Chapter 7 of Report on Ely Hospital

Complaints and Discipline among the Nursing Staff

272.The whole subject of discipline needs to be considered together with the way in which complaints or incidents relating to the hospital were dealt with. Questions of principle and organisation are necessarily interwoven with problems of personality and leadership. There is, as it seems to us, much truth in XY’s thoughtful and understanding view that: “The senior staff were very closely knitted together. One was saving the other from anything that might arise against one of them, and nobody had any chance of complaining … There is no leadership in this hospital. I would not say that the top does not care, but I think that through the years they have committed themselves in one way or another to something irresponsible; and they all have something in common and therefore they do not dare impose their ideas or use their authority for the better management of the hospital”. It is necessary now to analyse the reasons for this state of affairs and we do so by reference only to the more senior members of the nursing staff and the systems within which they had to work.

273 .There comes first the group whose direct responsibility for leadership is limited:

Deputy Chief Male Nurse “G”

274. “G” is 41 years old and a Registered Mental Nurse. He trained and qualified in psychiatric nursing at Whitchurch Hospital and came direct to Ely in 1956, in search of promotion. He has never received any training or instruction in the nursing of the sub-normal, nor has he attended any course or conference on that subject. He has always worked on Ward 17A, first as a Staff Nurse and later as Charge Nurse of that ward. In 1955 he was promoted to Deputy Chief Male Nurse, with continuing responsibility as Charge Nurse of Ward 17A. The low nursing standards in that ward (summarised in Paragraph 57 above) are no doubt formally his responsibility; but they are not significantly different from those which prevailed elsewhere within the hospital and it is right to record XY’s view of “G ” as a “very nice” man and a nurse who does his duty. He has probably contributed little in the form of leadership but it may be hard to expect too much from him in this direction so long as his position as Deputy Chief Male Nurse is combined with responsibility as nurse in charge of a ward. Given the right guidance, we feel that this comparatively young man can play his part in raising standards at the hospital.

Charge Nurse “C”

275. “C”, who is some 63 years old, was the last person to be appointed to the staff of Ely as a Poor Law Officer, or Attendant, under the Board of Guardians in 1928. Three of his sisters and one brother have also worked for a number of years at Ely. “C” is a State Enrolled Nurse by virtue of service done, but has never received any formal instruction in the nursing of the sub­normal. He has been Charge Nurse of Ward 17B since 1955. The low standard of nursing care on that ward (see Paragraph 87 above) is also his formal responsibility; but once again this was in line with standards prevailing else­where in the hospital and we see no reason to doubt XY’s view that “C” is, by his own standards, “a very capable nurse and very kind”. He has not, however, developed, during his long service at Ely, any strong sense of leadership or responsibility for setting standards of conduct. It is admitted that he often extended substantially his mid-day meal break, which he took away from the hospital, and similarly went off duty at the end of the day on numerous occasions substantially earlier than he should have done. He was probably not alone in doing these things but such conduct no doubt obliged him to adopt too often for good discipline an attitude of: “Don’t do as I do, do as I say!” In this setting it is easy to understand how (see Paragraphs 70 and 71 above) “D”, “K” and “L” obtained the impression that they would be ill-advised to do anything but accept the standards of conduct and treatment which they found to prevail. “Cs” irresponsible attitude towards “K’s” continued presence on his ward is symptomatic of a similar attitude. In this case too, however, it is important for “C” to be seen and judged in the entire setting. He is no doubt a kind and basically good man. Notwithstanding the limitations of his experience and lack of training, which could even now be broadened, he too is capable, given the right guidance and support, of playing a part in the improvement of standards at Ely,

Charge Nurse “M”

276. “M”, 49 years old, has better qualifications than any other member of the staff on the male side. Having served in the RAMC throughout the war and again from 1950 to 1955, he is a State Registered and Registered Mental Nurse. He has served in mental illness hospitals at Carmarthen, Netley (near Southampton) and Banstead in Surrey. He was appointed Deputy Charge Nurse at Ely in 1956 and promoted to Charge Nurse seven years later. (In February, 1964, he was dismissed by the HMC for “circumstances surrounding the taking of an overdose of drugs” but reinstated in May, 1964, after appeal to the RHB; we did not regard it as our duty to investigate in any detail the circumstances of this matter). Like the other nurses discussed above, he is formally responsible for the conditions summarised (see Paragraph 98 above) in Ward 21 and was, of course, personally involved in the case of Housman. A little sadly perhaps, in view of his high qualifications, there is nothing to set “M’s” attitude apart from those generally prevailing in the hospital. In his case again, it is right to record XY’s description of him as “a very capable man regarding his duties “. Given the right leadership “M” also is capable of playing an effective part in the improvement of conditions at Ely.

Assistant Chief Male Nurse “A”

277. “A”, 46 years old, went from the RAF to Whitchurch Hospital and there qualified as a Registered Mental Nurse in 1950. He too has received no training in the nursing of the sub-normal. He came from Whitchurch to Ely in 1954 and was promoted Deputy Charge Nurse six months later. Since 1956 he has been Charge Nurse of Ward 23 and assumed the additional responsibilities of Assistant Chief Male Nurse in 1966. Having held this position for 12 years, he too is formally responsible for nursing standards in that ward (see Paragraph 100 above). Once again, when seen in their context, there is nothing exceptional about these, although the ” slap-happy ” nursing methods employed are best exemplified by incidents from that ward. So too is the extent to which patients have been employed on the supervision of others; even in this context, it is plain that “A” has tried to maintain some kind of discipline by, for example, threatening the patient, Jonson, with the withdrawal of privileges when he over-stepped the mark. “A’s ” manner was perhaps a little “louder ” and more tempestuous than that of some of his colleagues; yet he too evoked a sympathetic tribute from XY and was probably rightly described as “a gentle giant”. It is, however, apparent from what we have said in Paragraph 100 above, that his ward was less well managed than the others and that he is probably not a good administrator. Some of his difficulties no doubt spring from the fact that, perhaps surprisingly, he has been required to double the duties of Assistant Chief Male Nurse with those of nurse in charge of a ward containing 64 patients. Once again we regard him as someone who would be capable, given good leadership, of playing a part in improving conditions in the hospital.

Charge Nurse “F”

278. “F”, in his 40s, in addition to being the Charge Nurse of Villa 2, is secretary of the hospital branch of the Confederation of Health Service Employees. After 5 years in the RAMC during the war, he qualified as a Registered Mental Nurse and came to Ely in 1957. He cannot be regarded as realistically responsible for the conditions which we have described (see Chapter 4 above) in Villa 2, for they have prevailed since long before he assumed responsibility for that ward in June, 1967. He has not a very forceful personality, as is exemplified by the way in which as trade union branch secretary, he appears to have been content with the fairly modest status assigned to the nursing staff at Ely. In the same way too, when representing “B” before the investigating subcommittee (see Paragraph 211 above), he cannot be said to have pressed “B’s ” case with vigour—although we can understand the difficulties of his task in combining with his comparatively junior position at the hospital the role of advocate against a senior member of the staff. He too struck us as a basically kind person, who has so far enjoyed no instruction or experience which would fit him for the difficult task of raising standards for the children now accommodated in the unpromising setting of Villa 2. Once again we feel that, given the right guidance and support, he is capable of playing a useful role.


279. The Matron qualified as a Registered Nurse for the Mentally Subnormal at Hensol Castle in 1941. She came to Ely in 1952 as a Staff Nurse and ascended the various rungs on the promotion ladder to become Matron in October, 1961. We did not have any opportunity, nor any real need since the allegations we were investigating all arose on the male side, of gauging her ability as an administrator. Villa 2 did, however, fall within her sphere of responsibility and we saw her primarily in that connection. She struck us as a kind and conscientious person, certainly more alive to the responsibilities of her position than the Chief Male Nurse. Like him, however, she appeared (understandably enough, in view of the 16 years which she has spent at Ely) to accept the limitations on her status to which we have referred in Paragraphs 266 to 268 above. She had, however, plainly taken several initiatives to improve conditions on her side of the hospital, although she too had never found the time to visit any other hospital or training centre for the sub-normal. We do not feel able to make any final assessment of her qualities as a leader but, in the right setting, she is plainly capable of playing a valuable role as a senior nursing officer.

280. The two senior nurses on the male side whose qualities we have not yet considered, the Chief Male Nurse and Night Charge Nurse “U”, can more conveniently be discussed after a fuller consideration of the system within which they had to work.

Investigation of complaints and incidents

281. A number of incidents never came to the attention of the HMC at all. Not all of them should have done so; but all should have been properly investigated and handled at the appropriate level of authority.

282. Some incidents of which complaint was made by patients’ relatives at ward level never came to the notice of the Chief Male Nurse or Physician Superintendent. By way of example we refer to:

(a)The complaint by the Dryden family about the handling of dentures on Ward 17A (see Paragraph 50 above).

(b) The complaint by his mother about the cutting of Newbolt’s toenails on Ward 23. (See Paragraph Plainly, such matters should have been brought to the attention of the Chief Male Nurse. This did not happen because of the absence of any clear rule, requiring such matters to be recorded in the ward report book at least. This lack of system was, as we have indicated in Paragraph 238 above, in contrast to the system said to prevail on the female side of the hospital.

283. Other matters did come to the notice of the Chief Male Nurse and appear to have been handled sensibly and with success. By way of illustration we refer to:

(a) The Conflict between “A” and “B” (see Paragraphs 182 and 183 above).

(b) The minor dispute between “U” and “P” (see Paragraph 191above).

In each of these cases, the Chief Male Nurse appears to have been successful in smoothing down ruffled feelings and restoring good relationships to the extent necessary to ensure the smooth running of the hospital.

284. In other instances, however, matters which came to the notice of the Chief Male Nurse appear to have been dealt with in a much less effective way, We instance the following:

(a) The way in which “K ” was allowed to remain in post at the hospital, notwithstanding unmistakeable warning signs about his unsuitability for such employment (see Paragraph 65(b) above).

(b) The way in which complaints by ” L ” and probably also by “D ” about the conduct of Charge Nurse “C ” appear not to have been followed up. (See Paragraphs 67 to 70.)

(c)The toleration of Charge Nurse “Cs” irregular absences from duty; it is true that the Chief Male Nurse did, from time to time, reprove “C” in respect of this but the overriding impression must be that he was prepared to turn a blind eye towards such conduct. (See Paragraph 275 above.)

(d) His failure to appreciate the implications of his knowledge (see Paragraph 207 above) that Night Charge Nurse “U” had “contrived” incidents involving junior members of the night staff which were the means to the end of getting such people transferred away from doing duty on the same turns as himself.

285. It is in this context that another incident, comparatively insignificant in itself, must be judged. XY on one occasion wished to be permitted to go off duty two hours early, in order to see a sistter-in-law from Nigeria, whom he had not seen for twenty-four years and who was in Cardiff for a short time. Neither Charge Nurse “C” nor the Chief Male Nurse was at first prepared to give XY “leave ” of this kind. In these circumstances, XY complained to the Chief Male Nurse that “C” was being more favourably treated than himself, since ” he has four or five hours off a day”. It was only when XY threatened to use this information as a lever, by going to the Hospital Secretary over the head of the Chief Male Nurse, that the latter eventually relented and gave XY the two hours off duty which he had requested. It matters not whether the Chief Male Nurse’s final decision in this respect was right or wrong. The disquieting feature is that he had placed himself in a position where he could not resist a request that was supported in the way described. We have indicated in Paragraphs 104-108 above, why we cannot feel satisfied that XY ever reported to the Chief Male Nurse any incident of violence involving Nursing Assistant “Q ” and a young epileptic patient. Accordingly, we have not felt satisfied that the Chief Male Nurse ever reacted on any such occasion to XY’s complaint by telling him, as XY alleged, that he was “seeing too much”.

286.Nevertheless, it is plain that, during his service at Ely, XY formed the clear impression that it would be fruitless for him to complain about any misconduct on the part of senior members of the nursing staff. He was not alone in this. Not only “D” and “K” but, expressly, “B” (see Paragraph 210 above), formed the same impression. There can be no doubt that the attitude of the Chief Male Nurse to matters such as those enumerated in Paragraphs 67 to 72 above, played a significant part in causing no less than four junior nurses, with evident justification as it now appears, to form the view which they did.

287.Certain complaints did reach the HMC. Few of these originated from patients or their relatives. There had, for example, been only one such about conditions in Villa 2 (transmitted to the HMC by the RHB in September, 1966). This was investigated by the Physician Superintendent, Group Secretary and Matron and led to the fitting of guards round the radiators in the villa. Although it was thought at the time that the parents were satisfied in respect of their other complaints about the bruising of their son and the attitude of the ward staff, this was not apparently the case; for the parents made the same complaints in a letter to us. We have taken them into account in arriving at our conclusions (in Chapter IV above) about Villa 2.

288.Quite rightly, of course, many incidents involving members of the nursing staff would be handled by the appropriate Senior Nursing Officer. What, however, of those incidents that did come to the attention of the HMC? We have already referred to the dismissal and re-instatement of Charge Nurse “M ” in the early part of 1964, on which we do not feel able to make any further comment. In the autumn of 1966, the HMC dealt vigorously and efficiently with a case in which a nursing sister was found to have been irresponsible in her care of dangerous drugs: and this complaint was followed up by appropriate changes of procedure, designed to prevent any recurrence. Again, in the autumn of 1967, the HMC dealt efficiently with a complaint that State Enrolled Nurse “D” had treated a patient with violence. He made no appeal to the RHB against his dismissal. It is thus apparent that the procedure for handling straight-forward complaints has worked fairly and well in most cases.

289.Rather more complex complaints, however, which have proved to be symptomatic of poorly functioning discipline on the male side, have not been handled in such a way as to produce satisfactory conclusions. We instance, of course, the two cases of “T ” and “B”, discussed at length in Chapter V above. The most disquieting features of these two cases may be summarised as follows:


(a) The Chief Male Nurse appears scarcely to have been involved in the investigation and presentation of the case; he was certainly not present at the hearing before the HMC; and, whether or not for this reason, his “unhappiness” about the manner in which “U” dealt with patients and other members of the night staff was not effectively communicated to the Committee. (The Chief Male Nurse’s exclusion from this stage of the proceedings may have been due, not only to the traditional lack of status of the nursing staff at Ely, but also to the fact that the former Hospital Secretary did not apparently hold him in high regard.)

(b) No evidence was heard, nor apparently sought, from the independent witness named by “T “.

(c)The upshot (apart from the fact that “U” was told to watch his step in future) was the prompt “resignation” of the innocent complainant, “T”.

290. In fairness to the HMC, it must be stated that the judicial way in which they considered the complaint was much admired by a medical member of the HMC, who gave evidence before us. “U” probably was treated according tc a high standard of justice. This very emphasis on justice may well explain the fact that the underlying, conditions which gave rise to “Ts” complaint were not appreciated or investigated by the HMC. (We consider this conflict between the needs of justice and those of good management in Chapter XII below.) And again in fairness to the HMC, it should be noted that this incident occurred at a time when persons concerned with hospital management were much less aware of the possibilities of victimisation, and associated matters, to which attention has been publicly drawn more recently.


291. The disquieting features of this case are as follows:

(a) Once again, the Chief Male Nurse does not appear to have been closely involved in the investigation or presentation of the case— although he was present at the hearing.

(b) “B” was not present at the hearing before the first sub-committee, because of an administrative slip up (which can occur in all worlds) meant that he had received no notice of the charge or hearing.

(c) Two of the ” witnesses ” named by “U” did not attend to give evidence—and no explanation for their absence seems to have been sought.

(d) Neither of the investigating sub-committees had any knowledge of “Ps” previous “history”, particularly in connection with the “T” affair—possibly because no records existed to ensure the availability of such information, after the Management Committees had been re-grouped in April, 1965.

(e) When the innocent explanation for “B’s” absence became available, the proceedings were not started afresh but treated effectively as an appeal.

(f) “B” did not at any time receive notice of the charges which he had to meet.

(g) At the re-hearing, “B’s” case was probably not very effectively presented (see our comments on “F” in Paragraph 278 above): and once again the sub-committee proceeded without knowledge of the matters referred to in sub-paragraphs (c) and (d) above.

292.In this case, as we have indicated above, it is plain that even the ends of justice were not served. “B” was only re-instated on appeal to the RHB to whom we had submitted a report about his case. Certainly the truth about the state of discipline amongst die nursing staff was not investigated nor discovered and would probably have never come to light had it not been for the appointment of our Inquiry.

293.The most disquieting feature about this case is that it matured after there had been much discussion about the possibilities of victimisation and, indeed, at a time when our own Inquiry was proceeding.

294.The “Sans Everything” problem had indeed been expressly discussed by the HMC with senior nursing officers on at least two occasions since the receipt of the letter from the Permanent Secretary, Ministry of Health0, dated 28th June, 1967, about ” Conditions of the Elderly in Hospital”. On one occasion, probably towards the end of August 1967, the Chief Male Nurse at Ely had been involved in such discussions : and the Physician Superintendent, Hospital Secretary and Matron of the hospital attended a special meeting of senior medical, nursing and administrative staffs, which discussed the subject on 25th October, 1967. At each of these meetings, the view was arrived at that there was no ground for disquiet on the ground of “undiscovered inhumanity ” at Ely—although it was plainly recognised that the possibility of an untoward incident could never be excluded. In these circumstances, it is, to say the least, disquieting that the “B” story should have ended as it did, with his dismissal. This is all the more the case when one remembers that he was known to the HMC (or its officers) to be one of the persons identified by XY as one of his alleged supporting witnesses; his standing in this respect was, in our opinion, only partially modified by the news, which reached the officers of the HMC during our Christmas recess, that he had at the outset been unwilling to give evidence for us. We formed the impression, moreover, that those officials of the hospital and of the HMC itself with whom we discussed the matter (after the facts had become more or less clearly established) did not even then fully appreciate the significance of what had emerged.

295. The important state of affairs appears to us to be as follows:

(a) Both “T” and “B”, qualified nurses, who had made well-intentioned complaints about conditions at Ely, and who were not themselves guilty of any offence, were in rather different ways obliged to leave the hospital service.

(b) An atmosphere had plainly come to exist at Ely, in which such well-intentioned members of the nursing staff had been persuaded that it was useless, if not positively hazardous, to complain of matters which disturbed them.

296. It was in this setting that XY felt obliged to ventilate his concern, not to anyone within or with responsibility for the hospital service, but to a representative of the News of the World. The fact that he felt it necessary to proceed in this way must occasion grave disquiet. We do not, of course, mean to imply that that newspaper was activated by anything but a very proper sense of its public duty. On the contrary, indeed. Our concern arises from the fact that XY felt that he had to take his complaint outside the system for it to receive the attention that it deserved.

297. In order to understand this unhappy sequence of events, we must say more about “U” and the Chief Male Nurse.

Night Charge Nurse “U”

298. “U” undoubtedly bears a substantial part of the responsibility. “U”, who was 54 years old, trained and qualified as a Registered Mental Nurse at Bramham (Bedfordshire) and Fulbourne (Cambridgeshire). He came to Ely at the request of the then Medical Superintendent as a Staff Nurse in 1947. In 1951 he was promoted Charge Nurse and three years later took up his present position as Night Charge Nurse. He was known to the HMC and its senior officers, to have a tendency to shout and “fly off the handle” at other members of the staff. The Chief Male Nurse knew that he was capable of displaying a similar attitude towards patients. He has in fact handled at least two patients (see Paragraphs 184 to 187 and 188 to 190 above) with a degree of roughness and lack of sympathy, which cannot, in our opinion, be excuser. As the Chief Male Nurse knew he had several times contrived the removal from the same tour of duty as himself of other members of the staff. He expressed his willing­ness to do just this in respect of “B”—and did indeed, as we believe, achieve this end when “B” was dismissed in the early part of 1968. We must, never­theless, remind ourselves that allegations against him along the foregoing lines have not been tried before us in anything like the way in which they would be investigated before a purely disciplinary inquiry—and for this reason, it would not be right for us to express a final view about Night Charge Nurse “U “. We should, however, be failing in our duty if we did not recommend consideration by the HMC of disciplinary proceedings against “U” in respect of the matters referred to in Chapter V above. It would, in our opinion, be desirable for the evidence which we have taken to be made available to the HMC to assist them in arriving at a conclusion.

Chief Male Nurse

299. The Chief Male Nurse, 55 years old, qualified as a Registered Mental Nurse in 1936 after training at Park Prewett Hospital, Basingstoke. He stayed there until 1940, when he joined the RAF for five years. About a year after his discharge, in 1947, he came to Ely as a Deputy Charge Nurse. His promotions ended with his appointment as Chief Male Nurse in 1956. It is right to acknowledge at the outset that he, like all the other members of the male nursing staff, has received no training or instruction in the nursing of the sub­normal. As we have recorded above, many of the more disquieting matters about discipline on the male side at Ely had come to his knowledge (see in particular Paragraphs 284 and 285 above). He must, therefore, be accounted more than formally responsible for the standards of nursing care which we have described and for the existence of the atmosphere, of which XY and “B” (amongst others) plainly become aware. Our impression of him confirms the view of others that he is a kind, conscientious, self-effacing and co-operative man, who does his best to carry out the instructions which he receives. But he himself acknowledged that he has never taken any initiative or made any representations about the conditions, establishment and organisation of the nursing staff on the male side. He has never suggested, whether for himself or for others, the introduction of training, visits to other establishments or courses; nor had he initiated any changes in such matters as occupational therapy or habit training on the wards. It is, of course, right to remember that he had never received any encouragement or instruction to do any of these things. His outlook was no doubt coloured if not by conditions prevailing at Park Prewett before the war, then at least by those which prevailed at Ely on his arrival in 1947. At that time, the status of Chief Male Nurse was no doubt lower even than it is today. This state of affairs was probably perpetuated by the view of the former Hospital Secretary (who served for 40 years at Ely until his retirement at the end of 1966). We were told that he never regarded this Chief Male Nurse as having a strong enough personality for his post and, possibly, tended to deal with him upon this basis. In this setting, it is scarcely surprising that the younger men fell naturally into the role of a good lieutenant and was insufficiently self-assertive to be in effective command of the male nursing staff. He probably has not realised the extent to which the Chief Male Nurse’s role has, or should have, altered over the years. It would, for all these reasons, be wrong to judge him too harshly. He is a basically good man but he is, in our opinion, not the man who could, on his own, initiate or carry through the major changes in attitude which are now required among the male nursing staff at Ely. This task will indeed call for exceptional talents.

Nursing structure

300. In practical and administrative terms, the nursing staff at Ely, senior and junior, appear to have had little contact with their opposite numbers at Whitchurch Hospital, a large and distinguished psychiatric hospital, with its own nurse training school. Certainly there seems to have been little or no beneficial interchange of ideas between the two hospitals, notwithstanding their physical proximity and membership of the same Group. At Ely itself, moreover, a more or less rigid division has been maintained between the two sides of the nursing staff—male and female. Little, if any, consideration seems to have been given by, or on behalf of, the HMC to the resulting isolation of the male nursing staff at Ely. It would be hard to identify a situation more ripe for review in light of the recommendations of the Committee on Senior Nursing Staff Structure (the Salmon Committee).

Management Committee:

301. Neither by members of the public, patients or their families, nor by members of the nursing staff has the HMC been regarded as the body with plain, final responsibility for conditions at Ely. Ely is one of three hospitals (out of the seven within the group) for which no patients’/relatives’ booklets are in existence, on which observations on conditions at the hospital are invited. The HMC has recently shown itself aware of the extent to which it is less than fully informed about conditions at Ely amongst other hospitals. At meetings of the HMC (of of special sub-committees) held during 1967, concern was expressed at the lack of opportunity for members of the HMC to inform themselves about conditions in the hospitals for which they are responsible, and not least about complaints arising in connection with those hospitals. And, even despite this evidence of awareness of the problems, it is apparent, from the circumstances of the “B” case, that the HMC have insufficiently appreciated their overriding responsibility, not merely for disposing of disciplinary complaints in a judicial manner, but also for the quality of nursing care and discipline.

302.We consider below the extent to which this state of affairs is the result of defects in the hospital management structure. In particular, we consider whether the existing system of organisation can, if well run, be relied upon to unearth and remedy the disquieting conditions in this Report.