Ashworth Special Hospital

HL Deb 12 January 1999 vol 596 cc97-112

4.1 p.m.

Baroness Hayman

My Lords, with the permission of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health.

"Madam Speaker, I wish to make a Statement on the report of the public inquiry into the Ashworth Special Hospital conducted by his Honour Judge Peter Fallon QC.

"This inquiry was established by my predecessor in February 1997 to investigate allegations by Mr. Steven Daggett, a former patient of Ashworth Special Hospital, that there was misuse of drugs, financial irregularities, possible child molesting and the circulation of pornographic material in the personality disorder unit at the hospital. I should also pay tribute to the work of my honourable friend the Member for Halifax who brought this matter to the attention of the Government. She subsequently received threatening phone calls which she believes came from people whose trade in pornographic videos was interrupted by her intervention.

"It is difficult in this short Statement to do justice to the inquiry report which is 473 pages long. The executive summary alone covers 44 pages. So I will highlight the major points in the report.

"The inquiry sat for a total of 66 days, taking evidence from a wide range of witnesses involved in Ashworth Hospital, both past and present. The report presents a shameful picture. The general allegations made by Mr. Daggett were largely true. There were serious financial irregularities, drug abuse, pornography and a poor quality of patient care.

"Mr. Daggett's main allegations referred to Lawrence Ward in the personality disorder unit. A ward within a personality disorder unit, set inside a special hospital, had been repeatedly visited by a seven year-old girl who was allowed unsupervised contact with patients guilty of sex offences against children. Her father brought her into the personality disorder unit and, without let or hindrance, gave her unsupervised access to one patient who had a history of molesting young girls, including indecent assault and attempted rape. She also visited another patient who was locked up in Ashworth because he had kidnapped, tortured, sexually assaulted, mutilated and eventually murdered a 13 year-old boy. I am glad to say that the inquiry report concludes that there was no proof that the girl was abused, but that she was being "groomed" for later abuse.

"The inquiry asked how a young girl could have been allowed to visit such men. It was told that Lawrence Ward was special and that there were not many incidents. All the patients were allowed to roam around much of the hospital unaccompanied. For a time routine searching did not take place. The inquiry was told that the ward espoused the philosophy of a "democratic community".

"I should emphasise that the present inhabitants of this so-called "democratic community" have between them committed murders, manslaughters, indecent assaults, indecent assaults on children, assaults or woundings with intent and a host of other offences.

"The inquiry also concludes that a small group of patients, led by the child murderer, was intimidating patients and staff and had gained a grip on the ward. It also concludes that there was a drugs problem on Lawrence Ward and that it was endemic throughout the hospital, but that there was no direct evidence that nursing staff were involved.

"The financial irregularities arose from a shop on Lawrence Ward, from the sale of pornographic materials, including videos, and from people conducting credit card businesses. From the report, Lawrence Ward appears a veritable outpost of the enterprise culture. The father who brought his daughter into Ashworth Hospital also supplied pornographic videos, which it seems he was allowed to deliver by car to the ward without being properly searched. There was a shop on Lawrence Ward which was supposed to sell confectionery and soft drinks. Its turnover, starting at £50 per month, soared to £14,000 between January and October 1996. The child murderer also ran an unofficial shop from his side ward.

"Unbeknown to senior managers, several patients, including Mr. Daggett, had been allowed credit cards. Eventually, when managers decided to end this arrangement, patients were forced to cut up their cards. But they retained the numbers so that they could renew them or continue to use them in phone transactions. Security was so slack that Mr. Daggett managed to change his name by deed poll, acquire a new passport and driving licence and use a credit card to take out a large sum of money prior to absconding.

"The inquiry found that security was so lax that neither patients, staff, nor visitors were properly searched. They confirm Mr. Daggett's claim that on Lawrence Ward the patients' rooms were not properly searched. This was illustrated when a full-scale search in January 1997 revealed a stock of children's underwear in the room of the man who had molested girls and male pornography in the room of the child murderer. Both of them had VCRs used for copying videos. A previous search of the bootroom on the ward had revealed 41 pornographic videos.

"The inquiry set out to find how this deplorable situation had come about and how it had been allowed to persist. What it found out is a shameful story of confusion, indecision, mismanagement and incompetence. Some of the professionals and managers failed to show a glimmer of common sense, let alone live up to the standards of their professions. The whole thing was a mess from top to bottom.

"In the past Ashworth had operated a harsh and repressive regime. Following scandals in the early 1990s the Blom-Cooper inquiry in 1992 recommended a more liberal approach. The Fallon inquiry concludes that these recommendations were implemented without proper consideration of their differing impact on different patient groups in the hospital. As a result, the patients with personality disorders enjoyed most personal freedom and reduced security. The report says that it was quite predictable that these failures could be abused by some of the patients.

"What is clear is that, because of the failure of top management to lay down and enforce clear rules for both patients and staff, security became less and less important. As a result, more and more problems arose but nobody attended to them. As the report says, "all too often the core principles of security were absent".

"Nobody was seen to be in charge of the personality disorder unit. That was because nobody—with the possible exception of the patients—was really in charge. The senior management was out of touch. Psychiatrists seem to have been incapable of carrying out their proper professional functions. Management decisions, if known, were frequently ignored by both staff and patients. The internal monitoring system did not work. The members of the board do not seem to have known what was going on. The external monitoring system did not work. Events within Ashworth were not reported to senior officials of the NHS or the Department of Health. Reports into serious incidents were suppressed.

"The Fallon report concludes that the whole system was at fault. I am sure that that is right. But the report goes on to criticise the individuals. I am sure that is right too because so many people at Ashworth failed to do properly the jobs they were paid to do.

"The report criticises a number of people by name. Ashworth Hospital Authority has already taken disciplinary action against some people and some others have left Ashworth. In the case of those criticised in the report who are still employed by the NHS whether at Ashworth or elsewhere, I expect their current employers to initiate appropriate disciplinary proceedings in the light of this report. In at least one case this report will be drawn to the attention of the General Medical Council and other professional regulatory bodies. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting has already commenced disciplinary action in one case.

"The report recommends that Mr. Paul Lever, chairman of Ashworth Hospital Authority, should step down in accordance with the principles of public accountability, and he has done so. Anne Marie Nelson, former chairman of the Special Hospitals Service Authority and present chairman of the High Security Services Commissioning Board, has also resigned.

"The running of Ashworth and terrible incidents at Ashworth were the subject in the 1990s of a whole succession of inquiries and reports. In 1990 one patient was murdered on Owen Ward and another on Forster Ward. In 1992 the Director of Security carried out security audits at Ashworth, Broadmoor and Rampton. Her recommendations for greater security at Ashworth were ignored. At about the same time a task force which was implementing the Blom-Cooper report described Ashworth as over custodial. The Fallon report describes the task force's policy as a recipe for disaster.

"In 1993 an inquiry into the women's services at Ashworth (which are not part of the personality disorder unit) produced a damning report. In 1995 there was an internal investigation into a hostage-taking on Owen Ward. The report was 59 pages long with appendices covering 385 pages. Again it was a damning indictment of what went on, but staff were shown only a nine-page summary and so was the official responsible for implementing its recommendations. Neither the Owen Ward report nor the Swan report was made available to the Health Advisory Service before the publication of its review of progress post-Blom-Cooper in 1995. Also in 1995 and again in 1996 patients attacked members of staff with razors. Later that year the discovery in mail addressed to a patient of a machine for embossing share certificates led to an inquiry which revealed security breaches, scams and money-making ventures in the personality disorder unit. Reports were prepared on all these incidents but no machinery was put in place to see that changes and improvements were made, and no one was ever given that task. I am determined that this report will not suffer the same fate.

"The Fallon report makes 58 detailed recommendations. Some cover the operational procedures at Ashworth. I am giving the hospital authority four months to develop an action plan to implement the necessary changes within the hospital and I am appointing Ian Pirnie to chair the authority during this process. Mr. Pirnie presently chairs the Morcambe Bay Health Authority. I expect that he will bring to this task the leadership and management skills that he demonstrated as an admiral in the Royal Navy.

"Other recommendations cover the general role and organisation of the special hospitals and their relationship with the rest of the National Health Service. These will be the personal responsibility of Sir Alan Langlands, Chief Executive of the NHS. I have given the task of ensuring progress on the more general recommendations which apply across government to Chris Kelly, Permanent Secretary at the Department of Health. All three will report directly to me and all three will be expected to deliver.

"The inquiry team gave final clearance to its report on Wednesday of last week. The printed edition arrived this morning. It is being published this afternoon. A detailed response to all its recommendations will be published as soon as possible. In the meantime I can say that the Government broadly accept most of the recommendations and I can give an immediate response to some of those which will be of most concern. First, security. The report recommends that security should be given a higher priority; that searches of patients and staff should be introduced; that no visitors should be allowed in Ashworth without being searched; and that there should be regular searches of patients' rooms. The Government accept these recommendations. We give top priority to the safety of the public and we have already taken action.

"All aspects of security have been tightened up. New rules have been introduced. And management are making sure that they are implemented for people entering and leaving the Ashworth site, within the site and on the wards. Further investment in extra security staff is being made from 1st April this year, with an extra £1.5 million going to the special hospitals and a further £4.5 million investment in physical security measures at Ashworth. This means that fully effective searches can be made of all visitors, staff, patients, goods and vehicles, including, where appropriate, x-rays, metal detectors and sniffer dogs. I have arranged for an independent review of all aspects of security including the use of post and telephones at all three special hospitals which will report direct to Sir Alan Langlands. The Social Services Inspectorate will conduct inquiries into the social work aspects of Ashworth and subsequently the two other hospitals, and report direct to me.

"Visits by children. We have already changed the rules on child visitors and gone beyond the recommendations in the report. In September last year we put a stop to child visits to ward areas and visits by children not close relatives of the patients. No visits are allowed unless judged to be in the best interests of the child. All visits by children must be off the ward and must be supervised. Any visits by a child must be by prior arrangement. These rules apply at all three hospitals, and I wish to make clear that anyone who breaches any of these rules can expect to be summarily dismissed from his job.

"The report recommends a review of the whole system of accountability within the NHS and between the NHS, officials of the Department of Health and Ministers, particularly in relation to the special hospitals and more generally. I share some of the inquiry's concerns about the system that I have inherited from my predecessors. I have made clear to the House who is to have personal responsibility for dealing with the various aspects of this report and that they will all report direct to me. That must be just for the present.

"The health Bill which we will be introducing shortly will put in place stronger and clearer accountability arrangements for the whole of the NHS and will end the internal market which has clearly inhibited more active management by the NHS Executive and regional officers. As recommended in the Fallon report, the commission for health improvement will cover the special hospitals. In addition the board of every hospital, including each special hospital, will have for the first time a statutory duty for the standards of treatment and care that they provide; there will be clearer powers for the Secretary of State to issue directions; and new arrangements for commissioning specialised services. I am giving further consideration to the question of overall accountability in the light of this report.

"The inquiry was set up to consider the personality disorder unit, not the future of the whole hospital and its high security psychiatric services. However the inquiry team recommended the closure of Ashworth Hospital. The Government do not accept that recommendation.

"In the policy document Modernising Mental Health Services on which I reported to the House on 8th December 1998, we made clear that we wanted to see a closer integration of the high security services with the other secure services and the reconstitution of the special hospitals as NHS trusts. For the foreseeable future the three special hospitals must continue to be the main providers of high security services. There is no practical alternative in the short term. To announce that the three special hospitals had no long-term future but that they could not be replaced for a good many years would run the risk of making them even more difficult to manage than they are now. In any case I do not believe that the problem at Ashworth is the bricks and mortar. The problem is management and that is what we are determined to tackle.

"The personality disorder unit at Ashworth is not a decrepit Victorian dump. It was purpose built. Work started in 1976 and was completed in 1984. Replacing it with smaller high security units spread around the country would not guarantee better security, higher quality treatment and care or more effective management. Those would still have to be planned, organised and worked at.

"The members of the inquiry team gave a great deal of thought to how best the legal, medical and penal system should deal with people suffering from severe personality disorder. They make a number of very useful recommendations for far-reaching changes. I very much welcome these ideas which will be given careful consideration by my right honourable friend the Home Secretary and by me as we develop new and more effective ways of dealing with people suffering from severe personality disorder whether presently in prison, in hospital or the outside world. Public security will be our main priority. The Government will also make sure that the recommendations in the Fallon report are made available to the teams reviewing the Mental Health Act and mental health services.

"The result is that this may lead to change in the role of the Ashworth personality disorder unit, the scale of operations there and how they are organised. It could well mean breaking the hospital up into smaller physically segregated units. But we do not contemplate its closure. We do, however, agree with the inquiry team that a new form of reviewable detention is needed for those people with a severe personality disorder who are considered to pose a grave risk to the public. We therefore announced in our strategy document Modernising Mental Health Services in December that we would be working up proposals that will ensure that the safety of the public is the prime concern and that a new regime is established for this difficult group of people.

"Since the Fallon inquiry got under way, there have been a lot of changes at Ashworth. The process of change has not been without its problems but progress is being made. The quality of the medical staff has improved substantially as a result of new appointments; management has improved; security has been tightened. But there is still a long way to go.

"I should add that, despite the catalogue of disasters accurately outlined in the Fallon report, many of the staff at Ashworth have been trying hard to do a good job. They work in very difficult circumstances. The patients in the personality disorder unit are often highly intelligent and manipulative as well as dangerous. They have to be looked after and checked on 24 hours of every day so that the rest of us can be secure. We owe it to the staff to make a fresh start at Ashworth and to encourage the good staff and management, partly by getting rid of the bad ones. The new arrangements and the new people should deliver a better performance all round.

"A natural question which will arise in the minds of most decent people is, 'How is the little girl getting on?'. I have checked. She seems to be doing pretty well. She is living a settled life and, under a court order, her father has no contact with her. She was being exploited by the adult world. I am determined to ensure that from now on the adult world looks after her instead. I hope that all will respect her privacy.

"Finally, I should like to thank his honour Peter Fallon, and the other members of the inquiry team and their secretariat for the thorough way in which they have gone about their business and the report they have produced. They have done their job. Now it is up to us to do ours".

My Lords, that concludes the Statement.

4.22 p.m.

Earl Howe

My Lords, I thank the Minister for repeating this very full Statement which has been keenly anticipated for some considerable time. This inquiry, under the chairmanship of Judge Fallon QC, was established nearly two years ago by my right honourable friend Mr. Dorrell, then Secretary of State for Health, in the light of extremely disturbing allegations of wrongdoing at Ashworth Hospital. It was the strong wish of my right honourable friend that the inquiry should be thorough and that its findings should be published in full. Therefore, I welcome today's Statement and the accompanying substantial documents, notwithstanding their content which, to all of us, can only be a matter of profound dismay. I join the Government in paying tribute to Judge Fallon and his committee for the work that they have done, which has clearly been considerable.

The main purpose of the Fallon inquiry was to review the clinical policies and management of the personality disorder unit at Ashworth. Uppermost in everyone's minds when the inquiry started its work were the apparent woeful lapses in security and discipline at the hospital; and unfortunately those fears have been fully borne out. But leading on from that was the concern shared by many, including my right honourable friend the then Secretary of State, that the reporting chain and the associated chain of accountability between Ashworth and Department of Health Ministers had failed. That aspect of the matter has also been covered in the report and I believe that the conclusions confirm what many already realised.

However, some of the Statement is couched in terms which imply a failure by officials in the Department of Health and by Ministers. I do not believe that Ministers can be held to blame for things of which they were not aware and of which they could not have been expected to be aware. I should be grateful if the Minister will confirm my understanding that the relevant officials in the Department of Health were indeed unaware of the serious nature of the activities which were taking place.

From this side of the House, we support all the report's central recommendations relating to security, discipline and accountability. However, I have a question about the role of the commission for health improvement. It appears from the Statement that the commission will, in the case of special hospitals, concern itself not just with clinical matters but also with matters of management and reporting. Is that a correct reading of the Government's intentions? What will now be the role of the Health Advisory Service and the Mental Health Commission?

The inquiry recommends the closure of Ashworth and the Government have rejected that proposal. I agree with the Government that the difficulties experienced at Ashworth do not relate to the bricks and mortar so much as to other factors. But I believe that they relate to more than just management. One of the comments made by Sir Louis Blom-Cooper in 1992 was that special hospitals are inherently unmanageable. To the extent that that is true, it reflects more than anything the ingrained culture of those institutions which management alone will find it very difficult to change. I do not say that that is impossible, but it is an extremely demanding brief.

I understand the Government's reasons for rejecting the closure option but it must be said that that recommendation by Judge Fallon is underpinned by some extremely careful analysis. To reject such a recommendation creates a heavy degree of responsibility on the Secretary of State's shoulders, as he must be aware. It is a responsibility to ensure that the alternative measures which he has proposed deliver the results that are required. I hope that the Government are confident that the measures to be taken will properly safeguard the public; will promote patient care; and will cure the long-running and intolerable problems at Ashworth. The Opposition stand ready to support the Government in implementing those measures but it really is vital that in the months ahead, the regime at Ashworth should be characterised by effective and transparent accountability. In the meantime, will the Minister say whether staff shortages are in evidence at Ashworth and, if so, in what areas?

At the heart of all this are the wider issues identified in the Statement; namely, the relationship between high security psychiatric care and the wider NHS and the integration too with the other secure services. I do not wish to initiate a more general debate on those matters this afternoon, but I urge the Government to look for new and imaginative ways of delivering the kind of secure therapeutic regime which Judge Fallon has so carefully identified and recommended and which will also overcome the inherent tendency of the present system, in its broadest sense, to hold patients in maximum secure surroundings for longer, sometimes far longer, than need be.

I look forward to the Government's further proposals as soon as it is practicably possible to bring them forward.

4.27 p.m.

Lord Clement-Jones

My Lords, I join the noble Earl, Lord Howe, in thanking the Minister for repeating the Statement made by the Secretary of State in the other place. There is a huge amount for which to thank his honour Judge Fallon and his colleagues. There is a great deal of meat in the report which most of us have not yet had time fully to digest.

There is a sense of shock and outrage, rightly, which rings through the Secretary of State's Statement. That certainly comes home very keenly to all of us from that Statement. Ashworth's situation was obviously a catalogue of terrible failures. First, I strongly welcome the Secretary of State's immediate proposals in response to the report. Clearly, there are many other aspects of the very long report which need to be considered. In particular, those are a review of security; the involvement of the Social Security Inspectorate; the restrictions on children; better accountability provisions; and also the involvement of the commission for health improvement when it is formed.

However, we know that the Secretary of State has emphasised very strongly, particularly in relation to the closure recommendation, that the problem is essentially one of management and not one of bricks and mortar. I share some of the reservations of the noble Earl, Lord Howe, in that respect. It has had three chief executives in six years and I understand that a very able manager, Hilary Hodge, was put in by this Government as chief executive. She was forced to resign by the staff of Ashworth, and it appears to be the case that the staff were at that time, and probably still are, too powerful relative to the senior management, despite a statement about changes having taken place in the management of Ashworth. So we have grave doubts about the continuance of this institution, together with that of other special hospitals. Maybe these hospitals are unmanageable and therefore it needs to be demonstrated very quickly that the culture can be changed and the argument about the closure of Rampton, Broadmoor and Ashworth over creating smaller and more regionally-based units can be overcome.

We on these Benches are prepared to see whether these hospitals have a future. I have some sympathy with the Government's desire to see whether that culture and management can be changed, and in particular whether that can be done not only by changes of staffing and management but also by the physical changes that are being suggested. This can only be done on the basis that proper inspection and review systems are instituted. I ask the Government whether they will be ensuring that the commission for health improvement will have the necessary expertise to carry out this particular kind of inspection.

Will the Government also consider whether there are problems now in the hospital regarding under-staffing in terms of the number of psychiatric nurses available. This obviously goes hand in hand with the question of nurses' pay elsewhere in the National Health Service. We need to ensure that only appropriate people are contained in these institutions, particularly in the light of the Secretary of State's determination to improve security in Ashworth. Will the Government be reviewing these aspects and ensuring that only those patients who are appropriate for this institution are contained within it?

Will they also ensure that the institutionalisation of staff does not occur again? Do the existing staff need to be dispersed? At the very least staff need to rotate through other institutions in the course of their careers. To this end, will the Government ensure that the Prison Health Service is merged with the NHS to ensure that this type of rotation can take place? In that context I ask the Minister: is she able to say when she thinks that the prison service health review will be published? There also need to be continuing education programmes for the staff so that they may be brought into much closer contact with the remainder of the NHS. Clearly the creation of these hospitals as special trusts may be a step in that direction.

In summary, we from these Benches welcome the steps already announced. We have an open mind about the future, but the Government need to be confident that they can make the necessary changes. What is needed is not only a vigorous response, as set out in the Statement, but also vigorous implementation. I ask the Minister whether she will keep an open mind and contemplate the closure of Ashworth if results cannot be achieved in short order. I am sure that the Minister will agree that this is an area in which all parties need to work together on a non-partisan basis, to make absolutely certain that these dreadful events never again take place.

Baroness Hayman

My Lords, I am grateful to both noble Lords who have spoken from the Front Benches for their considered responses to the Statement. As the noble Lord, Lord Clement-Jones, rightly said, it was a shocking document. It is a situation that I think we all find devastating regarding the events that have been described.

If I may deal with some of the points that have been raised, I think we are right to put emphasis on the need to make sure that special hospitals will continue to have the main responsibility for providing high security services. However, we recognise that the cultural difficulties are perhaps the most difficult, indeed the most important to address, to provide absolute confidence that these sorts of events will not be allowed to recur.

Perhaps the most important thing in all this is to end the isolation of these institutions. These sorts of events take place when institutions of whatever size are isolated from the rest of the therapeutic health and even prison communities, with which they are meant to interface. I believe that our proposals for ending special health authority status, for making these hospitals into trusts and for ensuring that they have relationships, professional and otherwise, with other NHS bodies will be crucial in all this.

In terms of issues like the rotation of staff, to which the noble Lord, Lord Clement-Jones, referred, these will be made possible by relationships of that type in the future. Likewise, I think that the recruitment of staff, which is always a problem, will be eased by its being part of a wider professional network. There is some evidence that at Rampton, which is beginning to develop these relationships with neighbouring psychiatric and health institutions, they are actually having more success in recruiting staff.

Referring to the matter of staff shortages, the NHS executive and the three special hospitals are undertaking a comprehensive review of workforce issues, and will consider any of the issues raised in the Fallon Report about staffing. There have been, and still are, difficulties about recruiting sufficient staff of the right calibre but, as I say, we expect that position to improve as a consequence of the partnership arrangements between high security services and the providers of other secure services.

The noble Earl, Lord Howe, asked about the transparency of accountability relationships. I set out in the Statement how we are taking action to ensure that those will be effective and transparent. There are very clear personal responsibilities which are outlined in the Statement for all to see. I agree that it does place an awesome responsibility on the shoulders of the Secretary of State. That is correct, but I think that in taking the steps he has to ensure that until we have the new arrangements in place those people who have been named in the Statement will be responsible to him for the changes which have to be implemented, he is very clearly taking that responsibility on board.

With regard to the issue of whether or not we should contemplate the closure of Ashworth at some time in the future, which was raised by the noble Lord, Lord Clement-Jones, I think one has to look at the reasons behind the recommendations for closure. It was not a matter of closure for its own sake but it was because of the problems of size, isolation and security. We need to take action on all those fronts.

The noble Lord asked how we were going to ensure that only appropriate patients were admitted to Ashworth. I believe this is a major issue because it contributes to the size and therefore the difficulty of management and the creation of a possible "isolation culture" within the institution. We have in hand action to try to deal with this. There are, for example, roughly one-third of patients at Ashworth who do not need high security provision: they need medium security provision. We are taking action to ensure that such provision is available. Again, we have to look very carefully at the people with learning disabilities who are admitted to special hospitals. We also have to look at the position of women in special hospitals. There is evidence, again, that if we provide dedicated services, sometimes they will need security but it may be medium security and not high security for a small number of patients. We hope it may be possible in some way to deal with the problem by breaking up the larger units into smaller ones.

So far as the commission for health improvement is concerned, I would ask noble Lords to await the publication of the Bill to see the exact powers it contains. It will be important that the quality and management of the regime, the delivery of clinical governance, is inspected. Also important is the delivery of the national service framework for mental health in which high security services will have a part to play.

That is not a simple task. It is a complex matter which will involve a large amount of work. There are interrelationships with healthcare and with the Prison Service to which the noble Lord, Lord Clement-Jones, referred. It is important that we recognise that these are health service establishments. We have to be aware that perhaps a third of the patients within them do not have custodial sentences. I believe that the right direction is to integrate these services into the NHS.

Finally, perhaps I may confirm to the noble Earl, Lord Howe, that officials and hence Ministers at the Department of Health were unaware of the serious nature of the events. As the Statement says, events and reports were not reported to senior officials of the NHS or the Department of Health. Reports of serious incidents were suppressed. As soon as they became aware and there was evidence, there was action at the Department of Health, although some of the events have been finally explained only with the publication of this report.

4.41 p.m.

Lord Sheppard of Liverpool

My Lords, perhaps I may press the Minister to say a little more about the issue of scale. If I heard the Statement correctly, it stated that that could involve breaking up the hospital into smaller units. In order to help me understand the size, how many patients are in the personality disorder unit?

I share the dismay of your Lordships' House at this disturbing and deeply disappointing report. Among several visits to Ashworth I visited on the day that Louis Blom-Cooper arrived to start the inquiry. Part of our dismay relates to the swing between what the report describes as an over-custodial approach and what is now seen to have been, in some instances at least, a very lax approach. It is difficult to say it in this context, but during my visits I have no doubt that I saw some extremely devoted and skilful staff. I know that morale has been at rock bottom over many years. The task before management today is very great.

The point has been made that there are fine buildings with wonderful facilities. A large institution makes it possible for a wide range of facilities for long-stay inmates. Does the Minister feel able to expand on the break-up of the hospital into smaller units?

Baroness Hayman

My Lords, the detail of how that might be achieved has to be an issue for the senior management within the hospital. About a third of patients in high security hospitals have a primary diagnosis of severe personality disorder. Currently there are 97 in the personality disorder unit at Ashworth.

If we look at the potential for moving into such units patients who could be managed in medium secure units and the development of specialist programmes related to the new form of reviewable detention, those provide possibilities for reducing the numbers in the personality disorder unit. There are also difficulties of size with regard to the type of people about whom we are talking. They are often highly intelligent and highly manipulative. There are self-evident difficulties about managing this specific large group of patients.

My noble friend rightly points out that within the hospital as a whole there are groups of patients other than personality disordered ones. I believe that there is potential for scaling down the size of the operation by making sure that those who need medium secure accommodation are moved into such accommodation. Equally, I believe that services for women and those with learning disabilities give the opportunity for separate management off site.

Lord Campbell of Alloway

My Lords, will the Minister accept the suggestion of the noble Lord, Lord Clement-Jones, in his remarkable speech? Perhaps I may support his view that this is a matter which should be dealt with on an all-party basis. Does the noble Baroness accept that the essence of making the system work in the future is the inspectorate?

I speak with some experience. I spent quite a bit of my life in high security institutions. It makes no difference whether it is a prison or a hospital. Each inevitably develops its own sub-culture. It is not just a question of management. In our present system management is often totally subservient to staff but it should be impossible for a situation to arise in future about which the ministry does not know. I wholly accept that officials did not know, but they should have known. It was their job to know: it was their duty to know; and if they had known they would have acted.

The only way to achieve that aim is by snap, unauthorised inspections on the spot. I have seen it happen in prison camps; and even that did not always work, but at least such a system stands the chance of working.

Baroness Hayman

My Lords, I am grateful for the noble Lord's bipartisan approach on this issue. I agree that the quality of the inspectorate and the task that it performs is a vital component in ensuring that we do not have to consider such a report again. However, this is one strand, an important strand. I believe that the accountability arrangements are important too. No inspectorate can be present for 24 hours a day. We have to ensure that management all the way up the line is held accountable; and that the systems for both clinical governance and, I believe importantly, for the regional commissioning of high security services—at regional level they will be another check on the quality of the service delivered—are part of a framework which ensures that a culture is not allowed to develop which takes the institution out of the mainstream.

I agree with the noble Lord that the commission for health improvement and other means of inspection are tremendously important but they are one weapon, and not the only weapon, in achieving what we both believe needs to be done.

Lord Jenkin of Roding

My Lords, it fell to me nearly 20 years ago to receive the report on Rampton. The House will remember that a television programme called The Secret Hospital disclosed a horrifying state of affairs at Rampton where, as my noble friend said, there was a classic example of the staff being totally in charge and the management totally incapable of managing.

I wish to address only one question to the noble Baroness. I understand entirely why the Secretary of State is extremely reluctant at this stage to contemplate disbanding the so-called special hospitals. There has been a great deal said—and I agree with much of what has been said by the noble Lord, Lord Clement-Jones, and my noble friend—about the culture that develops in such institutions. Indeed, the noble Lord, Lord Sheppard, talked about the violent swing from the reaction against over repression to what one can now see was a disastrous policy of laissez faire, if it is fair to so describe it. Those situations can only happen where there is this pattern of isolation.

I have listened with interest and enthusiasm to what the noble Baroness said about what is being done to try to break down the isolation. I believe that such isolation lies at the heart of why these institutions from time to time appear to go so disastrously off the rails to the huge disadvantage primarily of patients but of many others as well.

I ask that Ministers do not close their minds to the view that perhaps institutions of this size in the modern world with all its pressures are, as Judge Fallon said, inherently unmanageable. I recognise all the difficulties of trying to get communities to agree to establish separate smaller units within their own areas. One is very well aware of all the resistances that build up. Nevertheless, what has come through the discussion this afternoon, and I am sure will be in the debate following the report, is the question of how these cultures arise and flourish in the way they do. The answer is because they are isolated. They tend to be self-contained. They contain the problems that the rest of us, I fear, shuffle off onto the special hospitals. That is how these situations occur. I ask Ministers to recognise all the difficulties. In this case there are three large, fairly isolated, separate units very much of their own character containing a wide range of patients with different problems and needing different treatments. Can that ever be the right solution to this problem?

Baroness Hayman

My Lords, I have listened to the remarks of the noble Lord with great care, given his experience in this field. I am sure that he accepts and understands the reasons why we do not have alternative facilities readily available. We do not have guarantees that alternative bricks and mortar would not produce the same cultural difficulties. We have robust plans in hand to end the isolation of these units, and we can see a way of reducing size by focusing on the specific needs of specific groups and ensuring that they can be met. For those reasons we have clearly taken the view that it would not be appropriate to decide to close the hospital at this point, when we are looking at a completely new policy on personality disorder and a completely new structure and accountability for the special health services.

I am sure, however, that we would all agree, having seen this report, that we must keep a close eye on the effectiveness of the arrangements that we put in place and on whether they deliver the higher quality of care and reduce the problems that give rise to this report.

The Blom-Cooper recommendations were taken and applied across the board to all the patient groups within the hospital with very great problems caused by the application to the personality disorder unit where it was singularly inappropriate to relax the security. We do not want to fall into the same trap by applying the answers to the problems of the personality disorder unit—which contains a minority of the patients in the institution—across the board. I believe that we need a more focused and differentiated approach within an overall strategy of reducing isolation, ensuring that we have high levels of security, inspection and accountability.