HIGHBURY HOSPITAL, NOTTINGHAM (MENTAL PATIENT) (Hansard, 17 March 1959)

§ Lieut.-Colonel J. K. Cordeaux (Nottingham, Central)

It seems somewhat ironic that, so soon after such an enlightened Measure as the Mental Health Bill has been introduced, a Bill which unlocks so many doors in so many mental hospitals, which has been received with the unanimous support by all hon. Members, I should be raising on the Adjournment of the House what I feel is a rather shocking case of a mentally deficient patient who left hospital when, I suggest, he should never have been allowed to do so. The case in question is that of Mr. James A. Boulton, who used to live in my constituency and whose next-of-kin and other relatives live there now.

Mr. Boulton has been, to all intents and purposes, a mental deficient all his life. From 1928 until 1945. he was under the guardianship, first, of his mother, and, after she died, of his brother, Mr. Ernest Boulton, who drew a mental deficient's allowance for him. In 1945, Mr. Ernest Boulton, the brother, married, and he felt that he could no longer be responsible for looking after his brother. I say at once that I do not think that any criticism can be levelled at Mr. Ernest Boulton for that decision. From all my inquiries into the case, I am sure that it would be agreed by everyone that it would have been wrong for Mr. Ernest Boulton to have had his brother in the house continuously where there were young children.

From 1945 onwards, Mr. James Boulton was confined under compulsory orders in various institutions, the last of which was the Highbury Hospital in Nottingham. While he was there, during the course of last year, the Ministry of Health issued its Circular No. H.M. 58 (5), paragraph 9 of which begins as follows: It should now be possible, as recommended in paragraphs 559–560 of the Royal Commission's Report, to terminate the compulsory powers over many patients already in mental deficiency hospitals and certified institutions who can suitably be cared for without such powers". 364 As a result, Mr. James Boulton's case was reviewed, and the compulsory powers over him were terminated.

Mr. Boulton thus became an informal patient. What happened was that, on 13th October, 1958, he walked out of Highbury Hospital and did not return. It is not entirely clear what happened to him in the two or three days immediately after his departure, and I must emphasise that he is a man who could not possibly have secured a job in order to support himself, nor was he capable even of looking after himself. Apparently he lived rough, slept in derelict uninhabited houses, and he was certainly seen begging at a Nottingham bus station.

In that connection, I should like to ask my hon. Friend the Parliamentary Secretary to the Ministry of Health to say whether, when Mr. James Boulton walked out of the hospital, he took with him any money or belongings, or whether he had absolutely nothing except the clothes in which he stood. At any rate, we know that after two or three days he arrived unexpectedly at the house of one of his brothers, not the next-of-kin Mr. Ernest Boulton of whom I spoke, but Mr. A. Boulton.

Mr. A. Boulton's wife, seeing him arrive in a pitiable and destitute condition, took him in, fed him and tried to look after him. It was a difficult task, but she did her best. For instance, besides feeding him, she bought him a razor; she supervised him when he shaved, a thing which he found very difficult to do himself, for he was always cutting himself. She tried to look after his clothes and, to show the difficult task that she had, I would say that during the two months that this lasted Mrs. Boulton had to burn ten of his shirts and replace them.

Although she did her best to look after him, she was unable to do so except during the day time. She was not physically capable of looking after him for 24 hours and, moreover, there was no room in the house for him. She therefore reported the matter at once to the local health authority, and that authority agreed to take him in at nights in the reception centre. Mrs. Boulton therefore paid for his meals, for buying him such things as this razor, and she also paid his bus fare every day to and from the reception centre.

Mrs. Boulton was in an unfortunate position because Mr. James Boulton was 365 not actually living in the house and she could therefore get no assistance in any way from the National Assistance Board. Needless to say, when the local health authority was informed about this, it immediately took steps. It got in touch immediately with the Highbury Hospital from which Mr. Boulton had walked out, and a very dusty answer the authority got from that hospital. It said that it was considered that Mr. Boulton had—and I quote— discharged himself against medical advice. It said that his bed had been filled, and apparently that was the end of it. In fact, the hospital was not prepared to take him back.

The local health authority then tried several mental hospitals in the district, but none of them could take hint in. The authority then took the following action. On 22nd October the mental health officer of the local health authority informed the regional hospital board of what had happened, and a week later, on 29th October, the local health authority sent an official letter to the regional hospital board drawing attention to the need for accommodation for Mr. Boulton. Five days later, on 11th November, the regional hospital board sent a formal reply.

A week later, on 10th November, a further letter was sent from the local health authority to the regional hospital board in which these words were used: It is imperative that a bed be provided. Two days later a reply from the regional hospital board said it was regretted that there was no vacancy. The following day the local health authority sent a further letter to the regional hospital board asking for immediate admission for Mr. Boulton.

Six days later, on 19th November, the regional hospital board replied that it regretted that it was unable to find a vacancy. The following day the local health authority wrote another official letter using the words "It is imperative." So far as I can gather, there was no reply at all from the regional hospital board for another three weeks to this further urgent request. On 12th December the local health authority sent another letter suggesting that the matter would probably be raised in Parliament. As a result of tins, after nothing had happened for two 366 months, a bed was found within 48 hours in the Royal Victoria Hospital, Mansfield.

I would ask my hon. Friend at this point whether Mr. Boulton is now in the Royal Victoria Hospital, Mansfield, once more under a compulsory order. Whether he is or whether he is not, I say definitely that from what I know of the case, although I have no medical qualifications whatever, I am absolutely convinced that the compulsory order never should have been removed from him.

I will summarise the criticisms that I make against the authorities concerned. I have three main criticisms to make against the authorities of Highbury Hospital. First, I suggest that they failed entirely to comply with paragraph 9 of Circular No. H.M. 58 (5), which reads: It should now he possible, as recommended in paras. 559–560 of the Royal Commission's report, to terminate the compulsory powers over many patients already in mental deficiency hospitals and certified institutions who can be suitably cared for without such powers. Medical superintendents (or the appropriate medical officer when the superintendent is not medical) should he asked to undertake such a review as soon as possible, taking into account the attitude of the patient's relatives and the home circumstances as well as the attitude of the patient. This may require consultation with local health authorities, who are being asked to co-operate in the provision of reports on home circumstances when necessary. Obviously that requirement was not complied with. If it had been, they would have learned that there was no possibility of Mr. James Boulton being taken care of by anybody in an adequate manner when he left.

The second criticism that I make about the hospital authorities is their failure to carry out the standard practice recommended in paragraph 16 of the circular, which reads: Although formal notifications of discharge from hospital of patients not subject to detention need not be regarded as a statutory requirement, the standard practice should be to send informal notification to the local health authority of the area in which the patient is going to live, the general practitioner who will be providing general medical service for the patient after discharge, and the patient's nearest relative…In most cases they should have been consulted beforehand about the arrangements for the patient's after-care. That requirement was obviously disregarded.

When I first raised this point with my hon. Friend it was suggested that 367 probably the reason why the hospital authorities did not inform the next-of-kin as they were supposed to do was that the next-of-kin had not been in the habit of visiting Mr. James Boulton when in hospital and it was not, therefore, really worth while telling them. That being the case, it was surely the strongest evidence that one could have that there was nobody who was likely to be able to look after Mr. Boulton if he left hospital.

It was also suggested that the reason the local health authority in Nottingham was not informed was that the hospital authorities did not know, when Mr. Boulton walked out of the hospital, where he was likely to live. Where anybody could expect him to go except to Nottingham, where the hospital was and where he had always lived before living in institutions, I do not know.

Paragraph 16 of the circular certainly says that, although there is no statutory requirement for formal notification to be given to the local health authority of the place where a patient will reside, it is standard practice, and I suggest that if ever there was a case where it was essential to adopt that standard practice it was this case.

The third criticism I wish to make about the behaviour of the hospital is that when it realised the blunder it had made it should have taken Mr. Boulton back into the hospital at once. It is quite fantastic that it should have made the reply that Mr. Boulton had discharged himself against medical advice and that the bed was filled and the hospital could not, or would not, take him back. We know that if a court order is made in the case of a mentally deficient person he has to be taken in, and a bed has to be found for him. Orders are made in exceptional cases, and I suggest that no case could be more exceptional than the one I am now raising.

That brings me to the criticism of the regional hospital board. I suggest that when the board realised what a blunder the hospital had made it should have seen that a bed was provided somewhere in the region at once, and I would say that the board could also have done so if it had wanted, because if a court order had been made it would have had to do so. The fact that a bed was eventually provided after two months, when 368 it began to get round that the matter might be raised in Parliament, suggests that the effort could have been made very much sooner.

Finally, I want to make a general criticism. It must have been obvious to anybody, let alone a doctor, that poor Mr. Boulton could not possibly have got a job in order to support himself. It must have been known quite as well to the hospital as to other people that he could not even look after himself. He was 59 years old; of the last 30 years he had spent 17 under the guardianship of relations, and for the last 13 years he had been compulsorily confined in institutions. He was described in one of the letters that I have received from the medical authorities as a low-grade imbecile. There was no suggestion of any sort that anybody would—or perhaps I should say "could"—look after him.

What on earth did the hospital authorities think would happen to that unfortunate man when he walked out? Did they think it did not matter what happened? Did not they care what happened to him? Did they just think it was not their responsibility, and that they therefore did not need to bother about it?

I suggest that the behaviour of the hospital authorities at Highbury Hospital was shockingly inefficient, and also—no doubt quite unintentionally—callous. I also think it lamentable that the regional hospital authority did nothing for a long period to rectify the deplorable results of the hospital's action, or inaction. I can only say, in conclusion, that I hope that this tragic story will produce some good result, if my hon. Friend can assure me that such a thing is never likely to happen again.

§ The Parliamentary Secretary to the Ministry of Health (Mr. Richard Thompson)

My hon. and gallant Friend the Member for Nottingham, Central (Lieut.-Col. Cordeaux) has not left me all the time that I could wish in which to reply to his case, but I will do so as quickly as I can. He made a number of references to the Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. 369 We cannot discuss this case properly without bearing in mind one of that Commission's most important recommendations. It said: We consider compulsion and detention quite unnecessary for a large number, probably the great majority, of the patients at present cared for in mental deficiency hospitals, most of whom are childlike and prepared to accept whatever arrangements are made for them. So it was that the Commission recommended that mental defectives should be admitted informally in future and compulsory powers over those already in mental deficiency hospitals should be terminated whenever a patient could remain in hospital on an informal basis.

In the light of this, my right hon. and learned Friend, with I think wide public and Parliamentary approval, accepted these recommendations. In January, 1958, he requested medical superintendents of mental deficiency hospitals to review all patients to decide whether they could remain in hospital without liability to detention or whether, in the interests of the patient and of the public, compulsory detention should continue. That, of course, is the circular to which my hon. and gallant Friend has referred. I need hardly add that potentially dangerous or violent patients would naturally continue to be under detention.

At Highbury Hospital, following this review, the medical superintendent recommended that Mr. Boulton be discharged from compulsory detention. He is aged 58, he has been under supervision or guardianship since boyhood, but he has actually been in hospital since 1945. l know that that is a long period of years but, in relation to his age, it is the smaller part of his life.

My hon. and gallant Friend suggested that Mr. Boulton perhaps could not safely be left alone with small children. That reference is probably founded on two incidents which are thought to have occurred in 1925 and 1932, but neither of them was the subject of police proceedings and I must point out that for 13 years after the second incident, if indeed it occurred at all, Mr. Boulton lived at home with his mother and brother without any suggestion being made that he was dangerous to the public. Surely it would have been wrong for the medical superintendent in 1958 to continue his compulsory detention.

370 Criticism of the medical superintendent for failure to consider the attitude of relatives and the home circumstances was made by my hon. and gallant Friend. There is a distinction here between discharging a patient and ending compulsory detention where it is unlikely that a patient will leave hospital. In this case, the medical superintendent had no reason to think that the patient would leave hospital when compulsory detention ended. In fact, he did not do so for seven months, and I must point out that there are large numbers of mentally deficient patients in the country who are no longer subject to compulsory detention but who remain in hospital on a voluntary, informal basis.

After these seven months, during which he continued to remain at the hospital voluntarily, on 13th October, suddenly and without warning, and with £2 in his pocket, Mr. Boulton left hospital with another patient who had also just been discharged from compulsory detention. There is no doubt that the departure of Mr. Boulton, who up to then had been content to remain in hospital, was clearly instigated by the second patient. I add that that second patient has lived outside in the community ever since, without any difficulty of which I am aware.

Mr. Boulton's brother, as the next-of-kin, should have been notified. I accept that. But the failure of the medical superintendent in that respect, looking back on the thing, is understandable, because the brother, perhaps for good reasons, had never shown any interest in the patient and had never visited him. Certainly it is normal in such circumstances for the medical officer of health to be notified, but in this case the medical superintendent did not know where Mr. Boulton had gone. He just walked out of the hospital without any notice at all. He could have gone somewhere in the county. He might have gone to the City of Nottingham itself, or to some other administrative area.

Nevertheless, I am bound to say that it would have been advisable to notify the medical officer of health of the City of Nottingham, because, as my hon. and gallant Friend has pointed out, Nottingham was Mr. Boulton's only known address before his admission some 13 years earlier. I assure my hon. and gallant Friend that that procedure will be closely followed in future.

371 To start with, Mr. Boulton spent his nights at a reception centre run by the Nottingham Council and had meals with his sister-in-law. For the reasons which my hon. and gallant Friend gave, that was clearly unsatisfactory. The council requested the regional board to re-admit him, and that is where the difficulty arose. The vacancy at Highbury Hospital had since been filled and it was impossible to admit even one more patient. The reason was that the appropriate male accommodation there was authorised for 28 beds and there were already 40 male beds in use. With that degree of overcrowding it was not possible to re-admit him to Highbury. Elsewhere in the region, pressure on that kind of accommodation was also very great.

So it was that from 27th November Mr. Boulton stayed at the reception centre day and night. There was eventually a vacancy created at Victoria Hospital, Mansfield, on 15th December. Mr. Boulton was admitted there a few days later under compulsory powers and is now a compulsory patient.

The delay from October to the middle of December was not due to unwillingness or to the slackness of the regional board in the admission of the patient. It was a question of priority between him and other urgent cases. When a bed was found, it was only by utilising a bed normally used for short-term admissions, and that was possible only when one of the short-term admissions came to an end. The possibility of Parliamentary reference to this case did not affect the admission, although the two happened to coincide rather closely.

Subsequent events have shown that Mr. Boulton cannot look after himself outside, or be relied upon to stay in a 372 hospital voluntarily. He is not a violent man, but I would say that he was incapable of coping with life outside. His departure could not reasonably have been foreseen by the medical superintendent when it was recommended that he should become an informal patient.

If compulsory detention were continued in every case where the slightest risk existed of a patient leaving hospital against medical advice, we should never make any progress in the direction we want to go and which was indicated by the Royal Commission. Clearly no risks can be taken where a patient is believed to be dangerous, but there are balances in other cases which have to be weighed in favour of the liberty of the individual and the ending of compulsory detention.

This occurrence, unfortunate as it undoubtedly was, gives no ground for questioning the wisdom of the arrangements for enabling mental defectives to be in hospital as informal patients. These arrangements are, in general, working well, and as far as I can trace my Department has not had brought to its notice, in the 14 months since they were introduced, any case comparable with that which has been the subject of the debate. I should not want it to be thought that any general abuse was taking place. I have every reason to believe that this is an isolated case.

I hope that my hon. and gallant Friend will accept the assurance which I have given that the recommendation contained in the circular as to the precise procedure to be followed when one of these cases arises will be followed.