The Inquiries: A Lion’s Den

The Sans Everything inquiries (August 1967–February 1968) were disturbing. A sense of open mindedness to evaluate the allegations was minimal, and the Ministry expected conclusions to indicate that practices were satisfactory. This chapter explores three hospital inquiries in depth—Friern, St Lawrence’s and Storthes Hall—corresponding with availability of archive sources. The inquiry chairmen lacked experience of public sector administration, including of the way statutory authorities could cover up deficiencies. They discredited witnesses based on their personalities and status within the hospitals, rather than evaluating the evidence they gave. They made errors when judging standards, due to their stereotypical expectations and lack of knowledge about good clinical practice. The Council on Tribunals, the public body monitoring inquiries, criticised the procedures. Cabinet Minister Richard Crossman described the inquiries as ‘fairly well rigged’.

could decide on the process of his inquiry and on definitions of standards of care to underpin his committee's judgements. 1 This increased the chance of the committees producing different answers to similar questions, which would make overall conclusions hard to draw. Loosely defined protocols would also affect how the committees interpreted the Ministry's instructions to produce two reports for each inquiry, a full report and a summary with recommendations for publication. The brevity of some of the published reports belied the duration of the hearings, between four and seventeen days each.
Archive sources available for each inquiry vary substantially, so not all can be explored in a similar way or to the same depth. I have therefore focussed on three: Friern, St Lawrence's and Storthes Hall. Friern is particularly important because its story was at the heart of the AEGIS (Aid for the Elderly in Government Institutions) campaign, and St Lawrence's and Storthes Hall have the most comprehensive records, including verbatim transcripts of proceedings. 2 The other inquiries are included where they contribute fresh insights. The Ministry's and Regional Hospital Boards' (RHBs) prepublication handling of the inquiry reports and the critique of inquiry procedures by the Council on Tribunals shed additional light on their processes and outcomes.

FRIERN
The Friern Inquiry focussed mainly on 'Diary of a Nobody' (Robb 1967). It also covered the accounts in Sans Everything by Moodie, Moody and Crofts and four additional complaints that members of the public raised with the Ministry around the time the book was published. 3 All the Sans Everything witnesses were willing to give evidence. Douglas Lowe QC 4 chaired the committee, which included Isabel Graham Bryce as lay member. The inquiry took place at the North West Metropolitan (NWM) RHB headquarters, several miles from the hospital. 5 That, sensibly, would reduce prying and speculation by Friern staff about their colleagues attending. However, in addition to Lowe's formal briefing by the RHB, the location would facilitate informal communication between the inquiry committee and senior members of the RHB, including Hackett, who vehemently and openly denied AEGIS's allegations, risking weakening the committee's impartiality.
Noting that the hospital would be legally represented at public expense, Barbara requested Lowe to allow the Sans Everything witnesses representation, at her personal expense, in case of publicity. 6 She also asked that the dates for the inquiry be set to give her lawyer sufficient time to prepare the case. 7 These requests were consistent with the principles of the Royal Commission on Tribunals of Inquiry (1966), that a witness 'should be given an adequate opportunity of preparing his case and of being assisted by his legal advisers'. Barbara did not argue over the Commission's other point, that, for witnesses who help inquiries in the public interest, 'legal expenses should normally be met out of public funds' (p. 44). Lowe refused to allow the Sans Everything witnesses to have legal representation because, in a private inquiry, 'There ought not . . . be publicity.' 8 He overlooked, or had not been informed, that the Ministry intended to publish the findings. 9 AEGIS's lawyer advised the witnesses not to attend without representation. 10 During these negotiations, Lowe informed Barbara that the committee 'consists of busy people', implying that she was wasting their time. 11 Lowe's condescending attitude to Barbara, AEGIS's absence from the inquiry and the committee's principle that where a 'complaint cannot be investigated [it] must be dismissed' (MoH 1968, p. 26) had the potential to prejudice the inquiry.
Lowe's committee described the Sans Everything allegations as 'wild', 'unsubstantiated' and 'probably exaggerated' (MoH 1968, p. 23). It deemed the Sans Everything witnesses as irrational, incompetent and unqualified to criticise: 'none of them possesses a medical qualification' (p. 27). It was 'unprepared to accept any statement by Mrs Robb that has not been admitted or corroborated either in evidence given or in documents placed before them' (p. 27). Verbal corroboration was unlikely because evidence was not taken on oath and staff would not voluntarily incriminate themselves. Written confirmation was also unlikely: undignified practices, such as chastising or hitting a patient would not be documented and information that should have been recorded was not, such as the name of the firm that Miss Cloake hired to clear Amy's flat (Robb 1967, p. 84). The committee deduced incorrectly that because Barbara did not complain during Amy's admission (she did: the Diary went to the Ministry, and she met Tooth) 'the explanation is simple', the allegations 'are basically false' (MoH 1968, p. 31). How the Ministry allowed this inaccuracy to appear in the final published report under their authority is unclear.
In contrast to its approach to AEGIS, the committee was sympathetic to hospital staff who gave evidence and it had 'naturally borne in mind the effect on people's memory' of the time since the events (MoH 1968, pp. [21][22]. If staff members declared that they could not recall an event, or denied it, the committee concluded that the allegation was false. Overall, it believed staff rather than complainants (p. 25) much as the Patients Association (PA) warned in 1965. 12 The report used the word distortion to describe evidence only from complainants, not from staff. For example, it described Crofts' evidence: 'The discrepancies, distortions and omissions of vital facts may be due to the highly emotional state in which Miss Tasburg [Crofts] seems to have been' (p. 24). Her evidence was: 'a gross distortion of many of the facts, a suppression of other facts, and a remarkable inability . . . to perceive or accept the truth' (p. 26). Because the committee never met the Sans Everything witnesses, its conclusion about their characters was speculative, based on perceptions gleaned from the contents of the book, which they disbelieved, or on reports from hospital staff who were defending their practices.
The committee demonstrated misunderstandings and lack of knowledge about subjects on which it was expected to make judgements. For example, it concluded that many elderly patients desire 'nothing more than just to sit or loaf around owing to their mental condition [and] they are often incapable of animation' (MoH 1968, p. 22), that 'Neither spectacles nor hearing aids . . . would have been of much use to most of them' and that most were 'very old and senile' (p. 30). These descriptions were incompatible with other observations by the committee. For example, the committee reported that patients were sufficiently well for one in ten of them 'selected at random among those who had been in those wards in 1965' to be interviewed in 1967 (p. 42). How many this included is not stated, but if they were chronically mentally incapacitated to the extent of being 'incapable of animation' in 1965, it is unlikely that they would have been well enough to give meaningful answers two years later. If they had chronic schizophrenia, a common diagnosis of long-stay patients, they would not have improved. If they were 'senile' in 1965, it is unlikely that they would have remembered the events at that time in order to describe them accurately. If they were well enough to be interviewed in 1967, they would almost certainly have benefitted from spectacles and hearing aids two years earlier. The committee made other assumptions about older people, such as that it was acceptable for them to go to bed at 7 P.M. as 'owing to their age many would wish to do so' (p. 31). It allowed contradictory evidence to pass without comment, such as that Amy, 'as an informal patient, was of course, free to leave the hospital at any time' (p. 31) but also that 'her family would have to approve any arrangements for her transfer' (p. 32): only one was correct. It commented that many older people had 'not uncommon predatory proclivities' (p. 31), which meant that they tended to steal. It ignored the fact that most patients never left the ward and they lacked lockers or any other place in which to hide their allegedly ill-found gains. Whether staff might steal was not mentioned, although it happened in other hospitals (DHSS 1969, p. 123). 13 Some of the committee's judgements were based on standards incompatible with known good practice. There is no evidence that the medical member of the committee provided specialist guidance about this, thus allowing erroneous or outdated views to influence deliberations. For example, concerning locking ward doors, the committee wrote that they were locked to ensure the safety of patients: 'What is not brought out [in Sans Everything] is the undoubted necessity to keep many, if not all, wards locked because of the propensity of many patients to wander and the clear risk of their being lost or even injured on the near-by highway' (MoH 1968, p. 22). This was illogical, not least because the so-called near-by highway was a suburban street with one lane of traffic in each direction, about 200 metres from the hospital building and through a gate with an adjacent porter's lodge. Also, research by Mandelbrote (1964) and others (e.g., Martin 1962, pp. 18, 82), about the low risk of leaving ward doors unlocked, and Malcolm Campbell's observation that institutionalised patients at Friern were usually too frightened to go very far, 14 clashed with the committee's view. In an understaffed custodial regime lacking rehabilitation goals, Moodie's allegation (1967, p. 15) that the doors were locked 'for the sisters' convenience' seemed apt (MoH 1968, p. 22).
The committee accepted that some of the events in Sans Everything might have happened, such as shouting at or pushing patients, and unkindness, intolerance and teasing (MoH 1968, pp. 38, 45-46), but it dismissed allegations of cruelty towards Amy and other patients (p. 41). The committee justified staff behaviours that patients or onlookers could perceive as cruel and frightening as 'the result of long hours and overstrain' (pp. [45][46]. The committee investigated four unrelated complaints. These were only documented in the unpublished inquiry report. They shed more light on the inquiry process. Even though the witnesses gave evidence in person, the committee rejected all their allegations. It rejected one as 'illfounded or fictitious' 15 and a second as 'worthless', 16 without giving details about how it reached these conclusions. It rejected a third, Mrs Dickens' complaint on behalf of her brother, 'in toto'. 17 Dickens wrote to Barbara about the committee's hostility: her daughter was not allowed to accompany her into the inquiry room, and Mrs Dickens could not 'speak freely without being side-tracked and what I did say was at times twisted'. 18 A fourth complaint was from Rosemary Thomas, a psychology student on placement at Friern in 1965. Her allegations included forced feeding of a patient held down by four nurses, a patient 'dragged around' by a nurse (which the committee attributed to the patient's recalcitrance) and a nurse who 'thumped' a patient (who the committee regarded as 'merely being restrained'). The committee did 'not think that such treatment of patients was frequent, or indeed would be tolerated by sisters or matrons'. Thoughts were flimsy grounds on which to base conclusions, and it is dubious whether frequency could be a satisfactory argument concerning harsh behaviours (Abel-Smith 1967, p. 128). The committee agreed that some older patients were slapped to get them out of bed in the morning, but there were 'legitimate reasons for this, provided of course that the slap was not too severe'. The committee regarded demeaning practices only in terms of physical harm. It ignored undignified, psychologically damaging and untherapeutic methods, revealing little awareness of current knowledge (e.g., Barton 1959;Goffman 1961, Martin 1962, Mandelbrote 1964). The committee implied that patients were at fault, that nurses behaved appropriately and that slapping older people could be legitimate. It dismissed the student's allegations, describing her as 'an immature, idealistic, young woman. . . . Her attempts to describe conditions were a sincere reflection of what she thought she had witnessed.' 19 As Cohen wrote (1964, p. 24), hospitals worked as a caste system, with patients at the bottom. Genuine concern of individuals outside, or at the foot of, the NHS hierarchy appeared automatically rejected from serious consideration. It is possible that all the complainants at Friern were dishonest troublemakers, but taking into account the risk of victimisation to which they exposed themselves or their relatives, that was unlikely. Instead, rejecting their allegations was underpinned by arguments about their personal integrity and was in keeping with assumptions of NHS excellence, as expressed by Hackett and Robinson. In summary, evaluating the allegations at Friern linked to beliefs that staff would not permit malpractice; that patients could be treated harshly; and that patients, relatives, friends and vocational students were too muddled, emotional, ignorant or immature to interpret accurately what they saw and heard.
It was harder for the committee to refute what it witnessed directly when it inspected Friern. It was shocked by low ward temperatures (MoH 1968, p. 43), wards unattended at night (p. 48) and 'gravely inadequate' staff levels (p. 43). It found that 'indifferent communication' between staff, and 'the relatively bad name that Friern has got' (p. 49), contributed to understaffing. Visiting times were too short, evening meals served too early, wards 'too large and overcrowded' and local authorities provided insufficient accommodation and support for those well enough to leave hospital (pp. 47-48). Social work provision was inadequate, and the 'Committee are amazed by the antiquated arrangement whereby only one external telephone exists for the whole of the female side of the hospital' (p. 50).
Blofeld raised many of the same concerns two years earlier, but the RHB took no action to remedy them. Lowe's committee criticised the RHB and HMC for ignoring her report and the reports into nursing shortages. It condemned the RHB, which 'at times discounted if not disregarded' the HMC's requests to help them make changes (MoH 1968 p. 51). In contrast with Robinson blaming Sans Everything for lowering morale, 20 the committee attributed poor morale to ineffective management and defeatist attitudes of the RHB and HMC. The committee was 'far from convinced that Friern has had its fair share of even the limited amount of money available to the Regional Board' (p. 51). The report made twenty-three recommendations, mainly directed towards the HMC and RHB, and linked largely to their inspection rather than to the investigation of the complaints. Recommendations included acting on the reports about nurse staffing; negotiating with the local authorities for more social care; providing more occupational therapy; improving wards, patients' clothing and toilets; and noting that the RHB 'should allocate more funds to Friern' (pp. 52-53). The committee, however, wondered whether the relationship between the RHB and HMC 'was such as to enable them to work together to achieve a solution'. 21 The report directly criticised Hackett who 'presumably reflecting on the collective view of the Board . . . was remarkably complacent'. 22 It also criticised his response to Blofeld's report, especially the so-called resignations of the Chief Male Nurse and of the Matron. . . . neither was given any reason for what was in effect dismissal-Mr Hackett had said that he caused them to resign, together with Dr Sutton-because he regarded them as responsible for the inefficiencies disclosed in the Report.
The committee received no criticisms about these senior people (although that could have been an artefact of hospital protocol about criticising one's superiors) but it left the committee with 'an uneasy feeling that their treatment was arbitrary and possibly unjust'. 23 The committee summed up Hackett's approach, which 'betrays, we think, the superficial instead of searching approach to the shortcomings then revealed'.
The RHB discussed these criticisms. It resolved to unanimously record their continued and complete confidence in their Chairman [Hackett] who, by his untiring personal efforts during his three years of office, has done more than anyone to raise the standard of psychiatric hospitals in the region; . . . the Minister of Health to be informed accordingly. 24 The RHB removed the offending passages from the report after Lowe's committee signed it, but before publication. Dame Muriel Powell, the nursing member of the inquiry committee, was furious. 25 27 which could raise rumours about staff who entered the committee room. The local MP, Peter Bessell, created additional publicity, 28 further undermining the myth of a 'confidential' inquiry. He also, reasonably, remarked on the social damage such an inquiry could inflict on a stable rural community. 29 As at Friern and in Leeds, 30 other investigations were tagged-on. At St Lawrence's, the first week of the inquiry included the case of Sister W, suspended in July 1967, accused of hitting patients and swearing at them. 31 Sister W worked with older people and was implicated by Joyce Daniel in Sans Everything. Daniel planned to attend this part of the inquiry, in line with the Ministry's (1966) guidance that a complainant, and those who were the subject of a complaint, should have the 'opportunity' to be present throughout the hearing and of cross-examining witnesses. However, on the morning the inquiry was due to begin, she received a letter from Polson advising her that she should be accompanied by a lawyer. 32 This took time to arrange. Polson did not tell the committee why Daniel was absent, merely that she 'will not be able to assist the tribunal'. 33 Much during the first week related to Daniel's allegations, and the committee handed copies of her account to hospital staff and questioned them about it. For example, the committee asked Nurse X whether he had heard patients say 'Don't hit me, will you, nurse. Don't drag me' (Daniel 1967, p. 38). He conceded that he had, but attributed it to the patient being 'rather confused and misunderstanding' and that it was 'in the context where there has been no suggestion of any ill treatment at all' (MoH 1968, pp. [63][64]. 34 Polson probed neither how Nurse X ascertained the context nor how he assessed the confusion. Polson also used leading questions implying a negative response, such as, 'You have never seen anything like that at all, have you?' 35 His style of questioning raises issues about biases during the investigation and their effect on the outcome. The committee reviewed the hospital's internal investigations about Sister W's suspension, which, creditably, included senior staff asking patients about her behaviours, an uncommon practice at the time (Cohen 1964, pp. 9, 39-40). One patient saw Sister W: 'hit Sarah J in the face and left finger marks'. Another said: 'the sister uses bad language. . . . To the patients'. 36 The inquiry transcript illustrates Nurse Y's discomfort at witnessing Sister W's practices and being asked about them:

Polson:
What has sister referred to patients as from time to time? Nurse Y: 'Bitch' sometimes.

Polson:
Do not have any inhibitions. Nurse Y: Or 'bloody bitch', not often; I remember that because it was one particular occasion . . . I cannot really remember what gave rise to it . . .

Polson:
And that was to the patient? Nurse Z said she witnessed Sister W slap a patient punitively 'across the face', telling the patient that she 'had had enough of this silly nonsense', and the patient was then 'dragged to the toilet in tears'. Nurse Z challenged Sister W about this incident, and Sister W allegedly responded: 'you don't understand you have got to be hard with them.' 37 Sister W brushed off Nurse Z's criticism, supporting the notion that seniors disregarded statements from staff of lower ranks. Another ward sister commented: 'I believe it is fairly well known amongst staff that Sister W is rather noisy and gesticulating, and she frightens patients, and that I would call irregular treatment.' 38 The committee of inquiry exonerated and reinstated Sister W. It justified its decision: Due to pressure of work and shortage of nursing staff Sister W had to work under circumstances which in our view would have tested the patience of a saint. She has certain temperamental weaknesses in that she tends to shout at and bustle people along in order to get things done. She tends to lose her patience under stress and strain, and she has got into the habit of swearing at patients . . . we do not think she would ever deliberately ill-treat [any patient]. 39 Descriptions of her behaviour-bustling and shouting-were imprecise. Stating that they did not 'think' her actions were deliberate, was, similar to the inquiry at Friern, arbitrary and subjective. Their conclusion implied that undignified and disrespectful behaviour towards patients was acceptable if it occurred under pressure due to daily routines or was unintentional.
During the week, the committee examined other aspects of St Lawrence's, including having locked unstaffed wards at night, a hazard also identified at Friern (MoH 1968, p. 48). The committee at St Lawrence's chillingly highlighted disrespect for patients' lives when it asked the nursing superintendent what would happen in an emergency on a locked, unstaffed ward: 'Assistance has been summoned in the case of one upstairs ward and a night nurse down in the ward below with a patient banging on the floor. Apart from that we are dependent upon a patient in the ward being able to use the telephone.' 40 In October, at the beginning of the second week, Mr S, the lawyer representing staff who were members of the Confederation of Health Service Employees union said: 'quite frankly I anticipate that some of the allegations in the book may very well not be quite so impressive after cross examination.' 41 Against that proposition, the committee and the lawyers defending the hospital and its staff, laid into Daniel, starting with the validity of her affidavit. Barbara had changed some of the authors' personal details, with their agreement, such as dates of hospital employment, to help conceal their identities (Robb 1967, front matter). Polson interpreted the discrepancies between the information in Sans Everything and the hospital staff records as indicating that Daniel's entire report was a pack of lies: 'And, to put it more forcibly, it is a lie, is it not, sworn on the bible?' The entire contents of Sans Everything were similarly tainted, he said, since Barbara encouraged the authors to sign and knew the details were untrue. It was unfortunate that the affidavits were signed at the restaurant with the extraordinary name 'La Gaffe', the mistake, 42 and that the committee was unaware of Barbara's rationale for anonymity. It was even more unfortunate that Polson used the affidavit to distract from the main issues.
Mr S discredited Daniel for discrepancies between her report and the hospital records, such about the number of patients on the ward. Daniel (1967, p. 39) wrote seventies, the hospital records stated sixties, and Mr S commented: 'Well, it is a little artistic licence. She is a poet, after all.' 43 Daniel's meaning, that the ward was severely overcrowded, was lost. Another lawyer, Mr T, representing the HMC, described Daniel as 'sentimental and sloppy and perhaps soft, this has had an influence on her which it would not have had and has not had on other people'. 44 At the end of the first day Daniel wrote to Barbara: 'I cannot convey the air of hostility.' 45 Daniel, like Barbara, did misunderstand some things. So did the committee and the lawyers, which could lead to poorly framed questions and incorrect conclusions. However, the medical member of the committee gave little clinical guidance. For example, he offered no clarification when the committee disbelieved Daniel's allegation (1967, p. 41) that a patient became animated and spoke after months of being mute. The committee did not know that beginning to speak could be a response to kindly social interaction (Roland 1948;Barton 1959). 46 When a qualified nurse described the patient as 'incapable' of responding as Daniel described (MoH 1968, p. 73), the committee rejected Daniel's observation: the opinion of the hospital's senior staff, rather than independent clinical knowledge, guided the committee's decisions.
Another example of the committee's inaccurate knowledge concerned distress and depression. Daniel (1967, p. 40) wrote: 'Many patients moaned and wrung their hands. . . . The general air of cringing and weeping was beyond bearing.' Polson asked a ward sister: 'No doubt with a lot of old ladies of this character you do get them wringing their hands?' She replied that she would have been concerned if one patient had stopped doing so. 47 A lawyer explained that 'acute depression' was normal for older people in long-stay hospitals. 48 However, it was out-of-date to accept depression as understandable or normal and not to treat it (Roth 1955;Post 1962). Psychiatrists at another hospital in 1967 illustrated this. They reflected on their embarrassment, and the tragedy, of underdiagnosing depression: We felt very humiliated . . . when a woman who had been there for 30 years suddenly started to talk. . . . It was found that a mistake had been made six weeks' previously when she had been given tofranil [an antidepressant] instead of her usual largactil [a sedative]! Surely there is a moral in that? 49 The moral was that adequate assessment and treatment of depression, regardless of duration of admission, age or other factors, could improve well-being. Daniel (1967, p. 38) described an undignified process for bathing, with up to eight naked patients in the bathroom at once. This allegation was inconsistently supported and dismissed by staff during the inquiry. 50 Hair washing, done in the bath, was traumatic for some patients. Daniel (p. 38) alleged that bowls of water were 'thrown over nervous patients' heads.' Sister W told the committee that water was 'poured' over their heads in the course of hair washing as there were no alternatives, like showers or large basins into which patients could lean backwards. When asked 'Was it done with any malice?' Sister W answered 'No.' We do not know whether Daniel exaggerated ('thrown') or Sister W minimised ('poured'), 51 or if the truth lay somewhere in between. Nevertheless, staff attributed patients' fears and flinching to them not understanding why certain things were done to them, 52 rather than to inadequate explanation from staff, or slapdash or uncaring nursing practices that were not modified to accommodate patients' needs.
The committee also rejected Daniel's complaint about lack of 'scented soap' for bathing patients. That seemed minor, until explored in the context of Sister W's comment that staff washed patients with the same Lifebuoy soap as they used to scrub the floors. 53 Allowing that to happen, objectified rather than humanised the patients. Daniel also alleged that patients drank from the lavatory pans, but senior staff took the view: 'there are always in every psychiatric hospital patients who drink from toilet pans.' 54 Opinions from senior staff, that demeaning and disrespectful practices and attitudes were acceptable, normal or justifiable, ignored their detrimental effects on patients, visitors and staff and reinforced the continuation of the practices. The committee's obsequiousness to the hierarchical system of hospital management, and ignorance of current good practice, precluded candid scrutiny.
The committee did not attribute harsh nursing to malice and therefore did not consider it to be cruel. The contrast between their sympathetic reinstatement of Sister W and their hostility towards Daniel was startling. In his summing up, one lawyer said: 'The question arises as to whether we should dismiss this book as a tissue of lies or whether it is founded on some basis of fact. Of course we must admit that there is some foundation of fact upon which the whole thing is based.' To support his argument, he gave examples of 'dirty and smelly floorboards and chamber pots and slippers in odd places', patients dragged and an outbreak of scabies. 'We have the evidence, we cannot deny it' he said. Nevertheless, he concluded, 'The actual care of the staff for these geriatric cases is quite out of this world.' 55 After the inquiry the Ministry criticised 'the extraordinary way' in which the committee interpreted its terms of reference, 56 alluding to the duration of the inquiry, its 120-page report and the time spent on minute points and technicalities such as Daniel's affidavit. Polson criticised the South Western RHB, but the Ministry rejected his criticisms for two reasons. First, the Board did not appear before the committee 57 (although the Ministry did not apply the same criteria to AEGIS's witnesses who were absent from the Friern Inquiry and during the first week at St Lawrence's). Second, perhaps more justified, the subject fell outside the committee's terms of reference 58 in the context of the Lord Chancellor's advice advising to 'keep this kind of inquiry narrow' (Crossman 1977, p. 426).
Polson wanted the entire report published, but he did not fight when the Ministry refused. 59 He declined to summarise it for publication, so the Ministry delegated that task to the RHB. 60 The published version noted that the RHB allocated insufficient revenue to St Lawrence's (MoH 1968, pp. 80-81), but otherwise, unsurprisingly, it did not criticise itself.
The published report made eleven bland general recommendations, such as the hospital needing more staff with better communication between them, better supervision by senior nurses at weekends and improved food (MoH 1968, pp. [78][79][80]. Five of the nine paragraphs in the 'summary of findings' praised staff for high standards of work, the other four attacked Daniel personally. That alone justified Barbara's concern about anonymity for her witnesses. The report accused Daniel of misinterpreting, misunderstanding and distorting her observations, that her judgements were 'manifestly unsound' and her 'sentimental approach' conflicted with the 'objective attitudes' of other staff. It described Daniel as 'rather a solitary person with a somewhat simple mind' (p. 78). Daniel's correspondence with Barbara and the reports from her sons do not bear this out, instead suggesting that she was a colourful and socially integrated character. 61 The report concluded, demonstrating acceptance of low standards for older people, that 'we have no hesitation to say that in our unanimous opinion there is no substance whatever in the allegations of cruelty by staff' (p. 78) and that the hospital standards 'might well be emulated by the rest of the country' (p. 81).
Daniel wrote to Barbara. Staff who she thought would support her let her down, and her 'old terrible nightmares' returned since she had seen again the 'ministering angels', her former colleagues. 62 Daniel received threatening phone calls. 63 Her sons and her friends feared for her physical safety and suggested that she moved out of the area until the anger died down. She decided to remain because she had things to do at home, and 'I feel going away would look as if I am afraid.' 64 Afterwards, Daniel spoke little about the events to her sons, although Charles recollected in 2015 that 'I think in herself she was angry that the enquiry was a "whitewash".' 65 Daniel was concerned that Barbara might have 'lost faith' in her because of her mistakes, 66 but that worry was allayed, and Daniel continued to support AEGIS. 67 Daniel wrote, at the end of 1967, 'God bless you Barbara for all the wonderful work you are doing.' 68 In 1971, Daniel sent Barbara a newspaper cutting: 'St. Lawrence's to get another £750,000: plans include new geriatric unit'. 69 The plans included up-grading the building which contained four of the five wards where Daniel had worked (Anon. 1971).

STORTHES HALL AND SPRINGFIELD
Davie's allegations in Sans Everything concerned two hospitals, Storthes Hall and Springfield (Davie 1967, pp. 43-47). At Storthes Hall, as at St Lawrence's, the inquiry took place in the hospital, and evidence was presented in front of the staff being criticised. 70 Confidentiality was impossible due to Storthes Hall's 'jungle telegraph'. 71 Davie faced a barrage of 799 questions on the first day. The committee questioned, and lawyers cross-questioned, his motivation for contributing to Sans Everything, suggesting that he wanted to be the centre of attention, which he emphatically denied. 72 Potentially incriminating documents went missing, and the chairman could not 'understand why a book, the size of a London telephone directory, could be missing as easily as that'. 73 Lack of written evidence 74 meant that one person was pitched against another, hardly ideal for the proper conduct of an inquiry.
The committee took every opportunity to nitpick minutiae of language in Davie's Sans Everything report. This detracted from the main argument and aimed to show his ignorance to discredit his evidence. They quibbled, for example, over his use of the word bestiality (Davie 1967, p. 43). Mr U, a lawyer, cross-questioned Davie about the idea that bestiality meant only sexual intercourse between a person and an animal: Mr U: Is this your sense of responsibility, to use this term about the psychiatric hospitals for the public to read; to destroy public confidence in the treatment in hospitals . . . by using this term? Davie: I considered it a perfectly fair word to use. It means other things apart from what you describe. 75 Davie used the broader, and primary, meaning: 'The nature or qualities of a beast; want of intelligence, irrationality, stupidity, brutality' (Oxford English Dictionary, OED) but the lawyer did not accept that usage. In response to Davie's (1967, p. 44) comment that staff had little appreciation of psychological principles (which one nurse demonstrated when discussing 'punishment' and 'treatment' 76 ), another lawyer quizzed him on his understanding of the term psychological, which he answered competently. 77 A punitive, repressive approach to patients' socially unacceptable behaviour was common in psychiatric hospitals where custodial attitudes dominated (Martin 1962, p. 14). It could maintain discipline and help staff control patients, but it was not therapeutic.
Davie challenged the value of HMC or RHB inspections and highlighted barriers faced by patients who wanted to make complaints: 'anyone who has worked here knows that as soon as the visiting committee gets to the front gate, somebody is on the 'phone, and all wards know, and everything is very quickly put in order. And what they see is not a true picture.' Cross-examining, Mr V asked about patients raising concerns during inspections: 'Those witnesses who are capable of giving a logical account of themselves, are they spirited away, then?' Davie replied: 'No; they are there, and very often they feel that they would like to say something-maybe indeed they have. They would like to say something, but with one eye on the charge nurse, who will exact reprisals.' 78 The committee interviewed, Mr G, a patient deemed to have capacity to answer the questions put to him. Mr G was alleged to have been assaulted. He kept 'one eye on the charge nurse': we questioned [Mr G] in a side room in the presence of a few immediatelyinterested persons. Mr G described an assault by a Charge Nurse (one blow on the back of the head) of a wholly different character from the assault described by Mr Davie (very many blows with open hand on the face-not the head): he could not or would not name the Charge Nurse: he did not identify . . . his assailant although he saw him present in the room. There is no casualty report with the Case Notes of Mr G, nor is there any relevant entry in his case notes. 79 Disinclination of a patient to directly criticise a staff member who would potentially be his nurse again, illustrates the obstacles a patient could face in getting his voice fairly heard. Lack of corroborative clinical notes and discrepancies between the verbal reports were interpreted as evidence that there was no assault. This fitted with Davie's observations that when families and friends complained based on what the patient told them, staff responded: 'Well, the patient is insane in any case, and he is not to be relied upon. . . . We are really not brutes here, you know.' 80 Attributing patients' complaints to their illnesses 81 was similar to the response Mrs Dickens received about her brother at Friern. 82 Abel-Smith noted: Anything [patients] say to visitors or others may be too readily dismissed as a consequence of their confusion. . . . We have also to allow for relatives who are frightened of being told to take the patient home and look after him or her themselves, . . . they may be silenced by the threat of the return of the patient. 83 Davie also wrote in Sans Everything (p. 46) that cruelties 'took place not at Belsen, but in the north of England.' Asked about this at the inquiry, he explained his rationale for the analogy: 'The hospital was a "hell-hole": it was like Belsen because Belsen means a place which is brutal, bestial and beastly, and those epithets applied to the hospital.' 84 That fitted with the definition in the OED: '"Belsen" may be used hyperbolically to describe any very unpleasant place.' The committee would accept only the historical definition of the Nazi concentration camp. Their unrelenting questioning made Davie back down, 85 allowing them to conclude that he exaggerated. The committee also described him as 'consumed by malice towards the hospital, and towards nearly all who worked in it'. Such statements justified their approach of not seriously evaluating his evidence, while giving the impression that their inquiry process was valid. The committee wrote: 'if somewhere in his evidence there lurked some grains of truth, such grains are so deeply buried, and so obscured by distortion, falsehood and exaggeration that they are either quite undiscoverable, or unrecognisable as the truth.' 86 The final report on Storthes Hall stated: 'we were quite unable to give any credence to his evidence; and, accordingly found none of his allegations . . . to have been proved' (MoH 1968, p. 56). This contrasted with the response of a separate committee at Springfield Hospital which also evaluated Davie's evidence. It formed the impression . . . that while his evidence was confused, exaggerated and emotional, there was some basic sincerity about the man. He certainly did not invent his stories out of whole cloth. We conclude that he certainly witnessed one assault upon a patient. 87 Davie wrote one account in Sans Everything about his experiences in the two hospitals. Allegations were similar at both and staff at both denied malpractice. It is unlikely that Davie changed in personality, trustworthiness or motivation between working at the hospitals, writing about them and attending the inquiries. The committees and lawyers were the major difference between the two inquiries, and their conclusions diverged, about him and his evidence. 88 The Springfield Report surprised the Ministry. It was the only one to accept that a Sans Everything witness was genuine in his concerns, and the only one to uphold 'findings of illtreatment'. 89 The best explanation is that the committees' assumptions about Davie and the hospital staff affected the evaluation of evidence and therefore also their conclusions. Notably, and in contrast to the other inquiries, at Springfield, there is also ample evidence that the medical member of the committee advised the chairman and lawyers about hospital and clinical matters. 90 THE OTHER WITNESSES Davie, 91 Daniel,92 and Susan Skrine and Eileen Porter at Cowley Road Hospital, 93 all refused Barbara's offer to pay their lawyers' fees: the witnesses considered it part of their contribution to the AEGIS campaign. Similar to Davie and Daniel, other public-spirited witnesses had distressing experiences: Jean Biss described her experience of the St James's Inquiry as 'like being crucified'. 94 Dorothy Hurley, whose report to the News of the World was investigated tagged-on at Leeds, received a phone call 'telling me to be careful if I went into town as some of the staff were gunning for me'. 95 Moodie's former supporters at Banstead deserted him when faced with a formal inquiry. They were 'hostile towards me, and for me to attend the enquiry without witnesses, would enable them to prove quite easily, that black was in fact white. . . . When I do go into battle, I prefer at least a small chance of winning.' Most of those staff lived in tied accommodation, which Moodie, and others (Martin 1962, p. 9) linked to their reluctance to criticise openly. 96 Despite the unpleasant experiences at the inquiries, the witnesses continued to support Barbara and her work. Mabel Franks wrote to Barbara: 'Mrs Biss informed me that those nurses who are your disciples in this fight against wanton neglect and cruelty will never never let you down.' 97

THE MINISTRY PREPARES THE WHITE PAPER
The Ministry decided to publish all the inquiry reports about Sans Everything as a single white paper. This would 'soften the impact of the bad report and discourage accusations of "white-washing" in the good reports'. 98 The brief, negative one-and-a-half-page report about Springfield was tucked away at the back of the book. The reports included forty-eight recommendations for general improvements, including staffing levels, nurse education, communication within the hospitals, reducing overcrowding and working with local authorities to increase support and accommodation for older people in the community. Robinson ignored the Springfield Report, the criticisms of the Friern committee about the hospital and RHB, and the forty-eight recommendations. In a letter to Crossman he asserted that 'generally speaking the hospitals come out of the enquiries well'. 99 Robinson also told Crossman that the white paper 'would be completely uncontroversial because it would simply demolish Mrs Robb'. 100 He underestimated her.
The Ministry published abridged reports, partly because that was usual practice. 101 Shorter reports were more likely to be read, although they also carried the risk of inviting criticism by their exclusions. 102 It was therefore important that the committees, rather than the Ministry, made the summaries so the Ministry could not be accused of deliberately editing out controversial material. That did not stop the Ministry delegating the editing to at least one RHB, and condoning another changing a committee's report, to minimise criticism of the Boards in the published version.
The Ministry produced guidance notes to assist its staff when dealing with press inquiries after publication. 103 Aiming to reassure the public, the guidance stated: 'The depth of investigation made into matters alleged to have occurred years ago was only possible because of the quality of the records kept of the treatment and progress of patients.' With examples of poor-quality documentation at Friern and missing records at Storthes Hall, it was hard to justify that statement. The notes also informed the Ministry's staff that none of the solutions in the second part of Sans Everything was original, which begged the question that if they were known, why had none been implemented? It described Whitehead's 'medical solution' in Sans Everything as 'widely practiced', which was inaccurate when only a handful of such schemes existed nationally (Hilton 2016 views into a letter to the Times: that the allegations in Sans Everything were 'an indictment of every one of us who knew these things were happening and did nothing about it' (Robb 1968), a broad collective responsibility, resembling Roxan's view about journalists (Cochrane 1990. p. 75) and Cross's 106 and Rowe's views about nurses . Barbara informed the Council on Tribunals of her concerns about the conduct of the inquiries. The Council criticised: Robinson's decision not to establish them under section 70; the lack of common procedures for conducting them; and lack of uniform criteria for making judgements, such as about ill-treatment or standards for personal care that could be ethically complex to determine (Council on Tribunals 1969, pp. [13][14]. 107 Supporting the view about ethics, Townsend stated that it could be difficult to draw the dividing line between deprivation and cruelty, 108 and the Springfield committee recognised that 'it is often extremely difficult to distinguish between cruelty and necessary constraint'. 109 The Council wrote to Robinson about his choice of procedure for Sans Everything, and informed him that section 70 should be used as widely as possible. Robinson replied to the Council in a patronising way, irritating them by giving 'elementary information which he might have assumed we would already know'. 110 He ignored the Council's criticism that he had not observed NHS guidance on handling complaints. He explained that he could only instigate a section 70 inquiry in 'exceptional circumstances', but he did not clarify the principles which would underpin that decision. Greater rigour and uniformity and Council oversight, would have enabled more equitable and balanced treatment of witnesses and allegations that could have affected the conclusions. The Council particularly criticised Lowe for his conduct of the Friern Inquiry, including lack of compliance with NHS complaints guidance and ignoring the Royal Commission's recommendations about witnesses having legal representation, on which point the Ministry concurred with the Council. 111 The Council also criticised the report on Friern: because the committee 'heard no evidence from the witnesses whom AEGIS proposed to call, the tone of it struck us as being intemperate'. 112 The unrestrained language in Lowe's report was ironic considering that his committee deplored Barbara's 'flamboyant and exaggerated style' and stated that the Diary (Robb 1967) would have been 'more impressive if stated factually without adjectival adornment' (MoH 1968, p. 27).
The Council wrote directly to Barbara, supporting her criticisms and giving her permission to publish its letters. It thanked her for her input and stated that it would use her material when considering NHS plans for establishing an ombudsman and for creating procedures for inquiries that would come under their supervision. Barbara was delighted with this outcome. 113 AEGIS's press statement led to articles in national papers about Robinson mishandling the Sans Everything complaints (Anon. 1969a(Anon. , 1969bPrince 1969). The New Law Journal (Anon. 1969c) congratulated the Council for their stance, which made 'trenchant criticism' of Robinson. Personal letters congratulating Barbara included one from the editor of New Scientist: 'you have dented the bureaucratic shell'. 114 COMMENT Numerous difficulties underpinned the inquiries and hindered dispassionate evaluation, influencing the committees' deliberations and conclusions. The effect of the RHBs appointing the committees was probably less problematic than the nonuniform inquiry procedures each adopted and the RHBs altering the committees' reports to remove criticisms about themselves. The terms of reference centred on investigating the specific allegations in Sans Everything and examining the situation on the relevant wards. In the event, attempts to identify and prove specific incidents such as hitting, teasing or harsh handling proved virtually pointless, as Cross and Abel-Smith warned. 115 The truth did not emerge about anecdotal events: unkindnesses were unlikely to be documented in hospital records, some potentially relevant documents were 'lost' and staff, fearful of retribution, were not questioned under oath. James Loring, director of the Spastics Society 116 said: 'It is difficult to prove anecdotes of the sort contained in Mrs Robb's book-they concern ephemeral events. But we know of many similar cases. We couldn't prove them legally but we still know them to be true' (Anon. 1968).
The committees held stereotypic views of the excellence of the NHS and its staff, and less favourable views about older people for whom they accepted particularly low standards of care. The chairmen lacked experience of inquiries into public sector administration, and their unfamiliarity with internal NHS politics and protocols, at local, regional and national levels, 117 affected inquiry outcomes. For example, the committees ignored, or did not comprehend, the effects of the rigid, hierarchical nursing regimes that resisted change and inhibited honest, and potentially constructive, criticism (Dickinson 2015, pp. 145,171). The committees' questioning indicated their paternalistic attitudes towards the patients, their relatives, vocational students, and staff without formal qualifications. By contrast, gender discrimination was less overt, unexpected at a time when it was commonplace in the public arena and when the women's movement was in its infancy (McCarthy 2010, p. 105). This could be accounted for by each committee having at least one female member, usually a nurse at the top of their career, reducing gender bias but reinforcing acceptance of the soundness of the nursing hierarchy.
Lacking understanding of modern, proactive clinical practice in psychiatry and geriatric medicine, committees erroneously set standards according to the opinions of the senior staff they investigated rather than using independently derived criteria. If senior staff advocated a harsh, undignified or out-of-date approach, committees naïvely accepted it, despite similar behaviours being considered inhumane or disrespectful in more progressive hospitals. Too often, the committees qualified their judgements according to what they thought rather than what they knew. The committees employed recognised tactics and logical fallacies to protect their assumptions. These included criticising the complainants personally rather than evaluating their evidence impartially; describing controversial allegations as exaggerations that could be dismissed automatically; and using leading questions and ambiguous, vague language.
Historical analysis of the Sans Everything inquiries is in keeping with Crossman's opinion that the committees were 'fairly well rigged', 118 and the view of Max Beloff, Professor of Government and Public Administration at Oxford. Beloff (1967) wrote: 'the danger with our close-knit political-administrative network is that most inquiries are so manned that they turn out to be nothing but the system looking at itself, and finding more to admire than to blame'. These opinions corroborated the view of AEGIS's lawyer at the Leeds Inquiry who stated that an ordinary member of the public might 'think that the Committee was sitting merely as a stooge of the Minister to whitewash the accusations which have been made'. 119 Concerning giving evidence, Mr Cumming, Davie's lawyer, wrote to Barbara: I feel most strongly that the truth never did have a chance of emerging from people who were having to speak in front of a QC, a Physician, Matron, Chairman of a Bench of Magistrates, a Medical Superintendent, the Chief Male Nurse and the so-called accused Male Nurses, backed up by their Trade Union officials straining at the leash. 120 Imagery of 'straining at the leash' conveyed the inquiry's hostile atmosphere. The array of senior staff, legal professionals and local dignitaries, intimidated staff and patients who wanted to speak up, and precluded honesty, much as the style of official hospital inspections inhibited patients and ward staff from complaining. The structures and expectations of the committees of inquiry humiliated the AEGIS author-witnesses and gave them little chance of validating the Sans Everything case. These witnesses showed extraordinary dedication to AEGIS's cause and remarkable ability to remain dignified under pressure.