Under the nom de plume ‘Pertinax’, Hugh Clegg, professor of industrial relations at Warwick University (Briggs 2005, p. 1472), wrote in the BMJ:

More and more are responsible voices beginning to challenge many of the assumptions on which [the NHS] is based. Many must be rubbing their eyes and asking themselves why such a large carbuncle on the body politic has only just began to look so angry. The short answer is that there has been a conspiracy of silence, a conspiracy fostered by those in control and those afraid to speak (Pertinax 1967).

Barbara needed a strategy if she were to disrupt the conspiracy of silence about less favourable aspects of the NHS and succeed in improving care for older people in psychiatric hospitals. In October 1965 she established AEGIS (Aid for the Elderly in Government Institutions). The acronym occurred to her on a journey to visit Amy at St Peter’s.Footnote 1 AEGIS was a snappy name, with a significant etymology. In Greek mythology, it was a shield carried by Athena and Zeus, a symbol of protection. Doing something ‘under someone’s aegis’ means doing it under the protection of a powerful, knowledgeable or benevolent source. It was not a name for an organisation likely to admit defeat. Relating primarily to older people on the back wards, AEGIS aimed: ‘to call public attention to some very serious defects that exist in the care of patients; to devise remedies for them; and to propagate modern methods of geriatric care with their strong emphasis on rehabilitation.’Footnote 2

AEGIS adopted a role similar to the new breed of politically and media savvy health-related pressure groups emerging at the time, such as the Patients Association (PA) (Webster 1998, p. 68). AEGIS worked with the PA, whose broad remit meant that it comfortably delegated aspects of its work to enthusiasts with their own interests.Footnote 3 Working with the National Association for Mental Health (NAMH) was less straightforward. AEGIS’s political and press campaign contrasted with NAMH’s approach, which mainly encouraged voluntary work and maintained a successful educational programme about all psychiatric conditions, including those of older people (NAMH 1965, pp. 5, 13). NAMH was cautious about publicising the problems in mental hospitals but some NAMH staff thought it should undertake more campaigning.Footnote 4 NAMH’s low-key approach related partly to its desire to keep in favour with the Ministry, which provided much of its funding.Footnote 5 Its noncontroversial standpoint was evident following the debate in the House of Lords at which Strabolgi spoke. During the debate, Baroness Elliot of Harwood, praised the work of NAMH. NAMH’s report on the debate mentioned Elliot’s praise but not Strabolgi’s concerns, although the latter created press and public interest in the psychiatric hospitals that required a response (NAMH 1965, pp. 10–11).

AEGIS’s headed notepaper reflected its professional approach. It also gave the impression of an organisation of magnitude, identifying Strabolgi as president, Barbara as chairman and Harvey as advisor. AEGIS’s office was Barbara’s cottage. Meetings took place there, and the shrill front door bell or Brian’s footsteps on the wooden stairs would interject into the proceedings.Footnote 6 Brian took a back seat in the AEGIS campaign and would stay in the living room during meetings or make the tea.Footnote 7 AEGIS remained small and under Barbara’s direct leadership. She was the voice of AEGIS and the inspiration and energy behind it, but she did not work in isolation: AEGIS expanded to include a handful of experts who could advise on specific issues.

AEGIS’s early activities focussed on publicity, compiling Sans Everything, and planning tactically, aiming to kick-start the Ministry into action. AEGIS suffered from administrative and financial distractions integral to its story—namely, with the publisher over possible libel and with AEGIS’s failure to achieve charitable status. In this chapter we also explore the disturbing comparisons made between the long-stay wards in the psychiatric hospitals and Nazi concentration camps, a theme raised by contributors to Sans Everything, which recurred during the formal inquiries into the allegations.

AGEIS: Supporters and Early Activities

AEGIS drafted a letter about its concerns to send to the Times when a suitable opportunity arose, but it needed influential people to sign it.Footnote 8 One evening Barbara saw Abel-Smith on television. She sent him the letter, and he returned it signed the next day.Footnote 9 AEGIS’s goals were close to his heart: he knew from his students who worked in psychiatric hospitals for short periods ‘what it was really like when the doctors weren’t there’ (Abel-Smith 1990, p. 259). Abel-Smith was also disappointed with the lack of impact on government policy from Townsend’s study The Last Refuge (1962) about care for older people, which identified problems similar to those highlighted by AEGIS.Footnote 10 The Last Refuge initially received significant publicity, including a leader in the Times (Anon. 1962) emphasising government plans to close all workhouses and provide single-room long-stay accommodation and greater choice for older people. Soon after, the Nursing Homes Act 1963 gave local authorities more control over maintaining standards, a first step to improving facilities. However, by 1965, for longer-term support for older people—for which financial responsibility was hotly debated between the NHS and local authorities—there was little impact (Bridgen 2001, p. 512). Thus Abel-Smith came to realise the importance of pressure groups and publicity, which he sought for his own research. The Poor and the Poorest (Abel-Smith and Townsend 1965), for example, was memorably launched with a press conference and television and radio broadcasts on Christmas Eve 1965. The timing ensured an immediate impact, and when linked to the Child Poverty Action Group (CPAG), had a significant longer-term effect (Thane 2015). Abel-Smith regarded a ‘deliberately organised political campaign’ to maintain pressure on the government as the only way for AEGIS to achieve its objectives.Footnote 11

Abel-Smith introduced Barbara to Cecil Rolph ‘Bill’ Hewitt, a journalist who usually wrote under the name CH Rolph. A former police officer, in the 1960s Rolph was a left-wing political journalist at the New Statesman (Howard 2004). Rolph agreed to help Barbara make links with the press and manage public relations.Footnote 12 He chaired press conferences for her, gave AEGIS a platform in the pages of the New Statesman, ‘acted in the capacity which [Barbara] was pleased to call “legal adviser”’ and vetted her letters (Rolph 1987, p. 180). Vetting her letters was important because sometimes the language that best expressed her concerns was not ideal for the goals she sought. As Barbara’s cousin William Charlton advised her, ‘If you talk of “disgraceful negligence” and “ministerial complacency” they will think of you as an enemy, put themselves on the defensive and dig their feet in.’Footnote 13 Barbara and Rolph had a warm relationship; she characteristically ended her letters ‘love from B’.Footnote 14 Rolph wrote (1987, p. 182): ‘An invitation from Barbara had the same effect as a command.’ Passionate and tenacious about her campaign, Barbara was ‘incredibly good at seducing others to help her’, according to journalist Anne Robinson.Footnote 15

The Times featured an optimistic article on healthcare for older people in November 1965. In contrast to the usual pervasive negative expectation of inevitable decline, it explained that for physical and psychiatric illness, ‘if Granny becomes ill and goes into hospital where there is an active geriatric unit, there is a good chance that she will be back home in a few weeks’ (Special Correspondent 1965). The article provided an opportune moment for AEGIS to send its prepared letter. Barbara delivered the letter by hand to the Times that afternoon.Footnote 16 It appeared the following day, 10 November:

We…have been shocked by the treatment of geriatric patients in certain mental hospitals, one of the evils being the practice of stripping them of their personal possessions. We now have sufficient evidence to suggest that this is widespread.

The attitude of the Ministry of Health to complaints has merely reinforced our anxieties. In consequence, we have decided to collect evidence of ill treatment of geriatric patients in mental hospitals throughout the country, to demonstrate the need for a national investigation. We hope this will lead to the securing of effective and humane control over these hospitals by the Ministry, which seems at present to be lacking.

Signatories included Barbara, Abel-Smith, Harvey, Strabolgi, two other peers, two ministers of religion, an artist and a socialist reformer doctor, providing striking authority and prestige.Footnote 17 The letter had three messages: stripping took place, the Ministry mishandled complaints and AEGIS needed information from people ‘who have encountered malpractice’. AEGIS promised confidentiality in dealing with personal data. Getting published was a breakthrough in gaining public attention. Considering stripping an unsuitable subject, the Times had twice refused letters about it from Charles Clark, a lawyer, publisher and active member of the PA and NAMH.Footnote 18

Responses followed. Some people offered support, including the pioneering geriatric nurse Doreen Norton,Footnote 19 but in the main, Barbara received ‘an avalanche of anguish’ (Anon. 1965b). She answered every letter personally.Footnote 20 Some people asked her to visit their relatives with them, but voicing fear about complaints leading to staff reprisals against patients, they invariably asked her to keep the reason for her visit confidential.Footnote 21 The Times published correspondence with Maurice Hackett, then chairman of the North West Metropolitan Regional Hospital Board (NWMRHB), who had served on the Board in various capacities, including working on it alongside Kenneth Robinson. Hackett’s first letter (1965a) was sanctimonious: ‘We in the hospital world who are charged by the Minister to guard and protect the interest and care of patients in mental hospitals, are appalled at the irresponsibility of those who signed’ the letter from AEGIS. Hackett did not state the name of the hospital implicated but implied that he knew it. He wrote that a ‘public—or private independent’ inquiry was offered, which Barbara and Strabolgi knew was incorrect: Robinson offered a private RHB inquiry.Footnote 22 Barbara and Strabolgi decided not to refute that publicly because if they did, the likely outcome was that the Ministry or RHB would say they offered it verbally, and the authorities, rather than AEGIS, would be believed.Footnote 23 Hackett (1965a) stated that the RHB was now conducting its own inquiry, which was accurate, although it had not informed AEGIS. Strabolgi and Barbara responded to Hackett’s letter, noting that if Robinson had offered a timely inquiry when first approached, there would have been no publicity. They also queried why Hackett made no reference to stripping, AEGIS’s primary concern. They blamed the difficulties of providing adequate care on a lack of finances, not on cruel staff: ‘We have always recognised that the staffs of mental hospitals…work gallantly and devotedly under many difficulties…and no blame should be attached to them’ (Strabolgi and Robb 1965).

Hackett’s second letter to the Times informed the public about Strabolgi’s covering letter for the Diary in April, in which he invited Robinson to ‘study’ it, but did not explicitly give him ‘permission to make use of it’ (Hackett 1965b). Hackett had a detailed knowledge of the covering letter, indicating at least some communication about it between him and Robinson, but Hackett misconstrued its meaning. It would have been pointless to send Robinson the Diary merely to peruse, and Robinson knew this, as indicated by his initial offer to investigate.Footnote 24 Hackett blamed Strabolgi’s instructions for the Ministry not carrying out an inquiry. Robinson kept a low profile in the Times correspondence, permitting Hackett to respond on his behalf.

The First Friern Inquiry

On advice from the Ministry, the RHB constituted a committee of inquiry two days before AEGIS’s letter in the Times, and then informed Friern Hospital Management Committee (HMC):

The Board have for some time been concerned at a number of criticisms directed towards psychiatric hospitals in general and to Friern Hospital in particular…and have now agreed to the proposal of the Minister that there would be advantage to all concerned if an enquiry were to be held by the Board.Footnote 25

Evidence is not available to explain the timing, whether the Ministry and RHB knew about AEGIS’s plan for publicity, or whether waiting until November was due to Ministry or RHB reluctance to investigate, or to multiple legitimate competing pressures. The Ministry could have been aware of AEGIS’s plans because Abel-Smith was well known there (Sheard 2014, p. 187), and Robinson, Abel-Smith, Townsend, Crossman and Harvey shared other circles of activity, such as the Fabian Society.Footnote 26

The RHB appointed Ann Blofeld to chair the committee of inquiry. Blofeld, in a voluntary capacity, had served on the RHB since 1949 and chaired its mental health committee since 1963 (Anon. 1978).Footnote 27 The committee planned to investigate the administration of Friern Hospital, the care of patients and Strabolgi’s criticisms made in the House of Lords. The Diary was not included because Barbara refused permission for that in August.Footnote 28 On 2 December, Barbara and Strabolgi received identical invitations from Blofeld to attend the inquiry.Footnote 29 They were handwritten on Blofeld’s personal headed notepaper from her home address, an unconventional approach for a formal inquiry, suggesting a rushed afterthought. Barbara and Strabolgi followed Blofeld’s procedure: they replied with separate handwritten letters. When Barbara later asked Blofeld whether sending members of the public handwritten invitations to inquiries from private addresses was usual, she replied that she devised the procedures for the committee,Footnote 30 suggesting that the RHB lacked protocols for, and experience of, investigating complaints.

Barbara and Strabolgi were uneasy about the inquiry. In Barbara’s view, because all the committee members either served on the RHB or worked in the NHS within the region, it was not a ‘public—or private independent’ inquiry of the sort Hackett (1965a) referred to. Barbara expected an independent inquiry to be chaired by a senior lawyer who was not a member of the RHB and for witnesses to have legal representation.Footnote 31 Strabolgi was worried that Abel-Smith, the NAMH and the PA were using them as their ‘cat’s-paws’.Footnote 32 The day before the meeting, the RHB asked Strabolgi to arrive at 11 a.m., and Barbara fifteen minutes later. Still cautious, they planned to arrive together at 10:45 and to refuse to be separated.Footnote 33

At the meeting, Blofeld told Barbara ‘in rather bullying tones’ that she had not expected her to come. Blofeld was smug, such as announcing that she had ‘many years of experience of hospital matters’ and they should remember ‘all the work that she had done in this field without ever having been paid anything at all for it’. The Diary, despite not being within the terms of reference, was central to the discussion. The members of the committee appeared sympathetic and interested in Barbara’s points, the chairman less so.Footnote 34 Mutual distrust and antagonism seemed to characterise the meeting, hardly a recipe for a constructive outcome. Immediately after the meeting, Barbara wrote up her twelve-page account of it, which she hoped ‘to publish one day’.Footnote 35

Blofeld reported to the RHB in January 1966 with fourteen densely typed pages. The report expressed gratitude to Lord Strabolgi for helping the inquiry but was less appreciative of Barbara who was ‘also present’. Despite the antagonisms, the report was surprisingly insightful, particularly regarding the care of older people. It found that some were in Friern ‘merely because they are old’,Footnote 36 corresponding with Townsend’s research (1965, p. 229). The Friern consultant psychiatrists held divergent opinions about their older patients’ potential for discharge (if alternative support and accommodation were available), ranging from 6 percent to 83 percent for women patients and 2 percent to 58 percent for the men. Each consultant had their own patients, but clinical differences between the patients were unlikely to account for these disparate expectations. More likely, expectations indicated a haphazard approach to treating older people, lagging behind best practice recommendations. Compared to similar hospitals, Friern also lacked social workers to assist with arranging discharge: it had one qualified and two unqualified social workers with high rates of staff turnover (Ministry of Health (MoH) 1968, p. 49),Footnote 37 creating an impossible workload.

The committee noted lack of activities for the patients, but thought it might be ‘inhuman to attempt to stimulate the very old’. They also found an absence of dentures and hearing aids. The staff told the committee that these items were not permanently removed, but after a pair of spectacles went missing, staff collected them at night for safe keeping and handed them out the next morning. However, the committee visited during the day and saw patients without these items, incompatible with staff explanations. Possibly, staff levels did not permit them to redistribute the aids, in which case their alleged nighttime safe storage was futile, or the staff’s explanation for absent aids was incorrect.Footnote 38 Bedside lockers were a logical remedy. On some wards, staffing levels were ‘grave’, and some staff spoke little English.Footnote 39 On the day the committee visited ward E3, where Amy had been, it had fifty-three patients, with one sister, two untrained nursing assistants, a student and a ward orderly. Staff levels were too low to provide adequate individual attention to the patients, two of whom were confined to bed with fractured femurs and many others required time-consuming physical care because of incontinence and frailty.Footnote 40

The report condemned the twenty-four unstaffed locked wards at night, some with side rooms locked within them, because of fire and other risks: the Colney Hatch Asylum fire, which killed fifty-one patients was within living memory (Anon. 1903) (Fig. 4.1). Unequal provision of staff and resources favoured the Halliwick unit, undermining staff morale in the old building. For the hospital generally, the report described conditions unacceptable by 1960s standards: appalling ‘sanitary annexes’, inadequate ward heating, dismal ward environments and overcrowding. Medical care on the back wards was inadequate,Footnote 41 and poor care overall was associated with complacency and ‘lack of imagination, direction and drive’.Footnote 42 Complacency of the medical superintendent, senior nurses and the HMC shocked the committee.Footnote 43 The committee concluded that Friern was a hospital ‘in which progress generally is retarded’, displaying unwillingness to relinquish out-of-date practices.Footnote 44 The low standards raised the possibility that the RHB was uninformed, or ignored or concealed inadequacies, patterns recognised elsewhere (Martin 1984, p. 85).Footnote 45 Friern fitted with the Ministry’s descriptions of the worst psychiatric hospitals, and that ‘the difference between the most and the least progressive [hospital] is greater now than ever before’ (MoH 1964, p. 1). The report supported, rather than refuted, Strabolgi’s and Barbara’s allegations.

Fig. 4.1
figure 1

Memorial to victims of Colney Hatch Asylum fire, New Southgate Cemetery, 1903. Photograph by author.

The Outcome of Blofeld’s Report

Hackett chaired, and Blofeld attended, the RHB meeting that discussed her report. The RHB decided that the part of the report containing the most ‘serious concerns must be regarded as strictly confidential’, whereas the comments about limitations in day-to-day care, mainly on the back wards, were within the bounds of acceptable practice and were ‘a vindication of the Hospital’. The RHB planned to discuss the report with the Friern HMC but minuted no other actions.Footnote 46 The integrity of the RHB in dealing with a private, internal inquiry that it had no commitment to publish was a stumbling block, contrasting with the honesty of the inquiry committee. Similar to Friern HMC when faced with unfavourable reports on nurse staffing,Footnote 47 the main deficits were concealed, giving no chance of the report benefitting patients. Hackett sacked Friern’s clinical leaders—matron, chief male nurse and medical superintendent—because he regarded them as responsible for the deficiencies. He implied that blame lay solely with clinicians by not sacking the HMC or the ‘hopeless old chairman, hopeless secretary’ as Crossman described them.Footnote 48 The minutes do not document how the Board reached its conclusions and feeble plan of action, whether any Board members disagreed, or if Blofeld spoke at the meeting. After years of service on the RHB, Blofeld took on a new role in 1966 as Chairman of the Board of Governors of the Royal National Ear Nose and Throat Hospital (Anon. 1978), outside the RHB’s authority. It might have indicated her dissatisfaction with the response to her report.

A later investigation at Friern criticised Hackett for the sackings and described the Board’s apathy towards Blofeld’s report as ‘inexcusable’.Footnote 49 Strabolgi and Barbara never saw the report, but it would have shattered their doubts about Blofeld’s unconventional methodology and allayed their fears about an internal inquiry inevitably being biased. Strabolgi received a brief and bland summary from Robinson, which Rolph called a ‘whitewash’.Footnote 50 In December 1966, a year after Blofeld interviewed Barbara and Strabolgi, Barbara wrote to Hackett requesting a copy of the report. Hackett replied in a single line: ‘I have your letter of 18th December and have no comment to make.’Footnote 51 Hackett’s secretiveness was out of line with the Ministry’s recent memorandum on managing hospital complaints (see below, pp. 109–112), which emphasised that explanations should be sympathetic and sufficient and ‘it should be made evident to complainants that their complaints have been fully and fairly considered’ (MoH 1966b, pp. 1, 3). There was no justification for the content or tone of Hackett’s concluding letter to Barbara, which she described as ‘short and sour’.Footnote 52 His response was pivotal to her campaign: she decided then to publish the Diary.Footnote 53

Action on Stripping

The Ministry sent a letter to RHBs in December 1965 offering guidance on stripping, remarkably swiftly after the letter in the Times. The guidance also referred to personal possessions such as jewellery and watches.Footnote 54 The informal status of a letter rather than an official memorandum released the RHBs from any obligation to report back to the Ministry about the practices in their hospitals, or what was being done to improve them.Footnote 55 If, as the PA informed AEGIS, official ministerial guidance was usually ignored,Footnote 56 circulars that did not require feedback were almost worthless. The Ministry, despite claiming to deplore stripping, was half-hearted in its attempt to prevent it.

Friern HMC discussed the stripping guidance. Any action over dentures, spectacles and hearing aids to assist independence paled into insignificance compared to worries over the financial value of watches and jewellery.Footnote 57 The latter were more problematic for staff and the HMC because these objects might be stolen or given to relatives for safe keeping or not brought back after the patient went out on visits. Staff would, therefore, not know the whereabouts of belongings, leading to ‘difficulties and misunderstandings’.Footnote 58 The Friern discussions also indicated the enormous control staff had over patients’ lives. Staff control made life easier for the nurses but undermined confidence, independence and rehabilitation for the patients.

The Ministry’s letter on stripping was unavailable to the public because of its informal status. AEGIS and the PAFootnote 59 both sought confirmation about whether it had been circulated, and to what effect. With no answer from the Ministry, in February 1966, Barbara approached Eric Lubbock MP who agreed to ask about the guidance in Parliament.Footnote 60 The press picked up the issue (Anon. 1966a), raising public awareness. One outcome was an anonymous editorial in the Lancet, reporting that despite the Ministry’s letter, the practice continued, justified as ‘the custom of the hospital’ even though there was no medical reason for it, and it caused immense damage to personal pride and independence. The author stated that the quantity of an older in-patient’s personal possessions indicated the effectiveness of the ward: the more the better (Anon. 1966b). Rolph backed up AEGIS with an article in the New Statesman on stripping and other unacceptable practices. He based it on personal experiences of visiting psychiatric hospitals and on his work as a police officer, and acerbically asked whether it was really necessary to remove spectacles, hearing aids and dentures to protect individuals:

When the ‘senile dementia’ of your dormitory neighbours gets too much for you, you might break your spectacles and slash your wrists with the glass. Well, I’ve done my share of precautionary disarmament with people in police custody, but I never took anyone’s teeth away (Rolph 1966a).

Rolph’s article precipitated more letters, similar to those already received by AEGIS. In his memoir he wrote:

I can remember the shock of misery with which I read the letters that came to me after the New Statesman article…despairing cries of decent, ordinary people unable to get a hearing in the hospital world. These nurses told of pitiless neglect of the helplessly old, and of the common practice of ‘stripping’ (Rolph 1987, p. 181).

Abel-Smith and Rolph could not fathom out why Robinson was so uncooperative about stripping. Abel-Smith commented to AEGIS that ‘The moment you mentioned the word he flared up. And he doesn’t flare up often,…he’s been hit below the belt on it,…he is very sensitive.’Footnote 61 Barbara concluded: ‘the issuing of “advice” had been no more than a feeble, face saving exercise.’Footnote 62

Improving, Monitoring and Maintaining Standards

AEGIS proposed three ways to improve, monitor and maintain standards in the NHS: effective local complaints mechanisms; a health service commissioner or ombudsman to investigate complaints that could not be resolved any other way; and independent inspection of hospitals (Abel-Smith 1967). The PA concurred with AEGIS’s strategies and noted despairingly that, especially for elderly patients, ‘hospital boards and committees cannot be relied on to represent and protect patients’ interests’ (Hodgson 1966). Concerning complaints, no guidance for handling them was introduced at the inception of the NHS. The only formal mechanism outside the law courts was the General Medical Council, which, since 1858, managed complaints against doctors. In 1964–1965, the Ministry noted several examples of poorly managed complaints. It commented that one RHB enquiry did ‘not seem to be entirely consistent with the seriousness of the matters requiring investigation’.Footnote 63 The South West Metropolitan (SWM) RHB informed the Ministry that its HMCs were inadequately acquainted with ‘criticisms about their hospitals, some of which later result in quite serious complaints’.Footnote 64 Inadequate responses by RHBs to complainants left one civil servant grumbling: ‘We have to spend endless time in concocting phraseology in our replies to cover this deficiency’,Footnote 65 implying that the Ministry attempted to protect the RHBs rather than impartially investigate complaints. The Ministry’s motivation for its method of managing complaints was partly self-preservation, to avoid ‘disproportionate and damaging publicity’ when, it claimed, most clinical work was carried out to a good standard.Footnote 66

A three-page memorandum by the Ministry (1966b) about handling patients’ complaints was the NHS’s first official guidance on the matter (Mulcahy 2003, pp. 29, 31).Footnote 67 It had a two-year gestation, an extraordinarily long time for such a brief document, and the draft in February 1965Footnote 68 differed little from the final version in March 1966. National Archives’ files do not indicate whether publication was influenced by agitation from AEGIS or the PA or whether there were genuine administrative reasons for the time lag. The Ministry based the guidance on good principles sympathetic to the complainant, but it was not binding and lacked detail. It stated, for example, that ‘special arrangements may be needed in psychiatric hospitals’ but did not explain what that meant. Abel-Smith illustrated his understanding of this with examples of the difficulties faced by staff, and conclusions drawn by them, when responding to complaints in psychiatric hospitals.

Complaint 1::

Missing spectacles?

Response 1::

Not a valid complaint, as it is inevitable if the patient has nowhere safe to put them.

Complaint 2::

Patient frightened because of staff behaviour?

Response 2::

Not a valid complaint as the patient is confused.

Complaint 3::

Bruised patient who says she was struck by a nurse?

Response 3::

Not a valid complaint: sister says it would not happen on her ward and, anyway, it would be impossible to get to the truth.

Although Abel-Smith contributed to developing the new guidance (Cochrane 1990, p. 83), in his view, it was inadequate, especially for patients in hospitals with a cultural malaise and self-protective staff loyalty that would defeat expressions of concern by patients or their representatives. The recommended processes could work well for adverse medical treatment incidents but were unlikely to succeed for a ‘sick’ hospital (Abel-Smith 1967, p. 132).

The new guidance did not state who would assess the complaints, nor did it propose training or the means to achieve ‘adherence to a well-recognised procedure’ (p. 1). It advised prompt and impartial handling of all complaints, at all degrees of seriousness, and informing the complainant of the result of the investigation and action taken. Barbara received a copy via Abel-Smith (Cochrane 1990, p. 83). In the light of her recent experiences with the Blofeld Inquiry, Barbara must have pondered over the recommendation: ‘a small number of cases…so serious that they cannot be dealt with satisfactorily…should be referred for independent enquiry.’ The guidance (p. 2) defined independent as being chaired by an independent lawyer ‘or other competent person from outside the hospital service’ with a committee independent of the authority concerned and that ‘The complainant…should be allowed to make their own arrangements to be legally represented if they so wish’, in line with Barbara’s requirements.Footnote 69 Guidance on legal expenses for witnesses was not included: RHBs and lawyers held various opinions on this, from all to nothing.Footnote 70

The Institute of Hospital Administrators (Anon. 1966c) cautiously welcomed the guidance. It criticised the recommendation that complaints that could not be dealt with by staff in a ward or hospital department had to be stated in writing, because some people lacked the skills to write or dictate a letter, and ‘Perhaps that is why so many of them seem to make their complaint in the local newspaper office.’ It also stated that more staff education was required, commenting that if a hospital considers it acceptable to keep older people waiting for long periods in out-patient clinics or to deprive them of dentures or spectacles, then it will ‘hardly be able to satisfy people who complain’. It took up AEGIS’s concerns about older people to illustrate the need for adequate complaints procedures, which was heartening for Barbara.

The complaints guidance was categorised as a ‘pink’ circular indicating that the Ministry required feedback on its implementation. Ben Whittaker MP for Hampstead (Barbara’s constituency, another of her allies) asked Robinson, a year after its introduction, how often the procedures for more serious complaints that could not easily be resolved had been used. Robinson replied: once.Footnote 71 Whether RHBs and HMCs publicised and implemented the guidance was therefore doubtful, a hypothesis supported by other evidence. One person wrote to Barbara about attending a recent complaint investigation:

I feel worse than ever after the ‘Committee of Investigation’ last night, because I realise how utterly helpless one is against a hospital.

Every so often, Dr C would pull a face and say ‘Tch!’ I can’t really describe his facial expression or his attitude. He sat with his arms outstretched across the table, the sheaf of notes between and when he was speaking he kept his head bowed down to the papers or staring at his hands. I would call it ‘shifty’. He seemed ill-at-ease, yet he could ‘explain’ every point at great length, so make it sound as if all he had thought of was the patient’s comfort, and that I couldn’t be expected to understand.Footnote 72

The complainant requested a written report but did not receive one. Others wrote to Barbara about similar experiences. Most investigations ended in complete rebuttal of the complainant’s concerns. Frequently, administrators based their analyses on the doctors’ reports, without evidence of discussion with other staff, the patient, or the complainant.Footnote 73

At Friern, HMC minutes first mentioned the guidance almost a year after publication,Footnote 74 and at the NWMRHB, it seemed to have little effect. When the Daily Mail, in 1967, criticised Harperbury Hospital, aligning conditions there and in other ‘subnormality’ hospitals with eighteenth-century slave ships, the Board sought to uncover actions of staff that might have enabled the journalist to write his report, rather than whether there was substance to the allegations.Footnote 75

The new guidance made little impact at the Ministry which justifiably could have been expected to set an example. In 1967, a complaint submitted after a patient’s relative heard of AEGIS’s work, illustrated the old pattern of response. The complaint related to an elderly woman patient in a SWMRHB hospital. It described inadequate food; rude ward staff; staff insisting on bathing the patient even thought she was frightened and unaccustomed to sitting in a bath; and incontinence causing distress when the patient was unable to get out of bed.Footnote 76 The Ministry delegated the investigation to the SWMRHB, which subsequently fed back that it found no evidence of ‘cruelty or neglect at any stage of her treatment’.Footnote 77 It is unlikely that a balanced investigation would have produced such a reassuring, across-the-board statement, but concluding that her care was acceptable at all stages, meant that there was no need to make improvements. The Ministry accepted the SWMRHB’s assessment and wrote to the informant, criticising him: ‘We are sure you will appreciate that it is helpful if matters of this sort are brought to the attention of the hospital authorities at the time, when the necessary steps to investigate can be taken immediately.’Footnote 78 With condescending responses by those in highest authority, it is hardly surprising that some complainants, like Mrs Dickens at Friern, became exhausted, demoralised and gave up.Footnote 79

AEGIS’s second proposal was for an ombudsman or commissioner to investigate apparently unresolvable NHS complaints. The Labour Party (1964) election manifesto proposed a new office of parliamentary commissioner ‘with the right to investigate the grievances of the citizen’. The PA was not convinced that the government’s proposal would cover complaints of the kind that they handled,Footnote 80 so wrote to the Ministry in December 1965 recommending a separate NHS appointment.Footnote 81 In a curious case of interpressure group rivalry, Hodgson (1972) claimed that a NHS ombudsman was the PA’s idea, not AEGIS’s. About this, Barbara commented: ‘I discussed the idea of a Hospital Ombudsman with her in the Autumn of 1965—when she was being extremely kind and helpful—but she didn’t seem to bite on.’Footnote 82 The Parliamentary Commissioner Act 1967 did not cover the NHS. Doctors’ opposition contributed to that because they were concerned about interference by lay people in matters of clinical judgement, but there were also technical reasons (Anon. 1966d). These included, confusingly, that within the NHS, only the hospitals, for which the Ministry directly delegated management to the RHBs, would come under the new ombudsman, whereas the local ‘autonomous bodies’ which organised general practitioner and community health services, would not. The Ministry also thought it prudent to give the 1966 NHS complaints procedures a trial before introducing another scheme.Footnote 83 Reflecting ambivalence and diverse opinions on the matter, the Act was drawn up so that hospitals could be included with ease at a later stage.Footnote 84

AEGIS’s third strand was to establish a hospitals’ inspectorate. However, this was not on the government’s agenda in the mid-1960s. Explanations for this relate to the establishment of the NHS. The first white paper proposing a NHS (MoH 1944, pp. 10, 24) discussed ways to organise it and the possibility of an inspectorate. One organisational option for the NHS was to delegate responsibility to local authorities, as for schools. That model gave central government a supervisory role, with inspectors essential to it, to report back to assist with supervision. For hospitals, the Ministry adopted an alternative model of direct management through RHBs and HMCs. The Ministry would appoint these bodies which would be directly accountable to it, so inspection and feedback were not required. Mental hospitals, however, also had to comply with mental health legislation, so continued to undergo independent inspection by the Board of Control. Many staff appreciated these visits and the opportunity they provided to pass on information and ideas from one hospital to another and the way they could focus interest on needs long recognised by hospital staff but ignored by HMCs and RHBs (DHSS 1971, p. 1). In the course of the Royal Commission (1957) on mental illness and mental deficiency, the British Medical Association and Royal Medico-Psychological Association (later Royal College of Psychiatrists) argued for an independent inspectorate. Despite this advice, the Commission decided that ‘A central Inspectorate outside the Minister’s own Department is neither necessary nor desirable’ (Royal Commission 1957, p. 254). Thus independent inspections of mental hospitals ceased when the Mental Health Act (1959) abolished the Board of Control. This brought mental hospitals into line with general hospitals, a far-reaching step that implemented decades-old principles of treating people with mental illness, as far as possible, under the same NHS principles as those with physical illness. It would remove independent inspections but had the potential to reduce stigma and encourage community services (Hilton 2016a). In 1964–1965 when MPs requested inspectors for hospitals, Robinson reiterated that such a system was inappropriate.Footnote 85 In July 1965, the Daily Telegraph reported that the PA asked the Ministry to establish an inspectorate, basing their request on evidence from its members who reported that, too often, complaints made to hospitals were ignored or insufficiently investigated (Anon. 1965a). By the time Barbara compiled Sans Everything, the Ministry had provided no plans for an inspectorate.

Planning Sans Everything

Letters to AEGIS arrived from all quarters and via unexpected routes. The Ministry of Health forwarded to AEGIS some from aggrieved relatives, including one from Miss Geraldine Richardson who petitioned the Queen on the care of older people, and another from Miss Kathleen Gabb asking Mrs Wilson, the wife of Prime Minister Harold Wilson, to intervene on stripping.Footnote 86 It is inappropriate to discuss the hundreds of letters AEGIS received, many of which are stored in ‘closed’ sections of the AEGIS archive. Disclosure might be hurtful for descendants of patients or staff. For Sans Everything, AEGIS built its case from a few witnesses’ reports selected from the many responses it received.

AEGIS planned tactically. The book was timely, according to Rolph, in the broader context of public discontent about government conspiracies, cover-ups and ‘ministerial lying’. His examples included secret international dealings at the time of the Suez crisis (1956); the government inadequately handling the press concerning publication of potentially sensitive security material (1967)Footnote 87; and ‘Parliamentary question time every Tuesday, Wednesday, Thursday and Friday’. Rolph wrote to the publisher that it ‘will turn out to be a seminal book and that when all the tumult has died down (which will take quite a while) there will at last be some action.’Footnote 88 He was sure that a well authenticated sensational book aimed at the general public would create a sufficient stir to provoke appropriate investigations to achieve necessary changes. He hoped at least for a public inquiry, if not a Royal Commission or a House of Commons Select Committee. His expectations linked to the recent appointment of the Mountbatten Committee on prison security in the aftermath of spy George Blake’s escape from Wormwood Scrubs prison (Home Office 1966). Blake’s escape received significant press attention: ‘Everybody gets terribly frightened and worried and excited’, Rolph said, resulting in some high profile person being appointed to investigate, followed by changes and more evaluations. Rolph wanted the same for Sans Everything.Footnote 89

The title Sans Everything was not a given. The shortlist was scholarly and reflected the breadth of Barbara’s knowledge of literature, and the depth of searching characteristic of her work. From Juvenal’s Satire XI—morte magis metuenda senectus—she derived More to Be Feared Than Death. Another option was The Last of Life from Robert Browning’s ‘Rabbi Ben Ezra’: ‘The best is yet to be, The last of life, for which the first was made.’ Another possibility was Twice a Child, from ‘An old man is twice a child’ in Shakespeare’s Hamlet. Footnote 90 Sans Everything was a late addition.Footnote 91 The phrase originated in Shakespeare’s As You Like It: ‘Sans teeth, sans eyes, sans taste, sans everything.’Footnote 92 In addition, the ancestral motto from the Charlton line of Barbara’s family was Sans Varier, meaning without changing or deviating from the path, a maxim by which she abided and that could have contributed to her final choice of title.Footnote 93

The Witnesses and Their Statements

This section gives biographical sketches of the Sans Everything author-witnesses and an outline of their allegations (other than those about Friern, discussed in Chapter 3, pp. 69–76), plus some relevant contextualising material. Knowledge of the witnesses’ backgrounds contributes to understanding the subsequent inquiries. It also reveals similar personality and employment characteristics, likely to have influenced staff willingness to whistle-blow, a subject relevant to the NHS in 2016 (Hilton 2016b; NHS Improvement 2016). The amount of biographical detail available for each witness varies and is drawn from several sources, including from their correspondence with Barbara and from verbatim transcripts of inquiries and, for Joyce Daniel, from information provided by her sons.

Barbara chose accounts by staff and former staff that she thought were particularly clear, convincing, factual and informed. She met each author to ‘satisfy myself that they are reliable and well balanced persons’ (Robb 1967, p. xiii). She continued to be meticulous about confidentiality, for the witnesses’ security, because of victimisation of staff who were disobedient, or who complained or questioned hospital practices. Barbara thus gave the author-witnesses pseudonyms, except for Roger Moody who was content to use his real name. The pseudonyms derived from Barbara’s ancestry, reflecting her high regard for the witnesses and creating a link with her personal commitment to the cause. Barbara took Anne family names as surnames: Osbaldeston, Isham, Swinburne, Tasberg(h), Heneage, Fenton and Cra(y)thorne. The two male nurses she called Michael and Frederick, names of several ancestors and her two surviving brothers. The women’s first names linked to her aunt Louisa; grandmother Laura Adeline; great-grandmother and aunt who were both called Emily; and Elizabeth who died ‘for the faith’Footnote 94 (Table 4.1).

Table 4.1 The Sans Everything witnesses

The Witnesses, Their Names, Roles and Hospitals

None of the witnesses received payment for his or her writing or for involvement with AEGIS: they all participated to appease their consciences. As one witness, James Davie, said: ‘My motives are that if I hadn’t taken action as I have done here, I would never have been able to look myself in a mirror again. I was appalled. I am appalled.’Footnote 95

One of the Sans Everything author-witnesses was Joyce Daniel (Fig. 4.2). Born in 1911, her father, a lawyer, was Town Clerk of Devonport and later of Plymouth. She had no formal education beyond school age but in the 1930s was housekeeper for the novelist and poet Sir Arthur Quiller-Couch, then in his seventies. During the war, she had various jobs, including driving an ambulance in Southampton, a city that suffered heavy bombing. In 1945, she, her husband, and one-year-old son, settled in a cottage on a wooded smallholding outside Bodmin, Cornwall. When her husband died in 1959, Joyce went out to work to support her sons, Charles and Robin, who were then teenagers. Unusually, and resonant with the family’s unconventional interests and determination, they acquired their first steam traction engine in 1962, and restored it.Footnote 96 Joyce wrote to Barbara about her family and about using their traction engine to help roll the tarmac for a local airstrip.Footnote 97 Her correspondence with Barbara, with meticulous handwriting and eloquent expressions, suggests she was an able, sociable and thoughtful person, aiming to do her best for her family and friends.Footnote 98

Fig. 4.2
figure 2

Joyce Daniel, c.1964. Reproduced courtesy of Charles and Robin Daniel.

In 1964, Joyce Daniel took a job as an auxiliary (untrained) nurse at St Lawrence’s Hospital, Bodmin, working mainly on a long-stay female geriatric ward (Daniel 1967). She described, among other things: staff swearing at patients, hitting them and handling them roughly; communal bathrooms where forty-four patients were bathed in a single morning; patients ‘locked in the lavatory to keep them out the way’; and staff making crude remarks about patients in their hearing. She also wrote that patients responded warmly to her interactions with them. When she complained about staff behaviours, she was taken off duties with patients and transferred to cleaning copper pipes in the ward bathroom. Her colleagues were angry with her, saying her comments created an unpleasant work atmosphere and that nurses should be loyal and unified. She resigned.

Loyalty to colleagues was central to the function of a close-knit psychiatric hospital ‘total’ institution. The primacy of loyalty defended staff against criticism: the critic became the unacceptable deviant. Punishing critics was common—for example, ordering them to do domestic work rather than work with patients, making life intolerable so that they resign,Footnote 99 or dismissing them (DHSS 1971). Occasionally the Ministry became involved in an appeal against dismissal on grounds of transgressing the etiquette of loyalty. The case of Mrs Glynn in 1967 illustrates this. Glynn was a nursing assistant. She received a letter from her matron: ‘I feel that your disloyalty towards your colleagues and the fact that you are not happy with conditions at the Dene, leaves me with no alternative but to ask you to accept one week’s notice.’Footnote 100 Glynn was subsequently reinstated and matron was reprimanded.Footnote 101 Correspondence with the Ministry does not indicate the underlying reasons for Glynn’s discontent or if they were remedied. Russell Barton (1967, p. x) commented on the ‘misplaced loyalty of one staff member to another.…Victimisation of anyone who is critical, whether justifiably or not, may be automatic.’

Another witness, James Davie, worked at Storthes Hall Hospital, Huddersfield, then Springfield Hospital, Manchester. He lived in Manchester with his wife, Phyllis, and their daughter. He served in the RAF during the war, but no farther afield than the Isle of Man where he worked with injured servicemen. He then worked in the Savings Bank department of the Post Office before buying a hardware and ironmongery business. He sold the business around 1964, expecting to find alternative employment, but it proved difficult.Footnote 102 At that time he was studying French at Advanced (‘A’) Level.Footnote 103 Davie, like Daniel, was in his fifties, had diverse life experiences but had no nurse training and sought worthwhile, secure employment.Footnote 104 He also had a life-long stammer, worse under stress, making his decision to attend the subsequent inquiries even more admirable.Footnote 105

Davie took a job as an auxiliary nurse at Storthes Hall during a recruitment drive by the hospital (Davie 1967). He worked on several wards there, including a long-stay ward for men of all ages. His allegations included that staff hit and bruised patients or caused other injuries, then attributed the injuries to patients assaulting each another.Footnote 106 In the communal bathroom, he alleged that sometimes bathwater was not changed between patients. Sometimes, patients were punished by depriving them of food and water, nurses shoved them out of bed with a broom and he was left in charge of a ward, despite being unqualified.

In 1965, after leaving Storthes Hall, Davie went to Springfield. There, he alleged that an elderly, incontinent man was shaken ‘like a rabbit’ by the charge nurse, then thrown on the floor, and another was ‘throttled’ while being confined to bed as a punishment (Davie 1967, pp. 46–47). Senior staff were unhelpful when Davie complained, and he had the ‘impression’ that the doctors knew what was going on but did little to try to stop it (pp. 45, 46, 47). Davie, like Daniel, was proud of getting on well with the patients, which he attributed to patients knowing that ‘no violence was forthcoming from me’ (p. 44).

It is worthwhile exploring other happenings at Storthes Hall to contextualise Davie’s complaints. Storthes Hall HMC minutes reveal their preoccupation with the environment and administrative matters, paying little attention to therapeutic relationships, activities for patients or rehabilitation.Footnote 107 In 1961, the minutes contained more about the piano tuner’s contract, the purchase of a ‘chocolate and fondant enrobing machine’ and rabbit clearance on the hospital estate than about the patients.Footnote 108 The HMC made some progress in improving the environment, such as installing ‘armour-plate’ glass in windows in single rooms used to accommodate potentially violent patients: the new glass removed the need to close the wooden shutters, which would block out daylight, when it was necessary to protect patient and window.Footnote 109 Other problems at Storthes Hall included pilfering by staff.Footnote 110 In October 1965, police inspected the bags of staff going off-duty. Ill-gotten gains of five kitchen staff included one Bakewell tart, two pounds (weight) of cooked mutton, three loaves of bread, seven eggs and a dozen ‘chocolate crunch’. The minutes reported that the staff were reprimandedFootnote 111 but did not state who tipped off the police or why at that time.

In 1962, the HMC documented only one complaint, from a mother about violence towards her teenage daughter, a patient. The single-page report of the internal investigating committee does not allow detailed analysis but indicates that it accepted unquestioningly the nurses’ statement that the patient had ‘never been ill-treated or harshly dealt with’. In contrast, the committee rejected all the mother’s allegations. The committee concluded that the only actions needed were to thank the staff for their dedicated work and to transfer the ‘difficult patient’ to another hospital. The latter would avoid the HMC having to encounter the mother and grandmother ‘who both indulged in bizarre, unrealistic and paranoid complaints’.Footnote 112 The process of investigation, total rejection of the complaint, criticism of the complainant, unhesitating acceptance of the staff report, and removing the patient, resembled complaint handling at Friern and by the Ministry.Footnote 113

Storthes Hall had a custodial and paternalistic regime, a pattern seen elsewhere, such as at Friern. The Ministry knew that Storthes Hall had ‘a long history of difficulty’Footnote 114 but praised the new medical superintendent, Alfred Smith, appointed in 1962, as ‘courageous’, a ‘good’ man going to work in a ‘poor’ hospital.Footnote 115 Smith’s predecessor started at the hospital as a junior doctor in 1924 and remained there for his entire career.Footnote 116 Thirty-eight years in one traditional, custodial-style hospital, leaving a ‘poor’ hospital to his successor, implied a leader who made little attempt to modernise practice or who was complacent about existing standards.

Less is known about the other six author-witnesses, mainly because verbatim transcripts of the inquiries into their allegations have not been traced. Nevertheless, descriptions of their hospitals and their biographical sketches corroborate other evidence, about hospital practices, the authorities’ responses towards people making complaints, and the characteristics of the whistle-blowers. Jean Biss was a ward sister for seven years at the Retreat, the Quaker-run psychiatric hospital in York, before moving to St James’s, a general hospital in Leeds. There, she was appointed sister in charge of a psychiatric ward,Footnote 117 a prestigious post at a time when general hospitals were just beginning to provide psychiatric services. Biss had several concerns at St James’s, including dangerously poor clinical communication between doctors and nurses; unappealing and inadequate food for patients; insufficient bed linen and towels; too few ward staff; and unsafe practices such as nurses dispensing medication from memory without using prescription charts. She raised the difficulties with matron who told her that she was ‘too sensitive and felt too strongly about things’ (Biss 1967, p. 27). Biss resigned after four months.Footnote 118

Dennis Moodie was also a senior nurse who moved from hospital to hospital, frustrated by his inability to make improvements. He alleged wards being kept locked for staff convenience; violence towards patients; victimisation of staff who complained; and a HMC chairman who told him that his HMC was powerless to remedy the situation (Moodie 1967). When Barbara met Tooth she received a report about powerlessness at the Ministry, giving the impression that various tiers of NHS management could declare powerlessness, pass the buck, shrug off criticism and avoid taking initiative to make changes. This is compatible with Webster’s (1998, pp. 50, 55) finding of a degree of ‘ossification’ of some aspects of the NHS, and an impression of inactivity by the Ministry during the 1960s. Moodie (1967, p. 14) summed up the situation for staff who wanted to improve nursing care: ‘It becomes a case of “Give in—or get out”. And it is always easier, in all professions, to accept the status quo.’ He left Banstead Hospital in Surrey, and Friern Hospital, and at the time of Sans Everything worked as assistant matron at Claybury,Footnote 119 a hospital determined to make improvements for patients (Pitt 1968, p. 29).

Two of the Sans Everything authors, Eileen Porter and Susan Skrine, worked at Cowley Road Hospital, Oxford, the respected geriatric hospital led by Lionel Cosin. Porter looked for a job when her daughter got a place at university.Footnote 120 She was attracted to nursing, like Daniel and Davie, because the work would be ‘of some use to the community’ (Porter 1967, p. 27). Skrine graduated from St Anne’s College, Oxford, taught for sixteen years in England and in India, worked for the Auxiliary Nursing Service in India during the war and then in Palestinian refugee camps in Jordan. She joined the staff at Cowley Road in 1958.Footnote 121 Both women, independently, reported their concerns to their superiors, including understaffing; lack of instruction; the ‘almost unendurable’ smell of stale urine and faeces; patients having to be in bed by 5 p.m. for the nurses’ convenience; lack of respect for elderly patients, which left them frightened; and lack of dignity, such as failure to use screens for personal care (Skrine 1967; Porter 1967). Despite Skrine raising concerns to the HMC and to matron since 1964,Footnote 122 ‘the only noticeable result has been to make my position in the wards more difficult’ (Skrine 1967, p. 37). In Barbara’s opinion, many hospitals had good and bad parts, a ‘curate’s egg’:Footnote 123 at Cowley Road, while the leadership paid close attention to pioneering geriatric work in the acute-assessment wards, the long-stay wards were relatively neglected, as in the psychiatric hospitals.

Two social workers also contributed to Sans Everything. Social workers were, to some degree, outside the rigid hospital hierarchy so somewhat protected from the victimisation experienced by the nurses. Roger Moody was a trainee social worker at Friern in the early 1960s. In regard to older people, he criticised the way they were placed in mental hospitals and noted that ‘society…far from honouring old age, tries to banish it completely from the mind’ (Moody 1967, p. 68). The other social worker, Dorothy Crofts (1967),Footnote 124 described the care of her elderly father at Friern. Her descriptions paralleled Barbara’s experiences of visiting Amy, including lack of visitors on the ward, bed time by 7 p.m., patients fearful of staff, a struggle to obtain her father’s discharge and staff describing her father as confused, contrary to her perception of him.

The brief profiles of the eight witnesses make up a very small sample from which to draw conclusions. Nevertheless, some patterns emerge. Seven of the eight author-witnesses were in their forties or older, and the same number were ‘new’ to the hospital environment (like Montagu Lomax at Prestwich Asylum)Footnote 125 in the sense of a new job (at whatever level), as a student, or a visitor. Of the six nurses, four left jobs because of negative experiences. Skrine’s Oxford education, Davie’s French studies and Daniel’s eloquent writing suggest that they were working in positions below their intellectual potential. Although untrained in nursing skills, the experiences of the unqualified or recently qualified nurses were diverse, including war work, bringing up children and doing jobs that required numerous interpersonal skills, which helped them interact meaningfully with patients.

The allegations were remarkably similar, including understaffing which allowed time only for basic physical care; senior staff unresponsive to concerns voiced by staff or visitors; and lack of privacy, personal respect and understanding of patients’ emotional needs. Little was interpreted as deliberate cruelty. The witnesses considered it their duty to speak out, despite victimisation by doing so. Types of allegations, witness characteristics and responses by the authorities in Sans Everything were disturbingly consistent with those described by Virginia Beardshaw (1981, pp. 31–32) in her study of psychiatric hospital nurses fifteen years later. Similar to Martin (1984, p. 247), Beardshaw demonstrated that whistle-blowers were usually of low status in the nursing hierarchy, such as orderlies, nursing assistants and students, and that senior staff regarded them as having no business to put forward their views, because they were unsound judges, uninformed, inexperienced and immature.

AEGIS’s Advisors

Nurses and doctors joined the AEGIS team of advisors. They, as Rolph, Abel-Smith, Harvey, Strabolgi and the witnesses, all worked with AEGIS unpaid.Footnote 126 The relationship between the nursing profession and AEGIS was initially fragile: some people, including Robinson, interpreted AEGIS’s criticisms as a direct slur on the entire nursing profession.Footnote 127 However, AEGIS’s positive statements about nurses (Strabolgi and Robb 1965; Robb 1967, p. xiv), nurses as key witnesses for Sans Everything, some nurse leaders supporting AEGIS, and AEGIS’s actions to reduce victimisation of nurses who spoke out, did not endorse that view. AEGIS needed to build a strong relationship with the nursing profession to try to buffer any misinterpretations. This was complicated, partly because psychiatric nurses were not fully accepted into the profession. They were allowed to join the Royal College of Nursing (RCN) only in 1960, and then only if they also held a general nursing qualification. This late acceptance into the College was associated with psychiatric nursing evolving from the asylum attendants’ role rather than from traditional nursing. Bill Kirkpatrick (1967, p. 48), dual trained and widely experienced, offered his support after Strabolgi’s speech in the House of Lords (Cochrane 1990, p. 71). Kirkpatrick (1967, p. 49) served on the RCN’s new psychiatric committee. He brought other nurses into AEGIS and, importantly, helped place AEGIS’s concerns on the RCN agenda.

Kirkpatrick introduced Keith Newstead to AEGIS. He was Professional Secretary of the RCN and secretary to their psychiatric committee. At his first AEGIS meeting, he was cautious. He declared that he met with AEGIS as a private individual, not in his official RCN role.Footnote 128 Newstead was alarmed when Barbara announced that she intended to tape record the meeting, but appeared to relax when she reassured him that it was to ensure that all participants would receive an accurate copy of the minutes. By the end of the meeting Newstead seemed more confident that Barbara genuinely wished to improve nursing practice: ‘Can I meet you again some time, yes?’ he said before leaving.Footnote 129

Phyllis Rowe, deputy president of the RCN and matron of St Luke’s Woodside, a small psychiatric hospital in North London, also joined AEGIS.Footnote 130 She and Newstead confirmed AEGIS’s suspicions that nurses at any level feared reprisals if they complained. Some would not do so even if leaving a hospital, dreading that their next employer might hear of it.Footnote 131 Most were unaware of the complaints system and had the impression that no one would listen to them anyway. Staff left rather than complain, and fear of punishment affected morale.Footnote 132 Rowe wanted to see AEGIS ‘in the middle of a big campaign’,Footnote 133 and she followed that up consistently.Footnote 134

Allies within the medical profession, particularly psychiatrists, were also crucial. Psychiatrists Russell Barton, Tony Whitehead and David Enoch assisted AEGIS. Barbara first came across all three at a conference, ‘Tackling Senility’, at Severalls Hospital in April 1966. Whitehead said in his lecture, ‘We must not sit back and say that when the Welfare Department has provided more accommodation things will be better. We must do something now.’ In the panel discussion, Barbara asked him ‘What can we do? What can I do?’ Whitehead’s answer included getting questions asked in Parliament and bringing pressure to bear on the Ministry, which she was doing already.Footnote 135 During an informal discussion with Whitehead, it transpired that the parliamentary question about the guidance on stripping, which Barbara requested Lubbock to ask, both inspired his answer during the panel discussion and enthused him to write the anonymous editorial on the subject in the Lancet (Anon. 1966b).Footnote 136

Enoch’s lecture, ‘Ready for the scrapheap’, a title he took from a comment written by a senior doctor on a seventy-five-year old’s medical notes many years earlier,Footnote 137 also impressed Barbara. Enoch’s clinical responsibilities as a consultant psychiatrist included looking after patients on eight ‘chronic’ wards. Accepted practices, similar to those already described, shocked him, and he struggled with the authorities to improve them. He spoke about this in an oral history interview in 2015:

Bathing was in public…to all intents and purposes…the doctors would go in…we would see them bathing…yes…there was no privacy. That was one of the big things…I was a fresh young man, I wanted dignity, without thinking of the word…as a great word…the correct word…it just came.…

We had a long ward in Shelton, and that became mine. I went in through the door, there is an old picture, bent, with a rusty wire hanging, then I’d go into this long passage, dribbling men, some half naked, some badly dressed.

In each of the wards, starting with one female and one male, I got carpets. The men who went out to the farm got a second suit. Then they got a narrow cupboard.…And then they began to meet, with one of the staff chairing it, and to talk about the ward and what they wanted…and powerfully advocated privacy.Footnote 138

A few months later, Barbara wrote to Barton asking for a copy of a paper he had written. The ‘Dear Dr Barton…Dear Mrs Robb…Yours sincerely’ style soon disappeared, and their letters ended, with ‘Love from’. As Lammers (2007, p. 258) commented on the Jung-White letters, Barbara could ‘melt’ formality. Barton sent her wise, humorous, encouraging and cautionary lettersFootnote 139 and hosted a dinner party in her honour at Claridge’s, the luxury Mayfair hotelFootnote 140 (Fig. 4.3).

Fig. 4.3
figure 3

Russell Barton’s invitation to Barbara, for dinner at Claridge’s, September 1967.

Source: AEGIS/1/6, Library, London School of Economics. Orphan work: attempts have been made to identify copyright owner.

The AEGIS advisors contributed short essays to Sans Everything, which drew on their rich professional experiences and provided commentary, explanation and, importantly, ‘some answers’. Whitehead’s (1965) analysis of the psychogeriatric service at Severalls, reprinted from the Lancet provided a medical answer. Abel-Smith (1967) discussed his three-pronged ‘administrative’ solution—complaints procedures, inspection and ombudsman, adding that the NHS also required new buildings, more money and better recruitment and training of staff. Barton based his foreword on his experience of trying to change established custodial hospital practices to create humane, rehabilitative and community focussed services for patients of all ages. He knew the obstacles:

Institutions develop powerful instruments of defence for their protection and perpetuation. Sometimes their officers or governing bodies lose sight of the primary purpose for which they were planned and their energies become deployed in rituals or personality conflicts. The purpose becomes subordinated to the personnel (Barton 1967, p. ix).

He also warned of characteristic responses from those in authority to dismiss criticism, including the ‘No comment’ tactic; denial; hoping the fuss will die down; and discrediting the messenger, whether staff, patient or visitor, as malicious, vindictive or disgruntled or ‘too mad, too senile or too deteriorated to testify’ (Barton 1967, p. ix). Barton’s foreword chimed with AEGIS’s experience and with the struggles of the witnesses in their own hospitals. It warned of the authorities’ likely reaction to the book. AEGIS needed to prepare for potentially hard-hitting negative responses.

Kirkpatrick (1967, p. 48) endorsed the accounts of the nurse witnesses, adding that brutality took place in a ‘minority’ of hospitals, a tactful, vague and speculative quantification, widely used and loosely interpreted politically as meaning anything between zero and 49 percent. Abel-Smith (1967, p. 128) was dissatisfied with answers that referred to a minority of hospitals because he said that ill treatment should not occur in any hospital. Barbara was unprepared, however, for Newstead’s response at an AEGIS meeting, when she used the word minority to ease the nurses into the discussion. He corrected her zealously: ‘Now, Mrs Robb, I’m going to startle you by saying, for the real care of geriatric patients there are masses of bad hospitals…let’s be quite honest.’Footnote 141

Enoch (1967, pp. 136–140) wrote in Sans Everything about moral, ethical and legal issues. He gave examples, such as older people not fitting into ‘the materialistic plan of this present affluent society’ and doctors misusing compulsory orders under the Mental Health Act to achieve their rapid admission. He regarded concern for fellow human beings as a moral and religious problem, and ‘the mere fact that they [the Sans Everything events] can occur in our so-called Christian community is appalling’ (p. 136). He lay the blame for the situation on the whole of society, people who were involved in any way and those who did not want to know.

Barbara also teamed up with architect Peter Thomson to contribute plans for ‘Project 70’, a housing scheme on unused farmland around the psychiatric hospitals that would generate income for the NHS (Robb and Thomson 1967). It originated from Barbara’s meeting with Tooth, who told her that there was no money to rebuild the psychiatric hospitals. Named because of the urgency to get it under way by 1970, it provided a financial and housing solution. Homes built on publicly owned land would be low cost. Rents from tenants could be ploughed back into NHS projects and used to finance an assortment of services and housing for older people, in small blocks and integrated into the new communities. When AEGIS first published Project 70, enthusiastic press reports supported it (AEGIS 1966; Anon. 1966e, 1966f). Rolph (1966b) wrote in the New Statesman: ‘the staggering truth is that, until the AEGIS initiative’ there were no proposals for hospital land. A Lancet editorial expressed disadvantages of Project 70, particularly about moving older people when they were settled in one place, stating that human relationships are more important than the physical environment (Anon. 1966g; Robb and Thomson 1966). It was also fearful about ‘the danger of setting up an artificial community which will be emotionally cold and uninviting. No-one knows how long it takes a new town to become a real community.’ That view was surprising, because the government built the first wave of ‘new towns’ immediately after the Second World War, and created more to fill the housing deficit in the 1960s.

Project 70 would help achieve government goals of providing suburban housing and closing psychiatric hospitals, both of which needed to be done economically and effectively (MoH 1966a, p. 10). Ministry indifference, even to further research on the idea, was thus unexpected. Barbara attributed it to pig-headedness: Robinson was ‘in the grip of an ogre…called [Sir Arnold] France, and will just keep on saying that he thinks P. 70 stinks.’Footnote 142 Rolph and Applebey supported Project 70 and wanted it piloted. However, they agreed that Barbara should not approach Robinson about it. Rolph relished the opportunity to tell Robinson that ‘a Tory Government ought not to be allowed to get the kudos for Project 70, and that its eventual fulfilment seems to me an absolute certainty.’Footnote 143 Rolph wrote to Robinson, ‘an old friend’, at his home address, wanting the letter to ‘get straight onto his breakfast table’.Footnote 144 At their meeting, Robinson was ‘affable but intransigent’. Robinson objected to Project 70 on three issues. First, like the writer of the Lancet editorial, he did not want to move older people from place to place unnecessarily. Second, if relatives lived with the older person in these new towns, when the older person died the relatives would be ejected from their home. Third, that placing homes for older people in hospital grounds was against NHS plans to provide accommodation closer to their previous homes. Nevertheless, Robinson said he was interested in a Project 70 plan not on hospital land, although that was troublingly inconsistent with his first two objections.Footnote 145

Nazi Atrocities and Sans Everything

Extremely disparaging analogies compared the worst happenings in psychiatric hospitals with barbarities under Nazi rule during the 1930s and 1940s. Goffman (1961, pp. 24–30, 50) drew attention to common practices in psychiatric hospitals, prisons and concentration camps, including uniform haircuts, institutional clothing, stripping, depersonalisation and overcrowding as an economic way to process large numbers of people. Dickinson (2015, pp. 149–153) compared some nurses in NHS psychiatric hospitals to those in Nazi Germany who adopted unethical and inhumane practices and attributed their actions to obedience to authority. Nurses who carried out tasks in an inhumane or harmful way would try to limit any feelings of guilt and culpability. One way to do this was to ensure that they were not responsible for individual patients. This prevented a therapeutic relationship and reinforced their task-orientated work, which further dehumanised and objectified the patients. Approval from seniors encouraged and perpetuated the practices.

In Sans Everything, Barbara called her chapter ‘Ghettos for grandparents’, connecting with the ghettos into which mainly Jews were hoarded before deportation to concentration camps. Davie (1967, p. 45) compared Storthes Hall to Belsen concentration camp. Another critic of psychiatric hospitals who wrote to AEGIS, imagined collections of patients’ spectacles, dentures and other belongings in the hospitals resembling stacks of personal possessions removed from prisoners at Auschwitz.Footnote 146 Similar analogies appeared in reviews of Sans Everything:

Only a minority of hospitals are, of course, such Buchenwalds for elder citizens.…In this age, which we regard as one of compassion and of the responsibility of the individual, a book like this gives us a shock like the trial of Eichmann. Is group loyalty still more powerful than the conscience of the individual, and can ordinary decent human beings conform thus readily to the conventions of the institution within which they work? (Russell 1967).

Psychologists in the 1960s tried to understand how individuals carried out atrocities under the Nazi regime. They explored how detrimental and potentially murderous activities could be influenced by conforming behaviours within a group, obedience to authority and the failure of bystanders to intervene (Milgram 1963; Darley and Latane 1968; Haney et al. 1973). Understanding the psychological power of these factors makes the nurse-authors in Sans Everything even more remarkable for stepping ‘outside’ the group, evaluating working practices, and rejecting behaviours which their superiors condoned.

Barton also had strong views on the matter of concentration camps and psychiatric hospitals. In 1945, he was one of ninety-six London medical student volunteers who went to help at Belsen two weeks after liberation. Experiences there stirred him to strive for more humane psychiatric care. In 1968 he wrote about his experiences at Belsen in a widely read periodical and made controversial comparisons with psychiatric hospitals, including ‘I do not believe that the German public knew about the concentration camps any more than the British knew about the way old people could be treated in mental hospitals until recently’ (Barton 1968, p. 3085). Moodie made a slightly different point, that turning a blind eye to the goings-on in the psychiatric hospitals was similar to the response of German people to Nazi barbarities. He wrote: ‘Most of us cannot bear too much reality. Perhaps that is why Hitler made such headway in the ‘thirties: the majority of Germans—many of them good people in the accepted sense—were not prepared to admit what was happening in their midst’ (Moodie 1967, p. 14).

For the Ministry, use of concentration camp imagery reinforced its criticism that AEGIS exaggerated unnecessarily. When Anne Allen (1967a), whom the Ministry ‘generally regarded as a responsible journalist’,Footnote 147 wrote in the Sunday Mirror about the back wards, a civil servant attributed her report to being ‘fanned by Mrs Robb or AEGIS’.Footnote 148 In his view, Barbara exaggerated and encouraged others to do likewise, contrary to evidence that indicated Barbara was relieved when journalists did not embroider their reports.Footnote 149 The authorities assumed exaggeration when they heard about inhumanities that they could not believe (e.g., MoH 1968, pp. 22, 40, 73, 82), as happened during the Second World War with reports about Nazi atrocities (Gilbert 1984). Ignorance, disbelief and alleging exaggeration absolved the authorities from taking remedial action, especially in the face of competing priorities.

AEGIS’s Distractions

In addition to campaigning, AEGIS needed a secure infrastructure. There were two main issues: finances and the publisher’s concern about risk of libel. In 1966, Rolph told AEGIS that Barbara had spent ‘500 quid’ on her campaign.Footnote 150 Barbara replied: ‘Bill, I’m going to be very cross with you’, but he persisted, worried that she would be ‘scraping the bottom of the barrel soon’.Footnote 151 AEGIS was not a charity, but self-financed, ‘out of my dress allowance’ Barbara said (Anon. 1965b), although less expenditure on clothes did not stop her wearing her hallmark wide brimmed hats (Rolph 1987, p. 183).Footnote 152

AEGIS wanted to register as a charity, which would help its financial position. However, the definition of ‘charitable purposes’ under the Charities Act 1960 was nebulous. In 1960 this seemed wise, as future initiatives and needs could not be predicted, but vague criteria did not help the Charity Commission decide which organisations could register (Anon. 1968). AEGIS was one of many organisations working for the public good, penalised financially by the loose definition. The Times reported that the British Humanist Association relinquished its charitable status, because ‘If you are going in for petition-presenting, if you are going to campaign for changes in the law, if you are going to hold press conferences about national policies, you cannot, by legal definition, be a charity’ (Anon. 1967). The Commission rejected the PA’s application for charitable status,Footnote 153 and told AEGIS that it was ‘engaging in propaganda activities’ that, unless ‘purely incidental’, would have to cease. AEGIS appealed, as it was not a party political organisation, but the Commission stated that any activities designed to secure policy change must be ancillary to its main work rather than its raison d’être.Footnote 154 Lack of charitable status affected AEGIS’s income, such as making it ineligible for some private sponsorship.Footnote 155 It could still accept donations, and Barbara’s Aunt Missie was one person determined to contribute. She distributed AEGIS leaflets to her ‘front-line troops’ in various abbeys, organised a coffee morning and bring-and-buy in her village, and sent Barbara £45.Footnote 156 Nurses appreciating AEGIS speaking out on their behalf, also contributed. One group touchingly organised a whip-round in their nurses’ home as they ‘feel privileged to be able to help in some way’.Footnote 157

Concerning libel, Barbara took legal advice. Particularly relevant to Sans Everything was that libel included a statement of fact that was impossible to prove. Her solicitor read her book to check for libel, and she made minor corrections.Footnote 158 The publisher also demanded affidavits (written, sworn statements of fact) from the author-witnesses.Footnote 159 They joined Barbara and a lawyer to sign them at a lunch party at ‘La Gaffe’, a Hampstead restaurant.Footnote 160 Barbara did not sign a contract for her book because it required her to indemnify Nelson in respect of possible libels.Footnote 161 Despite lack of a contract, in the absence of any libel action, Barbara expected to receive royalties.Footnote 162 These would, if the book sold well, contribute to AEGIS’s income. Jung’s comment that he hoped Barbara would continue ‘dreaming of winners, because such people need winners to keep them afloat’Footnote 163 seemed prophetic.


Similar to other social rights campaigners tackling issues anew, such as Elizabeth Fry for prisons, William Wilberforce (1759–1833) who campaigned against slavery, and Lord Shaftesbury (1801–1885) who campaigned on child labour, factory reform and employment rights, Barbara upset many people by her frankness about unpalatable subjects most would rather have left undiscovered, and she encountered opposition from the authorities about making changes. Emphasising the inadequacies of older people’s care was unwelcome in the context of widespread negativity about older people’s health, within and outside the NHS (Hilton 2016c, p. 37), and economic considerations by the authorities, which perpetuated the ‘human warehouses’ of NHS long-stay wards (Anon. 1961). The Ministry had greater priorities, including solving the melt down of general practitioner services and creating new NHS hospital management structures (Webster 1998, p. 61).

Barbara succeeded in engaging some academics, politicians and health service professionals, but she could not break through the wall shielding the RHBs and the Ministry of Health. Robinson and Hackett ignored or defended existing hospital standards, which were often far removed from recognised best practice. Although Robinson’s view might be accounted for by his official sources of information (civil servants and RHBs), evidence is lacking that he earnestly tried to verify the accuracy of the negative reports. Hackett and his RHB repeatedly dismissed complaints and provided no evidence that they tried to remedy problems at Friern. Inactivity in response to Blofeld’s report, other than sacking the senior clinical staff, made Hackett’s (1965a) statement in the Times about the RHBs’ role to ‘guard and protect’ patients appear deceitful. NHS management gave the impression of an administrative system of concealment, complacency and fear of publicity about inadequacies, which was reinforced by stoic patients and by visitors and staff fearful of complaining and discouraged by the system from doing so. Staff, patients and relatives, with little opportunity to have their voices heard within the hospital authorities, contacted AEGIS directly. In Crossman’s words (1977, p. 727),Footnote 164 Barbara was ‘a kind of clearing house for all complaints about cruelty and torture in hospitals’.

The Ministry’s guidance on stripping and on managing complaints was timely in the context of criticism and publicity about these matters, but because the Ministry was hostile to Barbara and AEGIS, it was unlikely to credit them with raising the concerns, and unsurprisingly, searches of official archives reveal no clues about their role. The guidance on stripping was tokenistic and created little immediate change for patients. However, it sparked discussion in the hospitals, generated press activity, and provided opportunities for doctors such as Whitehead to publicise the issue for a medical readership.

On the background of lack of interest, denial, disbelief and ignorance about marginalised and stigmatised older and mentally unwell people in hospitals, in most places change was undetectable. As Abel-Smith indicated, a sustained campaign and raised public awareness were crucial to bring it about. AEGIS had to maintain pressure to allow public, professionals and government to begin to acknowledge the genuineness of its evidence, to give it serious consideration, and then to implement improvements. AEGIS had to avoid Barbara becoming demoralised from painful and repeated rejections of the sort which deterred other complainants. Abel-Smith was an asset, with one foot in the Ministry and the other in AEGIS. The other AEGIS advisors and author-witnesses were crucial to the process and passionately supported Barbara. AEGIS’s findings, proposed solutions and persistence echoed Barbara’s grandfather’s teaching about stinging nettles and dock leaves: if you search hard enough, you will always find the remedy (Allen 1967b).