The British Journal of Medicine recently published a case report of a woman who, over a period of 60 years, had been given an estimated 400 electroconvulsive treatments (Electroconvulsive therapy: a life course approach for recurrent depressive disorder by Sarah Carney, Musa Basseer Sami, Victoria Clark and Kompancariel Kuruvilla Kuruvilla.)
The report describes how the woman, born circa 1925, first received ECT in 1954 after the birth of her first child. Between 1954 and her death in 2014 she went into hospital on 24 occasions and each time was treated with a course of ECT. Since 2001, as her physical health deteriorated, the hospital admissions for depression became longer and more frequent and since 2006 she was on maintenance ECT every 2-3 weeks (although it “did not appear to prevent relapses”). In 2009 she was moved to residential care.
The authors regard this as a success story, concluding that: “This case report adds to observational evidence that maintenance ECT may be an underused treatment for recurrent depression and also recommends that greater emphasis be given to incorporating carers’ views when planning individualised treatment approaches”.
At the end of the article the authors say “Patient consent obtained” and I was left wondering how this was possible, since the patient was dead, and, in her final months had been assessed as lacking capacity. The BMJ consent form contains the words “I have seen and read the material to be submitted to the journal”. Had the woman been shown an earlier version of the article when she was still capable of consenting? But that isn’t quite the same thing. Or had the authors, after her death, obtained consent from her next of kin? That would be in keeping with BMJ guidelines but it is definitely not the same thing as patient consent.
The article says that the woman had always lived in the same town, and the author affiliations (Kent and Medway NHS and Social Care Partnership Trust in Ashford, Canterbury, Folkestone and Ramsgate respectively) suggest that the woman lived in East Kent. Thinking about ECT and consent in East Kent led me to recall the committee of inquiry into St Augustine’s Hospital in the 1970s. St Augustine’s at Chartham, near Canterbury, was the former East Kent Lunatic Asylum and its catchment area included Ashford, Folkestone and Ramsgate, although I think people from Canterbury were also treated at St Martin’s Hospital in the city. In 1976 St Augustine’s featured on the front page of The Times newspaper under the headline “Inquiry upholds complaints of grossly bad care for mental hospital’s patients” (31 March 1976). The article described how patients were ill-treated and neglected and how consultant psychiatrists and managers were intent on maintaining their power, suppressing criticism and discouraging new ideas from taking root within the institution. One psychiatrist was criticised for his use of ECT:
“One consultant, now retired but still treating patients at the hospital, had shown in one instance a casual approach to electro-convulsive therapy and in another had ordered a disturbingly large number of treatments. One patient had frequently to be carried to the treatment, sometimes pleading not to have it, and was then held down, the report says. Once he was so violent that he was injured and an attempt to anaesthetize him was discontinued.”
The inquiry into St Augustines in 1976 had its origin in the recruitment of a post-graduate student from Canterbury University as a nursing assistant. He made some relatively mild criticisms about ward management and only when he was ignored expanded them into a critique of the hospital as a whole, listing 70 detailed allegations of malpractice and mismanagement. The inquiry concluded that “many of the allegations… are fully proved, many others are proved in part. Few remain completely unproved”.
The hospital at that time was under the control of a triumvirate consisting of the former medical superintendent, Dr John Ainslie, who had been at the hospital since 1948 and in 1975 became chair of the medical executive committee when it replaced his previous position of medical superintendent, the chief administration officer, and, subservient to them, the chief nursing officer who had also been at the hospital for nearly 30 years. It was the existence of this triumvirate, along with the practice of promoting nursing staff almost exclusively from within the hospital, where many of them had family members also on the staff, that led, in the opinion of the hospital to a “relatively inward looking hospital”. With a predominantly older staff, it was also a rather backward looking one, a point that was demonstrated by a former member of the hospital management committee who was quoted in The Times as saying: “I doubt that this campaign of witch-hunting, digging up drains, opening cesspools, is in the best interests of patients or recruitment of staff. I believe it may be part of a coordinated movement throughout the world to attack psychiatric methods and mental health care.” Or, as the response of senior nursing staff to the critique put it: “A case of the modern trend of student bodies ‘doing their thing’. Sit-ins – kick the Admin – Up the Fuzz, etc. etc.”
Amongst the 70 detailed allegations in the critique were several concerning ECT. One was of a woman (called Mrs JKL in the inquiry’s report) who had first had ECT in the 1950s, at about the same time as the woman in the BMJ case report.
“Mrs. JKL had been both inpatient and outpatient at St. Augustine’s for about 20 years. She was a chronic schizophrenic and had required E.C.T. on several occasions. Her consultant was Dr. Q.”
The inquiry was not a public one and the staff who were criticised were not identified. Mrs JKL had been a patient at the Royal Victoria Hospital in Folkestone. Dr Edward Ritchie, a consultant at St Augustine’s, also had a position as consultant at the Royal Victoria Hospital.
The report went on to describe how, in July 1974, Mrs JKL, who by now was in her fifties and suffering from cancer, was admitted to St Augustine’s after her GP decided she was depressed.
“The following morning Dr. Q walked through the ward. As he passed Mrs JKL she said ‘good morning’ to him. On his own account that was the only contact he had with her before authorising a course of five E.C.T.s.
There was evidence that Mrs. JKL, after signing the form of consent referred to in the next paragraph, fell or slipped to the ground as she was getting out of bed prior to going for E.C.T., and that thereafter she said that she was unable or unwilling to walk. There was also evidence that Dr. Q was told of this and said that E.C.T. should proceed as arranged. Dr. Q denies that he was told of any such incident by the bed or that Mrs. JKL was, or might be, unable to walk. Dr. Q’s version was that he was told that Mrs. JKL was not prepared to get out of bed to walk upstairs to ECT, and that he thereupon gave instructions that she should be carried upstairs. This required four people as she weighed 15 to 16 stone.
When Dr. Q gave the form for consent to E.C.T. to the Sister so that she could obtain Mrs. JKL’s signature he had already signed the declaration: ‘I confirm that I have explained to the patient that nature and effect of this treatment; and had given written instructions for ‘5 E.C.T.s at 2 per week from Wednesday 31.7.74.’ Moreover, the form required a signature by Mrs. JKL to the effect ‘I, (Mrs. JKL) hereby consent to undergo the administration of electroplexy the nature and effect of which have been explained to me by Dr./M ‘. When the form was brought back with Mrs JKL’s signature no name had been inserted. Dr. Q says that he was told at that time by the Sister that Mrs. JKL was complaining of a pain in the leg.
Dr Q told us that although he would normally have seen the patient and explained the position, he did not do so on this occasion because he was afraid that his presence might cause her to say ‘yes’ to E.C.T. when she really wanted to say ‘no’. ‘I deliberately avoided seeing her. I felt that if I went to see this woman I might influence her into having it. I wanted her to have a free choice’. He told us that he felt she could more readily so ‘no’ to a nurse. Very shortly after this he gave some answers which were totally irreconcilable with that explanation for failing to carry out his normal practice. He referred to Mrs. JKL’s complaint of pain in her leg and said that he had decided before ordering her to be carried upstairs for E.C.T. that she had invented the pain to avoid E.C.T. He then had to agree that he had ordered her to be carried upstairs to be given E.C.T. at a time when he believed that she did not want to have it. She was an informal patient.
After she had received E.C.T. Mrs. JKL complained of pain in her back. The Duty Doctor was summoned and she was immediately sent to the Kent and Canterbury Hospital, from which she was transferred to the Brook Hospital, Woolwich, where she died on August 5th. It was not disputed that the information given by Dr. Q to a Sister in St. Augustine’s was accurate, namely that Mrs. JKL died from a combination of a tumour of the corda equina, metastases and two collapsed vertebrae.
What was the state of Dr. Q’s knowledge when he authorised E.C.T., and why did he fail to examine her?
Dr. Q told us that he had no knowledge of the X-ray taken in May, 1974 or the findings based on it. We proceed on that basis. However, he admitted that he knew:
i) that Mrs. JKL had local secondaries where the left breast had been removed, and that secondary tunours in the bones from cancers in the breast are common;
ii) that contrary to his advice no physical examination had been made at the Royal Victoria Hospital and no X-rays taken;
iii) that on the morning he authorised E.C.T. she was complaining of pain in her leg and was unwilling to walk, and that she was a woman who had not previously behaved in this way.
We have no doubt that the exercise of reasonable care by Dr. Q demanded that he should satisfy himself i) that Mrs. JKL required E.C.T. and ii) that she was physically fit for such treatment.
On the question of whether she needed E.C.T. he agreed that he had discharged her four or five days earlier as fit to go home on medication, and that her General Practitioner’s view that she required more E.C.T. might be wrong. He further agreed that he was the Consultant Psychiatrist whose duty it was to decide whether or not to administer E.C.T. Dr. Q sought at that point in his evidence to justify his failure to see her to decide whether E.C.T. was required by telling us that he had shortly before this read an article that E.C.T. can help in the treatment of cancer and he thought that Mrs. JKL would be a suitable patient on whom to experiment. That in our view made it even more necessary to examine her before commencing such an experiment and explain the treatment fully to her. He told no-one, and made no note, that one of the reasons for giving E.C.T. was to see whether it would help treat her cancer. Later in his evidence he said the real need for E.C.T. was fear that she might commit suicide in the future. None of these explanations begin to excuse Dr. Q’s failure to examine Mrs. JKL and make up his mind about her mental state before authorising the further course of E.C.T.
As we have said, he not only failed to make any examination of her mental condition, without which he was in no position to justify E.C.T. but he also failed to explain to her the experimental nature of the E.C.T. and what he hoped it would achieve. He should also have warned her of the increased risk if there was an metastatic disease of the bones.
When the second part of the Critique was received the Medical Staff Committee met and went through the incidents, seeking to identify them. The following note was taken of the explanation that Dr. Q then gave of Incident 67. ‘Patient with long chronic history (1955). E.C.T. ordered as usually giving good results in patients having had mastectomy. The patient was very depressed as well as suffering from carcinoma with metastases… Dr. Q would have no hesitation in prescribing the same treatment again’.
Our criticisms of Dr. Q have been based on his own evidence. His casual approach to E.C.T. on this occasion, and the large number of treatments given to Mr. GHI disturb us deeply. Neither are we at al happy about his use of E.C.T. as a diagnostic measure to distinguish between depression and dementia. Dr. Q estimated that he used E.C.T. for this purpose about once a month, although accepting that in some forms of dementia it would involve increased risk to the patient. We understand that Dr. Q, although retired, has facilities to treat patients at St. Augustine’s Hospital. The Regional Health Authority should consider this Report before extending those facilities.”
From the report of the committee of enquiry (chaired by J. Hampden Inskip QC) into St Augustine’s Hospital, 1976, pp. 68-71.
Dr. Q’s honorary contract was suspended in April 1976, and the suspension was conditionally lifted three months later, according to an article in The Times of 17 July 1976.