The inquiry into St Augustine’s Hospital: a postcript

In a previous post I wrote about the 1976 inquiry into St Augustine’s Hospital, Chartham, Kent.

Three years after the publication of the report of the committee of inquiry the chairman of the committee, J. Hampden Inskip, together with psychiatrist J. Guy Edwards of Knowle and Southampton University Hospital Groups*, published an article in the Lancet (24 March 1979), “Mental hospital inquiries”. It began:

“Major hospital inquiries burn up money that is desperately needed to improve the Health Service, disrupt the work of the hospital, and often have a devastating effect on individual and group morale, leaving in their wake a legacy of corrosive bitterness. They should be avoided wherever possible”.

What you might hope is that inquiries would leave in their wake a legacy of improved care for patients and redress for victims. The allegations of abuse at St Augustine’s hospital, everything from washing patients with the same dirty flannels to abuse of electroconvulsive therapy (ECT), in one case leading to a patient’s death, were found to be almost entirely justified. But the authors of this article were concerned only with the impact on psychiatrists and other staff.

The authors blame the Department of Health and Social Security for abolishing the “old system of physician superintendent, which for all its faults had at least a clearly understood chain of command, and for substituting in its place a multidisciplinary framework without any intelligible guidance as to how this was to be reconciled with the clinical autonomy of consultants as then understood”. Standards of care were inevitably low, they claimed, given the shortage of resources, “combined with an aging population” (the aging population is still blamed for all sorts of ills – it is just a different generation that is aging). The authors gave handy tips on how to avoid committees of inquiry: the setting of reasonable targets, and delegation, for example. If standards of care were slipping too far, consultants could write to the authorities and say they were too overburdened with committee work to provide patient care.

There follows a section on leadership: “Every group of people looks for a leader because it needs one”. Even though the National Health Service had abolished the post of medical superintendent, psychiatrists, according to the authors, could still assume the role of leaders. Then there was a long section on how committees of inquiry worked, what psychiatrists could expect if they had the misfortune to be involved in one, and how staff morale could be maintained. The advantages of a private versus a public inquiry were made clear: “More informality is possible, and the Committee can mingle with witnesses during tea-breaks, when tentative views can be expressed”. The witnesses were of course all clinical and management staff; no patients or their representatives were called as witnesses. In fact, patients were almost entirely absent from the minds of the authors. Concern about the abuses inflicted on the patients appears only parenthetically and is heavily qualified:

“An inquiry inevitably has an emotionally traumatic effect upon some people (if staff have behaved inhumanly to patients, this may well be deserved, although even here an attempt should be made to discover any mitigating circumstances).”

* The original version of this post said that J Guy Edwards was of the Royal South Hants Hospital and Park Prewett Hospital near Basingstoke. Park Prewett was the wrong Hampshire hospital. It should have been Knowle Hospital near Fareham (according to the 1975 edition of the Medical Directory).

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3 Responses to The inquiry into St Augustine’s Hospital: a postcript

  1. Guy Edwards says:

    Mental hospital inquiries and concern for patients

    The post-script to the St Augustine’s Hospital inquiry1, commenting on the paper the late J Hampden Inskip QC and I published in the Lancet in 19792, was published anonymously more than 35 years after our publication. Sadly, Judge Inskip died in 19913,4, some 25 years ago, so is unable to join me in this response.

    Prior to the publication of our article there had been a number of mental hospital inquiries, and others followed5. Hampden Inskip, a distinguished barrister, had been the chairman of the St Augustine inquiry6,7. I was a psychiatrist who had earlier been seconded to the Health Advisory Service to visit health authorities in England and advise the (then) Secretary of State for Health and Social Security on the services provided for the mentally ill – one of which was later subject to an inquiry. I had no connection with Park Prewett Hospital, Basingstoke, as suggested by the author of the post-script.

    The inquiries had identified conditions leading to poor care in psychiatric hospitals. They helped enormously in the development of good practices, the creation of new safeguards for patients, and improvements in care throughout the UK – as did the St Augustine’s inquiry. However, there were a number of misunderstandings concerning the role of committees of inquiry. Our paper attempted to explain some these and advise on steps that could be taken to help prevent inquiries.

    It is right that the anonymous author should express concern for patients but I respectfully suggest that he/she was misguided in believing that this was ‘almost entirely absent from our minds’. From the outset we stressed in our publication that inquiries burnt up money that was desperately needed to improve the health service and for patient care. And in stating that they should be avoided whenever possible, that did not mean at all cost. But it did mean that prevention was better than cure – both for patients and staff.

    In the Lancet and other high impact journals space is strictly rationed and authors are required to focus on specific aspects of medicine. Ours focused on the areas described. But although we did not specifically deal with the effects on patients and families, it did not mean they were far from our minds.

    No one who knew Hampden could reasonably think that he was unconcerned about patients. Outside his judicial duties, he devoted much of his time to voluntary work. Notably, he served for the Leonard Cheshire Foundation network of residential homes for handicapped people8 and compiled the Foundation’s handbook9 – a book devoted to patient care.

    References
    1 The enquiry into St Augustine’s Hospital: a post-script. https://ectstatistics.wordpress.com/2015/08/28/the-inquiry-into-st-augustines-hospital-a-postcript/ (Published on line 28 Aug 2015; Accessed 1 Feb 2016).
    2 Inskip JH, Edwards JG. Mental hospital inquiries. Lancet 1979; 1: 656-60.
    3 Obituary: Judge Hampden Inskip. The Independent, 19 Oct, 1991.
    4 Bell E. Judicial qualities; illustrations from past lives. Judicial Studies Institute Journal. 2008; 2: 18-57
    5 Martin JP. Hospitals in Trouble. 1984. Oxford, Blackwell. ISBN: 9780631144625.
    6 https://en.wikipedia.org/wiki/St_Augustine's_Hospital,_Chartham (Accessed 1 Feb 2016).
    7 South East Thames Regional Health Authority. 1976. Report of the Committee of Enquiry into St Augustine’s Hospital.
    8 https://en.wikipedia.org/wiki/Leonard_Cheshire_Disability (Accessed 1 Feb 2016).
    9 Inskip H. Residential Homes for the Physically Handicapped (Leonard Cheshire Foundation handbook of care). London; Bedford Press: 1981. ISBN 07 199 10676, 97807 19910678.

    J Guy Edwards, FRCPsych, FRCP
    Emeritus consultant psychiatrist
    Southampton

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