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Proper Communication
321 at breakfast. After this the children go to of the morning. The parents are activities their routine at home for dinner, and after afternoon activities are with the children for tea and the evening. Duties and general rotas are arranged so that the greatest number of houseparents are available in the evenings and at weekends. At no time, except for illness and short periods of annual leave, are all the house-parents away at the same time. Our staff now consists of:
morning and
The senior staff, one of whom is a member of each family group, besides carrying out nursing and supervisory duties and administrative responsibilities, are available during the day to look after children who are temporarily too disturbed for management within the group. Any child not fitting into his group activity thus has an interested, concerned, and knowledgeable adult to help him during his crisis. Despite the splitting up of the day, the psychiatrist is able to remain responsible for all aspects of treatment, medical care, occupational work, milieu management and systematic recording. Physical health and organic disease are regarded as of the highest importance, and physical examinations by specialists are arranged where necessary, but if the patient visits other hospitals for investigation he is always escorted by a familiar adult. Physical training and organised games under a qualified remedial gymnast are an essential part of treatment, and sometimes give the children their first opportunity to play together. RESULTS
The work at the unit has not the advantage of a generally " term psychosis ". In these children it is often to indicate precisely ill impossible very the amount of brain damage or maldevelopment, or the severity of psychosis or maladjustment. From the practical point of view all the children seem to be grossly deficient in their capacity to make appropriate human relationships, and the experiment has been directed towards countering this defect in every possible way. Our patients had various types of severe temperamental and emotional disturbance. Cases of primary and secondary autism, and brain damage resulting from physical trauma and severe infection, have been treated and observed. Some severely subnormal children with emotional disturbances have also been patients. Of 24 patients discharged since 1959, 13 are considered to have
accepted definition of the
improved (see table). Work, with these highly disturbed children, especially DIAGNOSIS AND PROGRESS OF
24
DISCHARGED PATIENTS
The categories used were chosen in view of the underlying different syndromes that were being treated. "Mixed" was intended to include a combination of generally disturbed conduct, accompanied by some symptoms of a psychotic nature, but not an overall appearance of psychosis. "Dull" was meant to include the area of intellectual ability between
subnormality and average intelligence.
residential or occupational, puts great strain on staff. Obsessional activities, noisiness, over-activity, overt sexuality, soiling and smearing, regurgitating food are all to be expected with some frequency. An apparent lack of interest in and indifference to adults also make acceptance of the children difficult. Consequently personal stability, outgoing capacity, and experience, not only of children, but also of life, are needed for this work. This has led us to prefer middle-aged people, especially those who have had children of their own. Though professional training in psychiatric nursing, or experience in the residential care of children, is of value in the management of disturbed children, personal maturity and a strong desire for the work often outweighs lack of professional training or directly relevant experience. During the early testing period mature untrained staff were nearly always able to accept guidance, provide support, affection, tolerance, and objectivity, so long as responsibility was shared with them. I wish to thank Dr. Ritchie Russell for providing a grant and for his encouragement. I also wish to thank Mr. R. Farnworth, my research assistant, for making many arduous inquiries when files on the patients were inadequate, and the nursing, child-care, and occupational staffs for the generous way they have responded to the demands of the situation and children.
to
the emotional demands of the
Medicine and the Law Proper Communication lump of coal had fallen on his finger and crushed it, a young man, aged 21, went to a severely cottage hospital. AFTER
a
There was no resident medical officer there; but a nurse telephoned the duty doctor, who told her to send the patient to Battle Hospital for treatment. The patient was accompanied by a friend who had a car. After the nurse had given the patient first-aid, he was instructed to go to Battle Hospital. Either because it was not clearly explained to him, or because he was suffering from shock and did not understand, he did not go to Battle Hospital but left the cottage hospital by himself. Later
he
saw
his
own
doctor to whom it
was
clear that the wound had
not been to what took
surgically cleansed. The doctor made no inquiries as place at the hospital but simply re-dressed the wound. Some two and a half weeks later the patient died of toxaemia due to tetanus infection which had entered the wound at the time of the accident. No anti-tetanus precautions were taken at the cottage hospital or by the patient’s own doctor. The patient’s father, as administrator of his son’s estate, claimed damages against the hospital management committee, as the authority responsible for the cottage hospital, and against the patient’s own doctor, alleging negligence. Mr. Justice SACHS said that under the National Health Service a patient might well be transferred from one person or place to another. A patient became a unit in a conveyor belt. Such a system might have considerable advantages for a patient. It might also have considerable disadvantages, as in the present case, when there was a lack of proper communication. Proper communication meant that which was reasonably necessary for safeguarding a patient’s interests. The communication could be made to the next person along the line, by a written message, by telephoning, or, in the case of a suitable patient, directly to him. The responsibility for ensuring that a proper system of communication existed rested on the hospital authorities and not on individual nurses. It was well known that in cases such as the present, anti-tetanus precautions had to be taken, and failure to do so
could
cause
death. It
was
for the cottage
hospital
to
322 the anti-tetanus injections or, if not, to take steps to that there was proper communication and that the patient got the proper treatment. The patient should have been given a document to take to Battle Hospital saying what had been done and what should be done, with particular reference to anti-tetanus precautions. The importance of going to the hospital, and the danger of not going, should have been emphasised to the patient. His Lordship would have come to the same conclusion-that the hospital was negligent-even if the patient had realised that he had to go to Battle Hospital, but was not told of the importance of going or the danger of not going. The patient’s doctor had probably assumed that the hospital had done all that was necessary, but he should have made inquiries from the hospital or the patient. Even if the doctor had considered giving an anti-tetanus injection and decided that it was not necessary, he would have been neglecting elementary precautions and therefore he, too, was negligent. The father was awarded E500 damages.
give
ensure
COLES
C.
treatment had to a decree.,
READING AND DISTRICT MANAGEMENT COMMITTEE AND ANOTHER.
-Queen’s Bench Division: Sachs,,. Jan. 30, 1963. Counsel and solicitors: Kenneth Jones, Q.c. (Blandy & Blandy, Reading); R. W. Talbot (Arthur F. Clark & Son, Reading); N. Broderick, Q.c., and John Spokes (Le Brasseur and Oakley for Richard Seymour & Co., Reading). C. J. ELLIS Barrister-at-Law.
Our Legal Correspondent writes: What exactly did the judge mean by saying that the responsibility for ensuring that a proper system of communication existed rests on the hospital authorities and not on individual nurses ? Presumably, the authorities are to lay down some guiding principles. In the present case, however, the failure lay in sending the patient to another hospital without sufficiently emphasising the importance of his going there. From this the following points arise: 1. In some cases the patient’s condition will be such that the obvious course is to send him by hospital transport. 2. If the patient is fit enough to go to another hospital either by himself or (as in this case) in a friend’s car, the hospital must consider the consequences if the patient does not go there or delays going. He needs to understand the importance of his attending the hospital to which he is referred. 3. If there is any risk of death if the patient fails to go to the other hospital, it may be better to send him by hospital transport, even though he is fit enough to go by himself or with a friend.
Continuous Care and Treatment A husband petitioned for divorce in March, 1962, on the ground that his wife was incurably of unsound mind and had been continuously under care and treatment for at least five years immediately preceding the presentation of the petition. The marriage took place in 1950. In June, 1953, the only child of the marriage was born. During her pregnancy, if not before, the wife showed signs of mental instability, and from the child’s birth until January, 1957, she was in and out of hospital. On Jan. 26, 1957, she was admitted to a hospital as a voluntary patient under the Mental Treatment Act, 1930. She had been there ever since, save for temporary absences. From Nov. 4, 1960, until Jan. 1, 1961, she had lived with her stepmother, with the approval of the hospital authorities, who had entrusted the stepmother with medicines for the wife, and instructed her how to administer them. There was another similar absence from Aug. 5, 1961, to Sept. 3, 1961. The Divorce (Insanity and Desertion) Act, 1958 provides that, in determining whether any period of care and treatment has been continuous, the court shall disregard any interruption of 28 days or less. The wife’s absence from hospital, however, exceeded 28 days on each of these two occasions. At the hearing of the suit, it was contended on behalf of the wife that the continuity of the care and
been
interrupted
so as to
disentitle the husband
Mr. Justice WRANGHAM said that, at the time of the wife’s absences from hospital, the relevant provisions of the Mental Health Act, 1959, were in force. The wife had ceased to be a voluntary patient under the Mental Treatment Act, 1930, and had become an informal patient under the 1959 Act. She was as free to leave hospital, either temporarily or permanently, as any patient in a general hospital for a physical ailment. The question was whether during her temporary absences from hospital she was receiving treatment for mental illness as a resident in that hospital. In his Lordship’s judgment she was. Residence could not be said to be interrupted by absence which was not, and was not expected to be, any. thing more than temporary. It was clear that the legisla. ture contemplated that residence might continue, even though broken by temporary absence, from the provision made by the 1958 Act that any interruption for 28 days or less should be disregarded. Although the wife’s absences lasted for more than 28 days, they were not interruptions of the period of care and treatment. They were part of the treatment. The statute did not require that every. part of a patient’s treatment should be carried out in hospital. The word " interruption ’contemplated a refusal by the patient to continue to reside in hospital and to accept the treatment given, though it was not necessarily limited to such cases. It followed that the wife had been continuously under care and treatment for the requisite period. The superintendent of the hospital had expressed the opinion, which his lordship accepted, that the wife was incurably of unsound mind. The husband was therefore entitled to a decree nisi of divorce. Dunn v. Dunn (by her guardian)-Probate, Divorce and Admiralty Division: Wrangham, J. Dec. 6, 1962. Counsel and solicitors: K. C. L. Smithies (R. V. Stokes & Co., Portsmouth); T. G. Field-Fisher (official
Solicitor).
D. R. ELLISON Barrister-at-Law.
Public Health Deaths in 1961 THE Registrar General has reported the final figures and detailed analyses of deaths in 1961 in England and Wales by cause, age, sex, area of residence, and time of year, together with statistics of the notifications of infectious diseases, infant mortality, and stillbirths during the year, and the first annual analysis of causes of stillbirth.l Number of Deaths There were 551,752 deaths in 1961, an increase of 25,484 over the previous year. The crude death-rate was 12’0 per 1000 population-the highest since 1951. The excessin mortality for 1961 over 1960 was mainly due to an increase in respiratory illness, for which deaths rose from 57,000 to 73,000, at Death The death-rates in 1961 for specific age-groups were generally close to the average for the five years 1956-60, except at ages 65 and over, where the rates were a little higher. To some extent this is to be expected since the average age within this group is rising as a consequence of improvementiD
Age
longevity. Causes of Death Deaths from cancer, coronary disease, vascular lesions affecting the central nervous system, bronchitis, and pneumonia accounted for over 60% of all deaths in 1961. 1. Registrar General’s Statistical Review of England and Wales for the year 1961. Part I: Medical Tables. H.M.
Stationery Office. Pp. 368. 25s.
morning and
The senior staff, one of whom is a member of each family group, besides carrying out nursing and supervisory duties and administrative responsibilities, are available during the day to look after children who are temporarily too disturbed for management within the group. Any child not fitting into his group activity thus has an interested, concerned, and knowledgeable adult to help him during his crisis. Despite the splitting up of the day, the psychiatrist is able to remain responsible for all aspects of treatment, medical care, occupational work, milieu management and systematic recording. Physical health and organic disease are regarded as of the highest importance, and physical examinations by specialists are arranged where necessary, but if the patient visits other hospitals for investigation he is always escorted by a familiar adult. Physical training and organised games under a qualified remedial gymnast are an essential part of treatment, and sometimes give the children their first opportunity to play together. RESULTS
The work at the unit has not the advantage of a generally " term psychosis ". In these children it is often to indicate precisely ill impossible very the amount of brain damage or maldevelopment, or the severity of psychosis or maladjustment. From the practical point of view all the children seem to be grossly deficient in their capacity to make appropriate human relationships, and the experiment has been directed towards countering this defect in every possible way. Our patients had various types of severe temperamental and emotional disturbance. Cases of primary and secondary autism, and brain damage resulting from physical trauma and severe infection, have been treated and observed. Some severely subnormal children with emotional disturbances have also been patients. Of 24 patients discharged since 1959, 13 are considered to have
accepted definition of the
improved (see table). Work, with these highly disturbed children, especially DIAGNOSIS AND PROGRESS OF
24
DISCHARGED PATIENTS
The categories used were chosen in view of the underlying different syndromes that were being treated. "Mixed" was intended to include a combination of generally disturbed conduct, accompanied by some symptoms of a psychotic nature, but not an overall appearance of psychosis. "Dull" was meant to include the area of intellectual ability between
subnormality and average intelligence.
residential or occupational, puts great strain on staff. Obsessional activities, noisiness, over-activity, overt sexuality, soiling and smearing, regurgitating food are all to be expected with some frequency. An apparent lack of interest in and indifference to adults also make acceptance of the children difficult. Consequently personal stability, outgoing capacity, and experience, not only of children, but also of life, are needed for this work. This has led us to prefer middle-aged people, especially those who have had children of their own. Though professional training in psychiatric nursing, or experience in the residential care of children, is of value in the management of disturbed children, personal maturity and a strong desire for the work often outweighs lack of professional training or directly relevant experience. During the early testing period mature untrained staff were nearly always able to accept guidance, provide support, affection, tolerance, and objectivity, so long as responsibility was shared with them. I wish to thank Dr. Ritchie Russell for providing a grant and for his encouragement. I also wish to thank Mr. R. Farnworth, my research assistant, for making many arduous inquiries when files on the patients were inadequate, and the nursing, child-care, and occupational staffs for the generous way they have responded to the demands of the situation and children.
to
the emotional demands of the
Medicine and the Law Proper Communication lump of coal had fallen on his finger and crushed it, a young man, aged 21, went to a severely cottage hospital. AFTER
a
There was no resident medical officer there; but a nurse telephoned the duty doctor, who told her to send the patient to Battle Hospital for treatment. The patient was accompanied by a friend who had a car. After the nurse had given the patient first-aid, he was instructed to go to Battle Hospital. Either because it was not clearly explained to him, or because he was suffering from shock and did not understand, he did not go to Battle Hospital but left the cottage hospital by himself. Later
he
saw
his
own
doctor to whom it
was
clear that the wound had
not been to what took
surgically cleansed. The doctor made no inquiries as place at the hospital but simply re-dressed the wound. Some two and a half weeks later the patient died of toxaemia due to tetanus infection which had entered the wound at the time of the accident. No anti-tetanus precautions were taken at the cottage hospital or by the patient’s own doctor. The patient’s father, as administrator of his son’s estate, claimed damages against the hospital management committee, as the authority responsible for the cottage hospital, and against the patient’s own doctor, alleging negligence. Mr. Justice SACHS said that under the National Health Service a patient might well be transferred from one person or place to another. A patient became a unit in a conveyor belt. Such a system might have considerable advantages for a patient. It might also have considerable disadvantages, as in the present case, when there was a lack of proper communication. Proper communication meant that which was reasonably necessary for safeguarding a patient’s interests. The communication could be made to the next person along the line, by a written message, by telephoning, or, in the case of a suitable patient, directly to him. The responsibility for ensuring that a proper system of communication existed rested on the hospital authorities and not on individual nurses. It was well known that in cases such as the present, anti-tetanus precautions had to be taken, and failure to do so
could
cause
death. It
was
for the cottage
hospital
to
322 the anti-tetanus injections or, if not, to take steps to that there was proper communication and that the patient got the proper treatment. The patient should have been given a document to take to Battle Hospital saying what had been done and what should be done, with particular reference to anti-tetanus precautions. The importance of going to the hospital, and the danger of not going, should have been emphasised to the patient. His Lordship would have come to the same conclusion-that the hospital was negligent-even if the patient had realised that he had to go to Battle Hospital, but was not told of the importance of going or the danger of not going. The patient’s doctor had probably assumed that the hospital had done all that was necessary, but he should have made inquiries from the hospital or the patient. Even if the doctor had considered giving an anti-tetanus injection and decided that it was not necessary, he would have been neglecting elementary precautions and therefore he, too, was negligent. The father was awarded E500 damages.
give
ensure
COLES
C.
treatment had to a decree.,
READING AND DISTRICT MANAGEMENT COMMITTEE AND ANOTHER.
-Queen’s Bench Division: Sachs,,. Jan. 30, 1963. Counsel and solicitors: Kenneth Jones, Q.c. (Blandy & Blandy, Reading); R. W. Talbot (Arthur F. Clark & Son, Reading); N. Broderick, Q.c., and John Spokes (Le Brasseur and Oakley for Richard Seymour & Co., Reading). C. J. ELLIS Barrister-at-Law.
Our Legal Correspondent writes: What exactly did the judge mean by saying that the responsibility for ensuring that a proper system of communication existed rests on the hospital authorities and not on individual nurses ? Presumably, the authorities are to lay down some guiding principles. In the present case, however, the failure lay in sending the patient to another hospital without sufficiently emphasising the importance of his going there. From this the following points arise: 1. In some cases the patient’s condition will be such that the obvious course is to send him by hospital transport. 2. If the patient is fit enough to go to another hospital either by himself or (as in this case) in a friend’s car, the hospital must consider the consequences if the patient does not go there or delays going. He needs to understand the importance of his attending the hospital to which he is referred. 3. If there is any risk of death if the patient fails to go to the other hospital, it may be better to send him by hospital transport, even though he is fit enough to go by himself or with a friend.
Continuous Care and Treatment A husband petitioned for divorce in March, 1962, on the ground that his wife was incurably of unsound mind and had been continuously under care and treatment for at least five years immediately preceding the presentation of the petition. The marriage took place in 1950. In June, 1953, the only child of the marriage was born. During her pregnancy, if not before, the wife showed signs of mental instability, and from the child’s birth until January, 1957, she was in and out of hospital. On Jan. 26, 1957, she was admitted to a hospital as a voluntary patient under the Mental Treatment Act, 1930. She had been there ever since, save for temporary absences. From Nov. 4, 1960, until Jan. 1, 1961, she had lived with her stepmother, with the approval of the hospital authorities, who had entrusted the stepmother with medicines for the wife, and instructed her how to administer them. There was another similar absence from Aug. 5, 1961, to Sept. 3, 1961. The Divorce (Insanity and Desertion) Act, 1958 provides that, in determining whether any period of care and treatment has been continuous, the court shall disregard any interruption of 28 days or less. The wife’s absence from hospital, however, exceeded 28 days on each of these two occasions. At the hearing of the suit, it was contended on behalf of the wife that the continuity of the care and
been
interrupted
so as to
disentitle the husband
Mr. Justice WRANGHAM said that, at the time of the wife’s absences from hospital, the relevant provisions of the Mental Health Act, 1959, were in force. The wife had ceased to be a voluntary patient under the Mental Treatment Act, 1930, and had become an informal patient under the 1959 Act. She was as free to leave hospital, either temporarily or permanently, as any patient in a general hospital for a physical ailment. The question was whether during her temporary absences from hospital she was receiving treatment for mental illness as a resident in that hospital. In his Lordship’s judgment she was. Residence could not be said to be interrupted by absence which was not, and was not expected to be, any. thing more than temporary. It was clear that the legisla. ture contemplated that residence might continue, even though broken by temporary absence, from the provision made by the 1958 Act that any interruption for 28 days or less should be disregarded. Although the wife’s absences lasted for more than 28 days, they were not interruptions of the period of care and treatment. They were part of the treatment. The statute did not require that every. part of a patient’s treatment should be carried out in hospital. The word " interruption ’contemplated a refusal by the patient to continue to reside in hospital and to accept the treatment given, though it was not necessarily limited to such cases. It followed that the wife had been continuously under care and treatment for the requisite period. The superintendent of the hospital had expressed the opinion, which his lordship accepted, that the wife was incurably of unsound mind. The husband was therefore entitled to a decree nisi of divorce. Dunn v. Dunn (by her guardian)-Probate, Divorce and Admiralty Division: Wrangham, J. Dec. 6, 1962. Counsel and solicitors: K. C. L. Smithies (R. V. Stokes & Co., Portsmouth); T. G. Field-Fisher (official
Solicitor).
D. R. ELLISON Barrister-at-Law.
Public Health Deaths in 1961 THE Registrar General has reported the final figures and detailed analyses of deaths in 1961 in England and Wales by cause, age, sex, area of residence, and time of year, together with statistics of the notifications of infectious diseases, infant mortality, and stillbirths during the year, and the first annual analysis of causes of stillbirth.l Number of Deaths There were 551,752 deaths in 1961, an increase of 25,484 over the previous year. The crude death-rate was 12’0 per 1000 population-the highest since 1951. The excessin mortality for 1961 over 1960 was mainly due to an increase in respiratory illness, for which deaths rose from 57,000 to 73,000, at Death The death-rates in 1961 for specific age-groups were generally close to the average for the five years 1956-60, except at ages 65 and over, where the rates were a little higher. To some extent this is to be expected since the average age within this group is rising as a consequence of improvementiD
Age
longevity. Causes of Death Deaths from cancer, coronary disease, vascular lesions affecting the central nervous system, bronchitis, and pneumonia accounted for over 60% of all deaths in 1961. 1. Registrar General’s Statistical Review of England and Wales for the year 1961. Part I: Medical Tables. H.M.
Stationery Office. Pp. 368. 25s.