’s ” management of the ward. “X” corroborates ” B’s ” recollection that the purported cause of complaint lay in the fact that “B” had commenced attending to patients in bed before 10.00,p.m. (“U” alleged that his complaint was founded upon “B’s” tardiness in making progress with this task). Whatever the precise nature of criticisms being made by “U “, it is clear that, as he put it, he ” remained in close proximity ” to “B ” (and “X”), directing the procedure of their work. “U agreed that it was ” most unusual . . . and very provocative ” to stand over a qualified nurse in this way. “U’s” conduct did indeed strike us as intended to be provocative; and, in due course, it had its effect—so that both he and “B ” lost their tempers. “U” claims that, in course of the exchanges which followed, “B” made it plain that he intended, not by way of idle threat, to “knife” “U”. “U ” further claims that he asked “X”, once the alleged threat had been made, to make a careful note of it.

200.”X”, when he gave evidence before us, was plainly a very anxious man. “I should hate”, he said, ” to live and die by my statements”. Under pressure, he purported to recollect that “B” had indeed threatened “to murder” “U “, although he was not certain about whether the word “knife” had been used and, if so, by whom. “U” claimed that it was he, himself in asking “B” whether the threat of knifing was true, who actually introduced1 the word “knife”.

201, In this situation, we can well understand “X’s” anxiety. When giving evidence before us, he—in contrast with “B “—was still employed at Ely, with “U” as his superior; he told us that he regularly travelled to work in the same car as “U ” and that “U” had recently discussed the whole incident with him. He appeared to us plainly to be cast, at least in “U’s ” expectation, in the role of a supporting witness for “U’s ” allegations. Even so, when giving evidence before us, he fulfilled “U’s” expectations only to a very limited and unconvincing extent. It is, moreover, significant (as will be seen in Paragraph 208 below) that when “U’s” allegations against “B”, which arose in part out of this incident, were investigated by the HMC, “X” was unwilling to attend before that body at all.

202 In the upshot, we have no hesitation in rejecting “U’s ” version of this incident. We believe that, as “B ” told us, “U”, having created a difficult and provocative situation, asked “” whether it was true that he had been threatening him and that “B” replied: “I have made no such threats to you or anybody else. I am just telling you to have a better way of approach to a member of staff, not shouting at somebody in the presence of patients and abusing somebody and picking up fights.” When “B” made it plain that he would, if necessary, report “U’s” behaviour, “U” told him—and these are “U’s ” words—that “B’s” conduct could lead to serious consequences and that if he, “U”, pressed the matter, “B” could very well end up outside the hospital and in any case could fall in a trap of his own making.

203. On the very night when this incident occurred, “B” in fact made a formal, written complaint to the Chief Male Nurse, the terms of which substantially confirm the account of the incident set out above. He complained of: “the continuous disgraceful attitude of ‘U’ on the wards and in the presence of patients, coupled with threats of my expulsion from the hospital”. And concluded that: “although U’ firmly believes that the Hospital Authorities has no power over him, I feel that it is time he puts a stop to shouting at staffs and upsetting the wards at night. Our main objectives should be aimed at creating a happy atmosphere for the patients comfortable and happy. It is regrettable that ” U’ is working against this aim “.

204 Once this report had been made, the Physician Superintendent interviewed “U”, who gave his account of the matter, naming “X” as a witness. “U” also complained that “B” had, on previous occasions, threatened to knife him; he gave as witnesses to this alleged threat the names of “L”, “X” and “Y”. “U” was invited to furnish a written report. This document was, in due course, forthcoming and was remarkable in its style and length.

205 A special sub-committee of the HMC was convened for 19th January, 1968, to consider the two complaints made by “B” and “U ” against each other. Both men were given notice of the time and place of hearing but unfortunately the notice addressed to “B ” posted on 15th January, did not reach him —since he was living at an address different from that contained in the hospital records (the address at which he was in fact living was, however, the same as that given for him in XY’s original statement to the News of the World, a copy of which had been furnished to the HMC on 9th November, 1967).

206. In the result, therefore, “B” did not attend the hearing on 19th January since he had not, in fact, received notice of it. Only “U’s” complaint was heard. After “U” had given evidence, the Physician Superintendent stated that he tended to “fly off the handle easily” and that there had been complaints against him in this respect. The sub-committee was told that “B” had, in the past, been alleged to sleep on duty—although he denied it. The Chief Male Nurse confirmed that he had in the past reprimanded “B” for sleeping on duty but stated that his relationship with other staff members was good although he resented the authority of “U”. The sub-committee were told that “B” was, by this time, a full-time student in the School of Occupational Therapy—which position contrasted with his part-time studies at the time when he was appointed.

207. The sub-committee discussed (without having heard any evidence about it) the complaint made by “B” against “U”, deciding that there was not a great deal of substance in it. Nevertheless, “U” was called before them and advised to be more tolerant in dealing with staff. The sub-committee does not appear to have been told, or reminded, of the earlier complaint (considered in Paragraphs 166 to 175 above) by “T” against “U”. Nor was anything said by the Chief Male Nurse of his belief that “U” had, in the past, brought complaints against members of the night staff (particularly women) which appeared to the Chief Male Nurse to have been made with the intention of securing their removal from the night staff. (“U” apparently preferred male to female people working with him.)

208. When the sub-committee considered what was described as ” the charge of physical violence” against “B”, they were told that two of the witnesses named by “U”—”X” and “Y”—would not testify. They did, however, hear evidence from “L” (incorrectly described in the sub-committee’s report as “Oldfield”) to the effect that “B” had said to him about “U” : “I will get that one—he will be found with a knife in him”. The Physician Superintendent apparently told the sub-committee that “Mr. Oldfield” was reliable and honest.

209. The sub-committee accordingly concluded that “B” had made the threat alleged and determined to dismiss him forthwith.

210. When “B” was notified of the decision which the sub-committee had taken in his absence, he wrote to demand reconsideration of his case, in the following terms: “Having now learnt a lesson, I shall from henceforth keep quiet, since my life is dependent upon this night duty. Knowing fully well that I have no parents to fall back on, the great responsibility of maintaining my wife, child, house and of paying for my studies, I pray you in God’s name to grant me the pleasure of continuing my night duty”.

211. When the error about “B’s” address had been discovered, the original sub-committee decided that their decision must stand but that “B’s ” letter should be treated as an application to have his case heard by a Committee of Appeal, which accordingly met on 29th January, 1968. Before the Appeal Sub-Committee the evidence of “B”, “U” and “L” was heard. “B” was represented by his trade union branch secretary at Ely, who did not, however, make any final submissions on “B’s” behalf. This Appeal Sub-Committee was not, apparently, told anything by either the Chief Male Nurse or the Physician Superintendent about the characters of the people involved but they did have before them the report of the original hearing, which contained the observations originally made by these two people.

212.”B” did not have sent to him, before the hearing of his appeal, either the original long letter of complaints made against him by “U” or any copy or version of the findings of the original sub-committee. He was, therefore, wholly unaware until evidence came to be called, of the charge which he had to meet.

213 In the upshot, the Appeal Sub-Committee expressed themselves satisfied that “B” had threatened “U” and his appeal was accordingly dismissed.

214. It was in these circumstances that “B” appealed to the RHB and penned his complaints in a letter to us.

The alleged knifing threat

215. “U’s” account of the occasions on which this threat is alleged to have been made by “B” is set out in some detail in his written report. Essentially, it amounts to this : that he was told by “L” how “B” had, during a supper break on Ward 17A on the night of 14th/15th December, 1967, threatened to knife “U”.

216. “U’s” letter suggests that “Y” was a witness to the making of this threat; and “U”, in his interview with the Physician Superintendent on 3rd January, 1968, again named “Y” as a witness. In the event, however, “Y” was unwilling to testify before either of the sub-committees appointed by the HMC and having left the hospital by the time we required him, was unwilling to give evidence before us. Moreover, when “L” came to give evidence about the incident, he said that it occurred in the presence of nobody but himself. In all the circumstances, it is plain that “Y” was unable or unwilling to corroborate “U’s ” complaint in this respect.

217. We have dealt in Paragraphs 199 and 200 above with the evidence which “X” had to give about the alleged threat. Although specifically asked to make a particular note of what “B” is supposed to have said on the night of 21st December, 1967, “X” gave no really satisfactory evidence to corroborate “U’s ” allegations. He was plainly, for the reasons discussed in Paragraph 201 above, in a very difficult position; and we do not regard him as affording any support for “U’s” suggestion.

218.The third witness named by “U”, “L”, did give evidence before us. His account of the threat alleged to have been made by ” B ” on the night of 14th/ 15th December, 1967, was to the effect that after ” U ” had left the ward, “B”, entirely out of the blue and unprovoked by anything on that occasion, observed: “I’ll get that one : he’ll be found with a knife”. This struck us as a most improbable occurrence. And, when one bears in mind the reluctance of the other two alleged witnesses to support “U’s” complaint, we are driven to the conclusion that there may well be substance in “B’s” complaint, made in the letter of appeal to the RHB, dated 13th February, 1968, that the witness “L”, had been “planted” by “U” ” to achieve his objective .

219. Indeed, the sequence of “U’s” alleged attempts to confirm the knifing suggestion is disquieting in itself, as follows : 1st December, 1967. “B’s” “offending ” entry in ward report book.

1th December, 1967. “U” expressed to ” B ” his displeasure at the “offending” entry.

14th/l5th December, 1967. “L” alleges that “B” made the knifing threat.

2lst December, 1967.

220. “U” invites “B”, in the presence of “X” to “confirm” the alleged threat; and, later on the same evening, claims that he invited “Y” to repeat to another Staff Nurse the threat which “B” is alleged to have made in the presence of “Y” (no one has in fact ever heard from “Y”, or anybody else, any evidence to suggest that such a threat was ever made in his presence).

221. One other piece of evidence was given, in support of the suggestion that “B” was the kind of person likely to threaten “U” with a knife. Assistant Chief Male Nurse “A” told us that during the evening preceding the incident on Ward 23 (referred to in Paragraph 183 above), “B” told a patient on Ward 23, Shelley, that he would “put a knife into” “A”. Although “A” apparently came to hear of this threat at the time, and although the incident which occurred on the following day was investigated by the Chief Male Nurse upon the complaint of “B”, “B’s” alleged threat on this occasion does not appear to have been reported or investigated until it was raised in course of our proceedings. Two of our members interviewed the patient Shelley, about this matter. He was a very simple soul, apparently at pains to tell us that some of the other patients on the ward could be very rough and troublesome and that the ward staff treated him with kindness. He claimed to have reported the threat to “A” on the morning after it was made and said that “A” discussed the matter with him on two subsequent occasions, once about a week before we interviewed him. In all the circumstances, we do not feel able to rely on Shelley’s testimony about the alleged threat, more particularly in light of the fact that it does not seem to have been reported or investigated until “B’s” alleged capacity for threatening the use of a knife against “U” came ‘closely to be investigated before us.


222. The significance of the “B” story is that it has impelled us to the conclusion that the charge made against him by ‘U”, to the effect that he was threatening to knife “U”, was without foundation.

223The whole tone of “U’s” report made it plain that he was more than anxious to be rid of “B”. “U”, moreover, acknowledged (see Paragraph 187) that he might well have told “B” at the conclusion of the Rossetti incident, that “B” would “not last long on night duty” if he did report “U”. And the Chief Male Nurse told us of his belief that “U” had contrived complaints against other members of the night staff, in order to secure their removal from duty which corresponded with his. In the circumstances, it seems probable that “U’s” unfounded complaint against “B” was provoked either by the incident concerning the night report book (1st December, 1967) or by “B’s” letter of complaint dated 21st December, 1967. It was only on 3rd January, 1968 in his interview with the Physician Superintendent that “U” first made his complaint against “B”.

224. There is no evidence to suggest that the Chief Male Nurse was aware of the unfounded nature of “U’s” complaint. And Assistant Chief Male Nurse “A’s” connection with the complaint is uncertain—although it is worth recalling he had himself told “B” to “go home” on an earlier occasion (see Paragraph 183 above). Equally, it seems plain that the investigating subcommittee appointed by the HMC reached their conclusions that “U’s” complaint was well-founded in complete good faith. We consider (in Paragraphs 291 to 296 below) the implications of a situation in which the HMC could, as they did, dismiss from their employment a qualified nurse, who was not only innocent of the charge brought against him, but also one of those people who, to the knowledge of the HMC and all senior members of the hospital staff, had been identified by XY as one of those who was prepared to give evidence before us. We should observe finally that the disquieting evidence which “B” had to give would, in all probability, never have come to light had it not been for the fact of his dismissal. For when he was interviewed by an official of the Welsh Board of Health, on 17th August, 1967, he denied knowledge of any cruelty—and thus appeared unwilling to corroborate XY’s complaints. It was only when he had been, unjustly as we believe, finally dismissed from the hospital service, that he became willing to give evidence before us. And it seems certain that he had maintained his silence for so long, notwithstanding his anxiety about incidents which he had observed, only because, as he said in his letter to us, he was made to understand by other staff that “U” had indeed been able to secure the removal of persons who made reports against him. “I was advised”, wrote “B”, “to keep quiet or else he would put me in trouble and get me out of duty”.

225 We consider (in Chapters 1 and 12 below) to what extent, if at all, anyone should be regarded as responsible for or blameworthy in respect of what appears to us to have been a plain case of victimisation of a kind which causes us grave concern. We also consider, in the same Chapters the much more difficult question of how the occurrence of such a case can be detected by those responsible for managing the hospital and of how its recurrence, in similar circumstances in the future at this or any other hospital, can, so far as possible, be prevented