Chapter 4 of Report on Ely Hospital

Villa 2

38. This ward, catering for male children, was not one of those referred to by XY. It was brought to our notice by four letters of complaint from parents who had read of our appointment. We were not able to interview the parents whose letter is referred to in Paragraph 287 below. Our decision to hear evidence from the three other sets of parents will, we hope, be justified by our conclusions about the very disquieting conditions which their complaints revealed.

139. Two of the three children on whose behalf we heard evidence were admitted to Ely as short stay patients. It was suggested to us that their complaints should be regarded as unrepresentative, since they accounted for only a very small percentage of the 414 short stay patients admitted during the five years which were spanned by their complaints. But the complaints appeared to us to be amply justified by our own observation of contemporary conditions in this ward. It is, moreover, significant that all three sets of parents who complained about this ward were more than usually articulate and energetic. We more than suspect that they must be regarded as representative of a larger group of less articulate parents, who are less accustomed and able to formulate complaints of this kind—and more disposed to tolerate without complaint the conditions which they happen to find prevailing. It will be observed that two of the three sets of parents eventually resorted to unusually enterprising devices, in order to obtain for their children a higher standard of medical care than would otherwise have come their way. The mother of the third patient had not resorted to any such device but told us that she had included in her Will an express request that her son should in no circumstances, after her death, be allowed to return to Ely. Such determination to avoid the facilities afforded by Ely appeared to us to deserve serious consideration.

140. The two villas (one for girls and one for boys) were both opened in 1958. They are said to have been built to Ministry of Health standards and to a new design—each for 50 severely sub-normal ambulant children. The present establishment of nursing staff for each villa consisted of a Charge Nurse, Deputy Charge Nurse, three Staff Nurses and six Nursing Assistants. The design and layout of each villa, as well as its staffing establishment, was severely criticised by the Physician Superintendent, the Matron and others who gave evidence before us. We consider these criticisms in more detail below and turn first to the complaints which were made to us. Although we found no reason to doubt that each of these complaints was substantially accurate, we did not regard any of them as involving allegations of misconduct or neglect against any particular members of the hospital staff—and did not investigate them from this viewpoint. They are of more importance because of the light which they cast upon the general standards of service provided.


141. This boy, who was born in January, 1954, was severely sub-normal, unable to speak, an epileptic, doubly incontinent and substantially overweight. He was admitted to Villa 2 on 9th July, 1962, while his parents were going on holiday. His father had a managerial job; his mother, who had been employed in the Civil Service before marriage, had obviously taken some care in the arrangements made for his admission to Ely and was plainly devoted to him.

142. When the parents telephones the hospital during Osbert’s stay there they were assured that he was quite happy and had “settled very well”. This impression was far from confirmed when they came to collect him on 21st July, 1962. The mother then found her child in such poor physical condition that she at first passed him by in the ward and failed to recognise him as her own. She found that his face was bruised and his legs scratched (these physical injuries can be attributed to the incident recorded in the patient’s notes when he had fallen down on the way back to the ward from the hospital school). Apart from these matters, both the child and his clothes were dirty, he had lost perhaps a stone in weight and was showing obvious signs of dehydration. The mother observed weals on his wrists as though they had been tied. She also complained about an apparent absence of recreational facilities for the children on the ward and of the parting remark made by an unidentified member of the ward nursing staff, to the effect that the parents were lucky, since they had had their holiday and that they were now free to “take him or leave him”.

143. The dehydrated condition of the child was to some extent confirmed by the notes which we saw from the Pembroke County War Memorial Hospital, Haverfordwest, where he was admitted on the day following his discharge from Ely and spent eight days.

144. The parents did not, before withdrawing their child from Ely, discuss his condition with any member of the medical staff, since the doctor, to whom the father apparently spoke “aggressively” on the hospital telephone, was not able to arrive before they had departed with their son.

145. It was suggested to us, and the explanation is at least partially acceptable, that the deterioration in the patient’s condition—namely the loss of weight in a very overweight boy—was attributable to the fact that he pined in his separation from his parents and may not, in its whole significance, have been observed by the nursing staff, who had to cope with as many as 50 young patients.


146. This patient, who was born in May, 1959, was severely sub-normal and possibly schizophrenic. His behaviour had become too disturbed for an ESN School and, immediately before admission to Ely, on 28th February, 1966, he had become very dirty, smearing faeces over his clothing and furniture at home. He was admitted for observation to Villa 2, but was transferred after two days to Ward 23, as he had shown signs of violence to smaller children and attacked a female member of the staff.

147. The patient’s father, who had been a Petty Officer in the Royal Navy and was working, when he gave evidence before us, as a Casino Manager, withdrew his son, after visiting him on 5th March, 1966. He complained of:

(a)The type of patient with whom his son had been placed (severely sub-normal, older men—in Ward 23);

(b)The stinking, filthy condition of the clothing which he was wearing on the date of his withdrawal—said to have been wet and covered with faeces to such an extent that they had to be immediately destroyed;

(c)The malodorous, heavily overcrowded and unattractive state of the ward (Ward 23) from which he was withdrawn; the dormitory was “a room full of beds with hardly room to walk down between them” and in the dayroom, there were many patients “strewn about in various states of undress”;

(d)The physical condition of the boy, with his external genitals and thighs raw and caked with faeces.

148.The patient’s father had, as it seems to us, some reason for asking what was the point of sending his son to “a place like this” for observation. It is, however, right to observe that the new, extended toilet accommodation for Ward 23 first came into use on or about the day when this patient was discharged; and that the Physician Superintendent of Ely wrote a helpful report on the boy, ten days after his discharge, to the Physician Superintendent of a hospital in North Wales, whither the boy was then being taken by his parents for further consideration of his case.

149. In light of the foregoing history, the entry on the patient’s notes, to the effect that his condition on discharge was “satisfactory”, seems hard to justify.

150. Peacock’s father was able, some time later, to use his influence with a doctor friend, who was on the staff of Whitchurch Hospital, to secure his admission there—where, in the father’s opinion, his condition very substantially improved. He had, in fact, mentioned his impressions of Ely to his Member of Parliament (when being interviewed by him in connection with another matter) but appears to have received no further information or comment from that quarter.

” Quiller “

151. This patient, born in July, 1956, was severely sub-normal (described as “autistic”), had attended successively a day nursery, an infants’ school, an ESN School and a Training Centre, and (after private consultation at Great Ormond Street Hospital), been recommended for admission to a Rudolf Steiner School. This suggestion did not appear to have the enthusiastic support of the relevant local health authority (Newport Borough Council) but the parents had arranged for their son’s admission to Ely on a short stay basis in order to “hold the position” without being regarded as “unco-operative”, so as to keep open, if possible, the chance of being supported in their search for a Rudolf Steiner place. Mrs. Quiller was anxious, so she told us, to secure some short term stability for her boy, who had been becoming increasingly difficult —because he was, as she suggested, “upset at all this being buffeted from pillar to post”.

152. This patient’s father was a certificated engineer. His mother had no qualification; but her sister, who visited the boy at Ely on one occasion, is a qualified and experienced Health Visitor. The parents withdrew their boy from Ely on 24th July, 1966, and were eventually able, by acquiring residential “Qualifications” in another region, to secure his admission to Lea Castle Hospital, where he is said to have settled down well. They made the point that he appeared content to be left by them at that hospital, as well as at Llanfrechfa Hospital (under the Welsh RHB)—in contrast to the great anxiety which he demonstrated every time they had to leave him at Ely.

153. The principal complaints in this case were as follows:

(a)The regularly filthy and stinking condition of the patient’s clothes, on each of the thrice weekly visits of his parents, they took him home, bathed him, and gave him a complete change of clothing (the mother’s offer to attend the hospital more regularly to collect her son’s soiled linen to launder herself was said by her to have been declined);

(b)General conditions in the ward, described by the patient’s mother as follows:

” Most of the children were in the playroom off the dining-room and quite a lot of them had no clothing on whatsoever. The chairs had their stuffing hanging out of the seats. These chairs had been wetted and so forth, and could not possibly be cleaned because of the condition of them. They did not have a thing to play with and so they just fought with one another those that were around, and (my son) never seemed to be without bruises and sores and cuts, which I was terribly upset about because of the filth that went with it”;

(c) The “couldn’t-care-less” attitude of the staff, who met any complaint with the answer that they were “not on duty at the time”. and were said generally to be absent from the dayroom and more often in the TV Room when the patients’ visitors came;

(d) Excessive use of sedatives; in contrast to the dose of 25 milligrams per day which he had been receiving at home, the patient was (according to his notes) receiving a daily dosage of 150 milligrams of largactil during his stay at Ely.

154. The foregoing complaints were substantially confirmed, and to some extent explained, by the evidence before us from the SHMO (speaking about the time when this patient was in this ward): “It was a badly kept ward … it was not clean at the time. It was smelly. The furniture was not arranged properly, patients were walking around some half naked, some had their shoelaces not tied, shirts not buttoned, dirty, some wet; but we had only two staff (referring of course, to the number on duty at any one time) for 60 patients. and they have other duties to perform regarding food, so they are not only changing the patients”

155.We were told that standards of care and management in Villa 2 had declined over the years because conditions there had “got on top of” the Sister who been in charge from 1958 until she was transferred elsewhere in March, 1967. We were told that, after another Sister had been unable (during a three months trial period) to cope with conditions there, the Villa was placed, in July, 1967, under the charge of its present Charge Nurse, a man who was qualified in the nursing of the mentally sick—and had previously spent eight years in Ward 23. The implication was that, in consequence of this change, the formerly reasonable standards attained before the decline of the sister originally in charge, had by now been restored. Having ourselves seen the conditions which now prevail in Villa 2, we are clearly of the opinion that the standards at present attained are still very far from being adequate. Indeed, they substantially confirm and justify the great concern of the parents whose evidence we have summarised above. In making this judgment, we wish to make it plain, however, that we are not seeking to condemn the nursing staff, present or past. The regrettable conditions to which we have referred appear to us to be the consequence, not of shortcomings of individual members of the staff, but of wholly inadequate management and leadership.

156. Our critical conclusions can be summarised under the following heads.

Design of Villa

(a)The Unit, intended for the accommodation of 50 sub-normal children is, in itself, too large to be manageable; all our witnesses agreed that 30 was the largest number of such children for whom adequate care, service and adequate accommodation could be provided in one Unit;

(b)The entire layout and design of the Unit appears to have been misconceived, even if intended for occupation by a smaller number of patients; the layout is U shaped. The dormitory is in one upright of the U with isolation rooms at the top of that upright; dayroom accommodation is in the lower, horizontal part of the U; services, bathrooms and so on are in the other upright of the U, with lavatories at the top of that upright; this means that all patients wishing to use the lavatories (and most of all any in the isolation rooms) have to traverse the entire length of the U to do so; the dayroom is scarcely large enough even for half the patients intended to be accommodated in the ward;

(c)Some of these deficiencies had been to some extent appreciated; in October, 1963, and again in June, 1966, the Hospital Management Committee had submitted requests for the construction of a verandah for this ward (as well as for its twin, Villa 1), which would permit the construction of a solarium, which would effectively enlarge the size of the dayroom; no capital fund has, however, been allocated to permit such development; it was also suggested before us (although not apparently at an earlier time) that a corridor should be constructed to link the isolation rooms with the lavatory, so as to permit easier access between them and, in effect, to provide a kind of enclosed airing quadrangle for the villa;

(d)While the adoption of these measures would no doubt represent a significant improvement on the accommodation at present available, they will scarcely be sufficient to mitigate the inherent and substantial deficiencies in design of the whole Unit.

Equipment of Villa

157. This was virtually limited to the bare necessities for washing, feeding, clothing and sleeping; there were no recreational or educational facilities; many of the lockers which were available (for which there was scarcely room between the beds) were without doors—and all of them were entirely empty; the chairs which we saw—although, at the time, undamaged—were of the Kapok-stuffed variety and not appropriate for a ward in which they were likely to be frequently soiled. We were told that more or less conventional (and readily destructible) toys were from time to time provided (on twice yearly application to the Management Committee and by gifts from parents and so on) but few of these survived for more than an hour or two. One substantial toy, made from a tree-trunk, was introduced some years ago, but was not replaced after it was eventually destroyed. And the psychologist has, on recent occasions, been providing some experimental toys. Little sustained effort appears, however, to have been made to provide special, much more substantial, toys of the kind which could be expected to survive under such conditions.

Activity of children

158. About two fifths of the children attend regularly at the school (or junior occupational centre) which was opened at the hospital in August, 1960 (to replace an earlier nursery school); an adventure playground is available near to the Villas, having been provided during the summer of 1966, by the local Community Service Volunteers; even so, the majority of the children (more particularly in winter) had to spend most of their time in the bare and inadequate dayroom; when we visited the ward—and, as it appears at other times—little, if anything, was being done to interest the children in any kind of activity; if is not, therefore, surprising that they have little to do save fight amongst themselves and to destroy anything that they can get hold of.

Staffing of ward

159. The staff establishment, as indicated in Paragraph 140 above, is five trained and six untrained; actual staff was one short of this establishment; this means that there should be, at any one time, one trained and three untrained nurses on duty in the ward. In our opinion, the establishment should be at least twice as large, including, say, six SRNs and four SENs, together with 12 nursing assistants.

160. Little, if any, thought appears to have been given to improving the number or quality of the present staff. Even the male Charge Nurse, appointed in June 1967 to “get a grip of the Ward” has never seen the inside of a children’s ward in any other sub-normality hospital nor has he ever visited any institution such as a training centre) that is providing similar service for subnormal children; it has never been suggested to him that he should do any of these things nor has any training, however rudimentary, in the management of sub-normal children ever been suggested or given to him.


161. The matters summarized above in our opinion give cause for grave concern about the lack of consideration (by those responsible for leadership and management) of the true role of a Unit such as that provided in Villa 2. The adequacy of the accommodation, equipment, staff and organisation of the Unit appears to call for urgent and specific reconsideration. We discuss below the most probable reasons for the continued survival of the state of affairs which we have described.