Extract from a special Inquiry.

‘We now report, with sadness, our findings and, in a spirit of hopefulness, make our recommendations […] We believe the public, as a matter of right, as well as by reason of the fact that it pays for the NHS, is entitled to sound and reliable standards from those employed to administer it’. 

Principal conclusions; the failure of staff to cooperate (largely because of the actions of the consultant psychiatrist who, through arrogance, withdrew from the original inquiry), the failure of duty by the area local authority and lack of effective monitoring by the regional health authority. A lack of implementing current government policy. No evidence (pretty much) of cruelty or ill-treatment of patients but extremely low standards of nursing care and accompanying poor quality of life of patients. A lack of effective nursing leadership.

A few years earlier, a member of staff flagged up that nursing staff ‘had lost their way’. A report pretty much ignored. Eighteen months later an officer visited the hospital and was disturbed by what she saw. Her views were ignored and no substantial improvement effected. Aside from some excellent nurses, there was excessive and improper use of seclusion.

The hospital buildings were neglected and dangerous. Standards of hygiene were often appalling. Faeces and urine were left unattended. Morale was extremely low and could be attributed to the psychiatrist who was a poor appointment in terms of personality. Other medical colleagues were reluctant to work there because of the ‘current practices‘.

Administration was poor at every level with no clear lines of communication. When the hospital was taken over after reorganisation it was already run down and experiencing difficulties. The ‘new administration at an area level adopted a philosophy of seeking to improve the situation by non-intervention and persuasion. This policy was soon shown to be ineffectual but it was nevertheless persisted in for too long. […] Even though there was a failure on the part of certain members of the area management team to keep their colleagues properly informed of adversed developments, the area management team was well aware that the situation was deteriorating but lacked either the will or the skills to do anything about it. There were fitful, sporadic manifestations of concern, but regrettably, these were often more ritualistic than realistic contributions to a resolution of the difficulties.’

A ‘wait and see‘ attitude was adopted at regional level despite knowledge of the price of waiting paid by patients.

The Normansfield Inquiry, 1978

Thanks to Chris Hatton for tweeting this link earlier.