The Baldovan Institution Abuse Inquiry: a forgotten scandal

Introduction

On 20 August 1967, the News of the World, a Sunday newspaper with a wide, national readership, published allegations made by a former nursing assistant of serious misconduct and maladministration at Ely Hospital, Cardiff, a large – 600-bedded – long-term institution for people with learning disabilities. They included neglect and ill-treatment of patients, widespread pilfering by staff, and a general failure by senior members of the hospital, including the physician superintendent, to exercise effective supervision. The newspaper forwarded the dossier containing the allegations to the Ministry of Health, and a Committee of Inquiry followed. It was chaired by Geoffrey Howe QC, a rising Tory politician, who was later to become a senior member of Mrs Thatcher’s cabinets. The Committee reported in March 1969. ¹ Its conclusions were damning. It found an institution that was physically, socially and organizationally isolated, with serious overcrowding, poor quality care, and nurses with little understanding of, and largely indifferent to, the needs of patients and wedded to practices ‘reminiscent in too many ways of the old era of custodial care’ (Ely Report, para. 271). All levels of the hospital hierarchy, right up to the Hospital Management Committee and the Regional Health Board, were accused of a serious failure of leadership.

The Ely Inquiry, despite labouring under several handicaps (it met in private, had no powers to summon witnesses or take evidence on oath, and most importantly, was denied legal support) holds a significant place in the development of learning disabilities policy; it was, claim Butler and Drakeford (2005: 7), ‘the first major institutional scandal of modern times’. It was followed over the next decade by a number of similar inquiries – Farleigh, 1971; Whittingham, 1972; Napsbury, 1973; South Ockendon, 1974; Normansfield, 1978 – all of which exposed the failings of institutional care and helped to foster a climate of reform. The Ely Inquiry led directly to the establishment of the Hospital Advisory Service, an independent body set up to carry out inspections and advise on hospital policy and patient care, and in 1971 a White Paper, Better Services for the Mentally Handicapped (Department of Health [DOH], 1971); this formally signalled the government’s intention to abandon a policy that placed the long-term institution at its centre in favour of one that advocated integration rather than segregation. As Martin (1984: 120) noted, after Ely ‘nothing would ever be quite the same again’.

However, the Ely Inquiry was not, contrary to general belief, the first in the post-war period to lay bare the failings of institutional care. Little more than a decade earlier, a scandal had surfaced at another long-term hospital for people with learning disabilities – the Baldovan Institution near Dundee – which had all the features that later brought Ely to public attention. But unlike Ely, which prompted ministerial statements, questions in both Houses of Parliament and general press outrage, Baldovan attracted little more than local concern. The report that followed made few recommendations requiring more than a tinkering with the hospital management, and it was quietly and quickly buried in the archives where it has lain for the past 60 years. ² My aim in this paper is twofold: first, to rescue the Baldovan Inquiry from the obscurity to which it has been consigned; and second, to ask why, unlike Ely, its impact was so limited and whether a more positive response might have hastened change.

The Baldovan Institution

The Baldovan Asylum for ‘the treatment of imbecile and idiot children’ was founded in 1853 on the Baldovan estate of Sir John Ogilvie of Inverquharity (1803–90). It was the first such establishment in Scotland, and one of the very first in the world. The Institution admitted its first children on 6 January 1855: 12 in total, although there was accommodation for 30. Sir John, and especially his wife, Lady Jane (1809–61), were the driving force behind the project, and from the very start they involved themselves in the management and day-to-day running of the institution. After Lady Jane’s premature death in 1861, much of the responsibility she had assumed was transferred to a newly established Visiting Committee, composed of local notables, assisted by a Medical Director. The land and buildings continued to be held within the gift of Sir John until 1875, when a feu disposition registered in the General Register of Sasines in Edinburgh conveyed the buildings and grounds of the Institution to a newly constituted body of Trustees.

The 1913 Mental Deficiency and Lunacy (Scotland) Act formally signalled the government’s recognition that mental deficiency ³ could no longer be left to voluntary efforts; it was a national problem requiring a national solution. Baldovan became a certified Institution under the Act, and in 1925 responsibility for it passed to an ‘Incorporation’ of three local authority District Boards of Control (the counties of Perth, Forfar & Kincardine, and Aberdeen), effectively changing it from a quasi-private, charity-based and comparatively small establishment to a public institution with the potential for significant expansion. In response, Baldovan, like other institutions in the sector, adopted a modified form of the colony solution: separate ‘villas’ (or pavilions) with common administrative facilities. This not only addressed the problem of overcrowding, but allowed for classification of inmates ⁴ along age, ability and gender lines. It also afforded greater opportunities for training and occupational activity. In 1927 the small farm acquired three years earlier was converted into a specialized pig and poultry farm, providing training for seven boys, and income for the Institution. Others worked in the gardens, or assisted the painters and engineers. An expanded occupational therapy department offered a range of activities, including boot-repairing, tailoring, basket-weaving, rug-making, leather work, sewing and knitting. For the girls there was the laundry and kitchen and general domestic duties. Upwards of 60 children attended the Institution’s school.

With the passing of the NHS (Scotland) Act in 1947, responsibility for mental health services, including mental deficiency (MD) hospitals, was assumed by the Secretary of State for Scotland. Under Section 11 of the Act, his responsibilities in the area covered by the City of Dundee and the Counties of Angus, and Perth and Kinross were to be discharged by the Eastern Regional Hospital Board (ERHB). It in turn delegated day-to-day responsibility for groups of hospitals in the region to Boards of Management. One of these Boards was the Board of Management for the Dundee Mental Hospitals, a group that included Baldovan.

In the immediate post-war period, the concern of government and public alike was focused squarely on physical health, and in the new comprehensive health service that was created, mental deficiency was consigned to the margins. Wartime exigencies had left mental health services–the institutional sector especially–facing a crisis of accommodation and staffing, which post-war austerity only exacerbated. At the same time, demand continued to grow. By 1956, when the Inquiry was held, the number of inmates at Baldovan had risen to over 400, ranging in age from 5 to 50 years, with a waiting list approaching 250. Serious overcrowding resulted, which the opening of new pavilions failed to resolve. The circle was only partly squared by allowing a number of the inmates out on licence. Treatment, care and supervision, however, inevitably suffered.

Background to the Inquiry

In June 1955, Mrs Rafferty, a nursing assistant formerly employed at Baldovan, went to the Physician Superintendent (PS), Dr Telfer, with allegations of ill-treatment of patients by three members of the hospital staff. On advice from the Chairman of the Board of Control, Scotland, Dr Telfer referred the matter to the Procurator Fiscal ⁵ and, after the resulting police investigation, charges were brought against three nursing sisters, although curiously enough, not the three who had figured in Mrs Rafferty’s original allegations. ⁶ The trial that followed opened at Dundee Sheriff court on 26 January 1956. It lasted for seven days, the longest jury trial to be held in this court up to that time, and ended with all three nurses, to general public approval, being acquitted on all charges. ⁷

However, the trial had revealed what the ERHB in its submission to the Inquiry Chairman later described as ‘a generally unsatisfactory state of affairs, both as regards the care and treatment of patients and the relations among the staff’, ⁸ that went far beyond the specific allegations that were the subject of the trial. The Board of Management was minded to set up an internal inquiry into the running of the Institution, to be undertaken jointly with its superior authority, the ERHB, but – given that any inquiry was likely to extend beyond the Institution to the upper echelons of hospital governance – this was thought to be inappropriate. Instead, a request was made to the Secretary of State to establish his own independent inquiry under Section 69 of the NHS (Scotland) Act, 1947.

The ERHB insisted that prior to the trial of the three nurses it

had no reason to think that the standard of care and treatment of patients in Baldovan Institution was anything other than satisfactory, except in so far as the standard of care might fall marginally below an ideal level because of unavoidable staffing difficulties. ⁹

It argued that this claim was supported by the General Board of Control, whose commissioners inspected the institution biannually. This seems difficult to square with the admission in the same memorandum that since 1950 the Board of Management for the hospital had dealt with ‘no fewer than twelve cases of disciplinary action against members of the staff … principally involving student nurses or nursing assistants’, adding that ‘it is not known whether this represents the total number of cases of disciplinary action in the hospital’. There had been earlier allegations of ill-treatment of patients, including assault, resulting in the suspension and occasional dismissal of staff, and evidence, too, of widespread pilfering and destruction of hospital property, which had led to police involvement and a special sub-committee of the Board being tasked to look into the matter. ‘No other Board of Management in this region’, the ERHB conceded, ‘has had to deal with disciplinary matters on such a scale for a whole group of hospitals, let alone for one single hospital.’ ¹⁰ This conclusion was echoed by the newly appointed PS, Dr William Telfer, who declared that on his arrival at the institution in 1954 he had found it in ‘a complete state of chaos [with] terrific discontent among patients and staff’. ¹¹ Clearly all was not well at Baldovan.

Indeed, in December 1954, shortly after Dr Telfer had taken up post, the ERHB had held a joint meeting with the Board of Management following complaints made by two unnamed members of staff to the local MP that had prompted a request from the Secretary of State for ‘a full and urgent inquiry into nursing conditions’ there. Concerns discussed – all clearly union-generated, much to the irritation of senior management, who regarded it as a deliberate attempt to foment discontent – included staff shortages and turnover, nurse training, security, and general working conditions. While each complaint was dismissed as unwarranted, unsubstantiated or in hand, it was acknowledged that there were ‘faults in the administration [of the Institution] which required attention’, in particular ‘the relations between the medical staff and the matron’. However, given that, following a three-month interregnum, a new PS (Dr Telfer) was now in post, it was confidently predicted that the firm leadership he would provide would quickly resolve any outstanding problems. Six months later, Dr Telfer felt able to inform the ERHB that ‘staff relations had improved and that the situation in general was satisfactory’. ¹² Such complacency, however, was quickly punctured when Mrs Rafferty came forward with her allegations.

The Inquiry

The formal announcement of the Inquiry was made on 20 February 1956. It was to be chaired by Thomas MacDonald, QC, ¹³ assisted by a senior medical commissioner from the General Board of Control, Scotland, Dr H.B. Craigie. His remit was ‘to enquire into, and report on, the whole administration of Baldovan Institution including in particular the arrangements for the care and treatment of patients, and to make recommendations’. The Inquiry opened on 19 March 1956 and lasted three days. It was held in private, with witnesses giving evidence on oath. In total, 25 current members of staff gave evidence, including Drs Duncan (Acting PS) ¹⁴ and Couston (Registrar), the Matron (Miss Christie) and the Administrative Assistant (Mr J.S. Brown), as well as seven former employees. Other persons giving oral evidence included Dr Jardine, Chairman of the General Board of Control for Scotland, and officials from the two unions (the Confederation of Health Service Employees [COHSE] and the National Union of Public Employees [NUPE]) representing the staff at Baldovan. Written statements were provided by unnamed serving and former members of staff, patients’ relatives and the general public, some of whom also gave oral evidence. It is worth noting that none of the patients was asked to give evidence, nor was Mrs Rafferty, although in the case of the former, the evidence they had provided at the trial would presumably have been available.

Given the comments made by the Sheriff-Principal at the trial and the publicity they had attracted, a formal inquiry of some kind was inevitable. Unlike the Ely Inquiry, however, which in the manner of most inquiries of this kind was set up primarily to establish the truth of the allegations, the Baldovan Inquiry was not primarily concerned to get at what had happened; that, for the most part, had been established at the trial. Rather, its purpose was to produce an explanation: How had the institution been reduced, in the words of its PS, to a state of ‘complete chaos’? Officials in Edinburgh at the Department of Health (DHS), who controlled the process throughout, although from a distance, were determined to keep the Inquiry narrowly focused and low key and not allow it to descend into a retrial of the three sisters; their aim was ‘to find out what was wrong at the Institution and suggest how it might be put it right’. ¹⁵ Investigation of the allegations of ill-treatment and neglect – little different in nature or degree from those which featured in the Ely Inquiry, and extending to a total of 11 patients, not just the 5 who had been the subject of the trial – ‘occupied a good deal of [the Inquiry’s] time’, and 4 pages of the 17-page Report; however, it produced only ‘meagre results’ and, significantly, did not feature in the Report’s conclusions or recommendations. It revealed underlying administrative problems, failures of communication at all levels, poor professional practice, and some indifference to the medical needs and welfare of patients, but no evidence of outright neglect, still less ill-treatment, although, given that all three nurses had been acquitted at their trial, it could hardly have come to a different conclusion.

Staffing difficulties

At the nurses’ trial, much was made of the twin problems of staff shortages and serious overcrowding, and indeed in the immediate post-war period, Baldovan, along with all other MD institutions at the time, had experienced difficulties in recruiting and retaining staff. Attempts to solve the problem were sought by extending the search to Ireland, Continental Europe and among Displaced Persons, at some cost but with little success. At the end of 1954 the total number of nursing staff in post (including students, nursing assistants and nursery governesses, not just trained staff) was 78, of whom 5 were part time. There were 50 vacancies, almost half (21) of which were for trained staff. Turnover was high: in the three-year period 1952–4, almost as many (69) nurses left the employ of the Institution as started (71). Of the 78 nursing staff, 44 had been at the Institution for less than four years, including 17 who had served less than one, but the ERHB in its memorandum to the Inquiry rejected the suggestion, made at the trial, that ‘the hospital is seriously understaffed in people employed on nursing or quasi-nursing duties’. It claimed that the nurse–patient ratio at Baldovan was c.1:6, only slightly higher than the Scottish Health Services recommendation of 1:5. ¹⁶ But this bore little relation to the number of staff on duty at any one time, and it was the case that a ward in the hospital had recently had to be closed because of staff shortages, resulting in serious overcrowding in some pavilions, especially those occupied by the more demanding, ‘low grade’ patients.

It was not, however, just a question of the number of staff but their quality. In February 1956, two-thirds of Baldovan’s nursing staff were unqualified, including 20 per cent who were officially, but misleadingly, designated as ‘students’, despite the fact that they ‘… clearly did not have the capacity to pass State examinations’, as well as ‘a considerable number of married women, with young families, who had no intention of undertaking training’ and who, when required to do so, chose to resign. This inappropriate use of the student grade had apparently resulted from an informal agreement with the unions, who feared that the excessive reliance on nursing assistants to solve staff shortages would discourage the recruitment of qualified staff. ¹⁷ For such people, however, nursing, and particularly nursing at Baldovan, was clearly neither a profession nor a career, still less a vocation; it was a job. Here, in part, lies the explanation for the high turnover of staff, as well as the disciplinary problems that plagued the Institution: in seeking to attract and retain staff, Baldovan was to a considerable extent hostage to the shifting state of the local jobs market.

Staff divisions

Despite the fact that evidence both at the trial and the Inquiry was given on oath, many of the witnesses at both proceedings clearly perjured themselves or at the very least were economical with the truth. Commenting on the evidence given at the trial of the three nurses, the ERHB was of the opinion that ‘it is difficult to escape the conclusion that lies were told on one side or the other’. ¹⁸ This practice persisted into the Inquiry, confounding the Chairman’s attempts to get to the bottom of what was going on at Baldovan. Much of what he heard, he dismissed as unreliable, even downright lies, and he accused some members of staff, including the Matron, of making malicious and unfounded allegations with the intent of damaging colleagues’ reputations.

All this reflected the deep divisions that existed among the staff at Baldovan at the time, a situation described by the Deputy (and Acting) PS, Dr Duncan, as verging on ‘a cold war’. These divisions centred around individual nurses’ relationships with the Matron, although whether there were other less idiosyncratic factors at work is an open question and one difficult to answer. It is tempting to think of the fracture running along seniority lines with the majority of ward sisters and charge nurses coalescing around the Matron and adopting an oppressive attitude towards the junior, untrained staff. On the other hand, at least one ward sister gave evidence for the prosecution at the trial, and others were the target of false allegations from staff members who might be thought of as members of Matron’s circle. While ‘no member of staff below the status of ward sister spoke of her manner in favourable terms’, five junior nurses were prepared to give evidence for the defence at the trial and, by implication, supported the Matron’s position. ¹⁹

An alternative explanation is that staff divisions reflected inter-union rivalry. Both the Inquiry Chairman and the ERHB were in little doubt that this was a contributory cause of the disharmony in the institution. COHSE was long established within Baldovan, and the majority of the staff belonged to it; all three of the nurses who were prosecuted were members. NUPE was a newcomer and quite recently had embarked on an aggressive recruitment campaign, although it is not possible to say whether this was successful, as neither union could – or was prepared to – provide the Inquiry with details of its Baldovan membership, despite the Chairman’s best efforts to obtain the information.

Management structures

The nursing complement at Baldovan divided more or less equally between male (35) and female (30) staff. The senior male nurse held the title of Deputy Chief Male Nurse, a position that in theory afforded him direct access to the PS and was intended to give him practical, if unofficial, authority over all matters affecting the male staff. This, however, does not seem to have been accepted by the Matron, who continued to claim ultimate authority and responsibility for all nursing matters, with the Deputy Chief Male Nurse subordinate to her, and this was a cause of some resentment, especially among the male staff. For some time there had been calls from many quarters, especially from the trade unions, for the appointment of a Chief Male Nurse with authority over the male staff equal to that of the Matron’s, as was the position in most other MD establishments at the time. The previous PS, Dr Gibson, had voiced support for this as far back as 1950, and the Board of Management had agreed in principle, but postponed taking action, mainly on financial grounds. It had instead compromised by creating the post of Deputy Chief Male Nurse, a decision which Gibson predicted (correctly as it turned out) was likely to undermine the position of the Deputy Matron. ²⁰ These problems of the management structure were exacerbated by the complete breakdown in the relationship between the newly appointed PS, Dr Telfer, and the Matron, Miss Christie, and it was on this that the Inquiry focused.

The location of institutional authority

Underlying the problematic relationship between Miss Christie and the medical officers, Dr Telfer most especially, was the ambiguity surrounding the location and nature of authority within the Institution. Dr Telfer seemed uncertain of his authority, particularly as it might extend to the nursing staff. Shortly after arriving at the Institution, he met the Chairman of the Board of Management and raised the matter, only to be informed that ‘he was responsible for the whole day to day management of the Institution, including control of the nursing staff’, ³² a responsibility which he was informed extended to the recruitment, dismissal, promotion or demotion of nursing staff in line with DHS guidance. ³³ The practice at Baldovan, however, did not wholly accord with this. Under Dr Telfer’s predecessor, Miss Christie had in fact been ‘required … to act on her own initiative on disciplinary matters without reference to him’ ³⁴ (emphasis added), and this she clearly continued to do after his departure; it is not clear whether this was out of a genuine belief that she was authorized (‘required’) to do so or because she held Telfer in so little regard.

The Inquiry accepted that neither in Dr Telfer’s letter of appointment nor in his contract were his powers spelt out, although adding that ‘this might reasonably have been inferred by him because of the nature of the appointment and of his title as Superintendent’. ³⁵ The ERHB concurred: ‘If such a doubt did exist in Dr. Telfer’s mind [regarding the extent of his powers and responsibilities] the Regional Board had no knowledge of it nor indeed can they understand why it should have arisen. It appears to the Regional Board to be much more likely that Dr. Telfer’s difficulty in asserting his position owed more to his lack of experience of hospital administration and his known weakness for alcohol.’ ³⁶

The Inquiry did not entirely absolve senior management of responsibility for the situation at Baldovan, in particular singling out the Board of Management, and its Chairman, Alexander Donnett, for criticism: ‘His answers to questions were vague and evasive and his attitude generally indicated a lack of concern for the smooth working of the Institution.’ ³⁷ In what could only be seen as a clear rebuke, it stated that

… it is specially important that the Chairman [of the Board of Management] should be a person of wide outlook and human sympathy who can be relied upon to give advice and guidance to the Superintendent when called upon, and to accept personal responsibility before his colleagues for the counsel which he has given. ³⁸

Donnet, very clearly, in the opinion of the Inquiry, was not such a person. Dr Jardine, only too well aware of Telfer’s lack of administrative experience, had advised him prior to his appointment ‘to seek a close association with the Chairman of the Board of Management, as a person to whom he could go for advice and guidance, and who also would be able to put Dr. Telfer’s case and point of view to the Board of Management’. But from the very start, Donnet had made it clear that he was unwilling to perform this role, informing Dr Telfer ‘that he did not wish in any way to be involved in any questions of difficulty in the Institution, and … that Telfer must run the Institution without any assistance from him’. Donnet was a former trade union official, and the Inquiry attributed his attitude to an unwillingness to become involved in any potential inter-union disputes. Whatever the reason, Dr Telfer ‘was thus deprived of the friendly help which Dr. Jardine hoped he would get, and knew he required’. ³⁹

Conclusions and recommendations of the Inquiry

In line with the narrowly conceived terms of reference of the Inquiry and the expressed intent of its Chairman and the officials at the DHS to avoid any appearance of a rerun of the earlier trial, the conclusions and recommendations of the Inquiry were equally narrow in their scope. What had happened at Baldovan was seen essentially as an unfortunate aberration peculiar to that institution, with no wider implications for the long-term hospital sector, let alone mental deficiency policy more generally. Moreover, although the administration of the Institution had been called into question and, in fact, had been the explicit focus of the Inquiry, it was given a clean bill of health. The Board of Management may not have been ‘beyond criticism’, but the ERHB was thought to have ‘performed its functions adequately’ and ‘no fundamental changes [we]re called for’. ⁴⁰ The problem, it seemed, was not one of administrative structures or failings, but rather of personalities; change these and, it was implied, the situation would right itself. So the dismissal of the matron, Miss Christie, and the restructuring of the Board of Management were called for. Other resignations and dismissals were to follow, including that of Sister MacKenzie, the only one of the three prosecuted nurses still in the employ of the Institution at the time of the Inquiry. No doubt such action would have extended to Dr Telfer had not it been pre-empted by his untimely death. ⁴¹ The wider problem of staff shortages, which, the Inquiry concluded, lay ‘at the root of much of the friction between junior and senior staff’ and, it was argued, could well have led to the adoption of ‘unorthodox methods of controlling patients’, was to be addressed by re-establishing a comprehensive nurse training programme. The operation of the local employment market and the problems of recruitment more generally were not mentioned, still less the status of mental deficiency nursing, either within the nursing profession itself or with the general public.

A number of quite minor alterations to the hospital regime were proposed, all to address specific anomalies that the Inquiry had brought to light: changes to the frequency and method of stock-taking; imposition of a rule to ensure that there was always at least one medical officer on campus at all times; tighter procedures for controlling the movement of patients within the hospital system; more transparent procedures for seconding nurses for general training; and, to avoid any repetition of the confusion that Dr Telfer experienced on taking up his appointment, ‘further specification of the powers and duties of the Physician Superintendent’, particularly in respect to staffing matters. There were two further recommendations which, to modern eyes, may seem peculiar to their time and at odds with present-day thinking and practice. The first was that the Board should do what it had long been urged to do and create a post of Chief Male Nurse ‘equal in status with the Matron and [with] full administrative and nursing control over the male staff’, thus dividing the nursing administration along gender lines. The other was for the provision of more on-campus staff accommodation, with the inevitable, if unintended, consequence of adding to their isolation, a factor which the Ely Inquiry was to identify as contributing to the problems it had found. ⁴²

Publishing the Report

MacDonald delivered his report to the Secretary of State on 9 June 1956, but it was not forwarded to the ERHB until the 22nd, with the firm instruction that ‘its terms be treated as strictly confidential to members and officers of the Regional Board’. ⁴³ There had in fact been some debate within the DHS as to the propriety of releasing the report to anyone outside the department. To do so, it was maintained, ran up against ‘a strict rule’ ⁴⁴ that ‘such reports are confidential to the Secretary of State and are not disclosed to other parties’, and initially it was proposed to send the ERHB only an ‘extract’. This seemed perverse even to some officials within the Department.

The ERHB was far from happy with this ruling and pressed to be allowed to forward ‘the whole report’ to the Board of Management. As it pointed out, not only did it contain implicit and explicit criticisms of the Board of Management, but also this Board would have to implement many of its recommendations. Thus, for practical reasons, if not simply as a courtesy, the Board of Management should at least be shown the paragraphs (16 of 44) that called for action. If this were accepted, then, it was further argued, ‘there would be no point in withholding the other sections of the report, which are mainly informative’. ⁴⁵

A lengthy and tortuous correspondence ensued. At one point the DHS appeared to relent, even going one step further than the ERHB required: ‘In all the circumstances we agree that the Report should be made available to the Board of Management members, the Medical Superintendent, and the Secretary of the Board of Management’ ⁴⁶ (emphasis added). But it subsequently seems to have had second thoughts and reverted to its original position, arguing ‘where action is taken after considering a report of this kind, the justification for that action is not that the reporter may have recommended the particular course, but that the facts and circumstances established at the Inquiry are regarded by the responsible authority as justifying that course’. It suggested that a way round the problem would be for the ERHB to ‘communicate to the Board of Management a statement of the relevant facts and circumstances which the Regional Board consider to have been established as a result of the Inquiry, and which appear to call for such action’ ⁴⁷ (emphasis added). Although clearly unhappy with the position it had been placed in, the ERHB in the end reluctantly conceded, with its attempt to at least distance itself from the actions imposed on it being slapped down by DHS officials; on 9 August it forwarded, as instructed, a summary of the Report, not apparently the full version, to the Board of Management. ⁴⁸

The delay in communicating the Report’s findings to the Board of Management, let alone to the wider public, led to questions being asked in Parliament. Assurances were given that a public statement would be forthcoming ‘in due course’. However, it was not made clear who was to be responsible for that statement. With officials at the DHS clearly pulling the strings, but anxious to conceal their actions from public gaze, the official silence continued to the growing anger and frustration of local politicians and community leaders. The situation was brought to a head in late September as a result of a leak to the press, which in all probability had come from a member of the Board of Management – not, it would seem, of the Report itself, but of the summary with which it had been provided. This received extensive press coverage over the weekend of 23–24 September and prompted the DHS to instruct the ERHB to issue a lengthy press statement, which it duly did on 26 September. This outlined: the administrative and management structures operating at Baldovan, the background to the Inquiry, and the principal findings and the steps that were being taken to implement them. It emphasized that no instances of ill-treatment of patients had been established and any problems that had occurred in the past, far from being symptomatic of fundamental administrative shortcomings, were largely attributable to the toxic relationship between the PS and Matron, which had had such damaging effects on staff relations. ⁴⁹ A copy of the statement was forwarded to DHS next day.

Aftermath

On receipt of the Report, or at least a summary version, the Board of Management set about implementing its recommendations. The death of Dr Telfer and the enforced resignation of Miss Christie allowed for the introduction of new brooms, in the form of a new PS and Matron, who took up post in August and November 1956, respectively. They, together with the newly appointed Chief Male Nurse, began a programme of reform: work placements for patients, both within the institution and with outside employers, were greatly expanded, and steps were taken to eliminate the exploitation that had marred such programmes in the past; occupational therapy was revitalized with an emphasis on the development of social and vocational skills in order to equip patients for return to the community; and the number of patients allowed out on licence was greatly increased. All this took place against a background of a significant building programme to relieve the overcrowding, plans for which had been approved even before the announcement of the Inquiry. However, the two new pavilions that resulted, allowing for an expansion of numbers to about 600, were not opened until 1962.

The issue of an adequate nurse training programme proved more difficult to resolve, due in part to a lack of qualified teachers, but equally to insufficient suitable candidates. In their absence, there was perforce a continued reliance on nursing assistants. At Board level the departure of its chairman followed by the resignation and retiral of a number of its members allowed for a restructured Board of Management along lines recommended in the Report. This was followed in October 1956 by the new secretary issuing a memorandum setting out the powers and responsibilities of senior officials, and in particular the extent and limits of the PS’s authority, again in response to the Report’s recommendations. In a largely symbolic act, presumably intended to draw a line under the unfortunate events at Baldovan, in 1959 the Board agreed to change the name of the institution to Strathmartine Hospital. Meantime, while all this was going on, the government quietly consigned the Report to the archives to be embargoed for a period of 50 years, ⁵⁰ a decision that was endorsed on review in 1994 on the grounds that it contained ‘unsubstantiated allegations against named individuals and confidential details of named patients’, a strange argument given that the local newspaper, the Dundee Courier, had at the time carried extensive reports of the trial of the three nurses, providing its readers with all the information that the government seemed so anxious to conceal – information that has remained in the public domain ever since.

Discussion

A decade or more later, the initial response of government officials to the Ely Inquiry Report was little different. They too were reluctant to see the report published in full, arguing instead for a much shorter and anodyne version. This, however, was doggedly opposed by the Inquiry Chairman, Geoffrey Howe. Surprised and dismayed by ‘the tenacity with which officialdom can resist the sanction of publicity for manifest mismanagement’ (Howe, 1994: 42), he refused to put his name to anything other than the full report. A three-month battle of wills ensued. In the end, unlike the ERHB in the Baldovan case, he got his way, but it was a close-run thing. How can the different outcome be explained?

The answer comes down to a combination of contingencies and political will. In April 1968, following a Cabinet reshuffle, the Prime Minister Harold Wilson had charged his Cabinet colleague, Richard Crossman, with the task of bringing together two separate ministries – the Ministry of Health and the Ministry of Pensions and National Insurance – to form one giant department, the Department of Health and Social Services (DHSS), with responsibility, among other things, for all long-term hospitals in England and Wales. The new department came into existence on 1 November 1968, with Crossman as its first Secretary of State. ⁵¹ On 10 March 1969, six months after his officials had received it, Crossman was presented with the Ely Report and given only two days to reach a decision regarding its publication. ⁵² Resentful at being backed into a corner, his anger and determination to resist were only increased on subsequently learning that Ministry officials had long known of the situation at Ely. In his diary he describes learning of this at a meeting with officials on 12 March:

One of the most dramatic moments of this meeting was when I referred to our not knowing anything about it, and Bea [Serota ⁵³ ] said, ‘Didn’t we? You ask the Chief Nurse what she knows about it.’ Dame Kathleen said ‘Oh yes. We used to have people going down there, regularly visiting.’ I said, ‘Did they report?’ ‘Yes’. ‘When was the last report?’ ‘Three or four years ago.’ ‘Have you got it?’ Bea had arranged to have it and she threw it across the table to me. It was a deplorable report, admitting scandalous conditions, bad nursing, the basis of all the News of the World revelations that Geoffrey Howe had confirmed. I asked what had happened to this when it came in and the answer was that it had gone on file. (Crossman, 1977: 410–11)

Crossman was an experienced politician. He knew full well the repercussions that could follow any appearance of a cover-up, especially given all the publicity that the affair had already attracted. He reacted by seeking to turn a potential embarrassment for the government into a public relations success, not only by insisting on full disclosure, but also arguing for the establishment of an independent inspectorate reporting directly to the Secretary of State. Having just taken charge of the DHSS and with no personal responsibility for previous departmental shortcomings, he brought with him no baggage and was thus in a strong position to take on his officials and demand change. Moreover, as a senior member of the Cabinet, with the ear of the prime minister, he also had the political clout to get his own way. But it proved a hard fought battle, with senior officials in the department resisting him all the way. ⁵⁴

For Crossman, the timing was propitious. There had been growing public concern with the iniquities of the institutional sector, going back to the post-war National Council for Civil Liberties (NCCL) report, 50,000 Outside the Law (1951), and parent groups were emerging to campaign for a change in policy. ⁵⁵ The publication of Goffman’s Asylums (1961), Robb’s Sans Everything (1967) and Morris’s Put Away (1969) lent powerful academic support to their demands, and in that same decade Nirje (1969) had begun to spell out his principle of normalization, offering a radically different way of thinking about the ‘problem’ of learning disabilities. However, while in retrospect we can see here a very different understanding of institutional ‘care’ beginning to form, making for a public increasingly receptive to radical reform, there is no evidence that any of this penetrated the mind-set of those officials who had to respond to Ely or influenced their decisions.

The Ely Report was finally published in full on 27 March 1969, accompanied by ministerial statements in both Houses of Parliament, and later in the year, on 15 October, the Hospital Advisory Service was launched under its first Director, Dr Alex Baker. The subsequent publication of the 1971 White Paper, with its formal rejection of an institution-centred policy, could be said to have completed the Ely-inspired process. This too was largely Crossman’s work, but as he left office at the 1970 election, it fell to the new Conservative administration to introduce it. None of the above factors were in play at the time of the Baldovan Inquiry. A problem located geographically and administratively at the margins could not attract the publicity or the attention of central government that was so important in determining the response to Ely, ⁵⁶ and a weak local executive was no match for a civil service intent on limiting scrutiny and closing down debate.

If the response to Baldovan had been different, would this have brought about reform earlier? It seems unlikely. It took many more institutional scandals and enquiries before what Baldovan (and Ely) revealed about institutional ‘care’ changed minds and was reflected in policy, let alone practice, and even then it proved a slow process. Ely itself brought about no great change on the ground; its significance was largely symbolic. Even before the Ely revelations, there had been growing unease in government circles with a policy that absorbed money and attracted criticism in equal measure. Enoch Powell, then Minister of Health in a Tory government, in a speech to the Annual Conference of the National Association for Mental Health in 1961, had committed the government to a 15-year closure programme aimed in particular at the old Victorian institutions. ⁵⁷ Although by 1976 the number of large, 1000-bedded, institutions had fallen, this had been more than compensated for by an increase in the number of 500-bedded ones, and by the late 1970s there were still 50,000+ persons in long-stay institutions. Scotland’s attachment to the long-term hospital was even stronger (Long, 2017; Stalker and Hunter, 1999); the rate of hospitalization was higher and the pace of de-institutionalization slower (Baker and Urquhart, 1987). Not until the late 1980s did efforts to move patients out of hospital get under way in earnest. The need for the long-term hospital was simply taken as a given, as Crossman had made clear in his ministerial statement when introducing the Ely Report: ‘For the foreseeable future many thousands of them [i.e. the “mentally subnormal”] will need resident hospital care for very long periods; and this means that there is no prospect of doing without this class of hospital …’. ⁵⁸ The failure of practice to match policy aspirations was at heart a failure of perception. Change finally came about not as the result of further revelations of institutional abuse, but rather from a radical shift in the way we came to think about people with learning disabilities and their rightful place in society. This change was not officially recognized until the publication of the 2001 White Paper Valuing People (DOH, 2001) and, in Scotland, The Same As You (Scottish Executive, 2000). Baldovan/Strathmartine closed in 2003.