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Ashworth revisited

BMJ 1999; 318 doi: (Published 23 January 1999) Cite this as: BMJ 1999;318:271
  1. John Gunn, professor of forensic psychiatry
  1. London

    Almost two years ago, on 10February 1997,the then secretary of state for health, Mr Stephen Dorrell, announced yet another inquiry into Ashworth Special Hospital. The previous public inquiry, chaired by Sir Louis Blom-Cooper, was published in August 1992.A serious set of allegations prompted the new inquiry, including possible paedophilia involving a child visitor to the personality disorder unit.

    I have been closely interested in the special hospitals for over two decades, and my wife spent five years working as medical director for the Special Hospitals Service Authority (SHSA).

    • When dealing with the professionals the report resembles a witch hunt

    Was the time, effort, and money worth it? The answer has to be no. There are many good things in this report (p 206,p 211). Part 1sets out an account of the background to the inquiry, and part 2details the development of Lawrence Ward at Ashworth Hospital, where the alleged criminal activities took place. Part 6is a lengthy digression on the nature of personality disorder.

    Why then is it a disappointment? Numerous practical problems are listed, but few practical investigations were undertaken. Some of the recommendations cannot be argued with, but the overall conclusion that the whole of a major high security hospital should be shut because of serious irregularities on one unit is not really credible. Mr Dobson has already indicated that he does not accept this recommendation.

    A preoccupation with the concept of personality disorder has misled the whole inquiry. No such inquiry could answer major academic questions about the nature or validity of personality disorder. Furthermore, the committee is muddled. Sometimes it believes that patients with this diagnosis should be dispersed, sometimes it believes they should be concentrated. It has not grasped the evidence of more than one witness: the suitability of a patient for a unit is to do with much more than diagnosis—namely, intelligence, social skills, impulsivity, aggressivity, and age.

    It is extraordinary that the committee did not undertake some simple research. It commissioned a doctor to see how one part of the personality disorder unit was functioning. Why did it not consider evaluating the variety of clinical problems of patients who had been placed in that unit, the needs of those patients, and the varieties of diagnosis, which would have extended way beyond “severe personality disorder”?

    An outside analysis of the material it presents leads to the conclusion that, firstly, the previous Blom-Cooper report was mistaken; secondly, Ashworth Hospital has internal management problems; and, thirdly, there was (is) a paucity of skilled staff. None of these difficulties is tackled head on in the recommendations. Worse, no attempt has been made by the committee to understand the context in which high security services operate in Britain. There are severe and chronic staffing difficulties, a slow but steady changeover from a prison- type culture to a hospital culture, and a largely hostile press.

    Perhaps the worst aspect of the report is its unfairness. The committee set out the issues for an inquisitorial inquiry of this kind at the beginning, but it did not examine the serious judicial limitations of this type of inquiry. Witnesses did not know what they were to be accused of. The committee debated whether it should allow people to see what they were going to be accused of before the report was published. It decided against this, and, as a result, at least one person I know well has been severely criticised, inaccurately in part, and for strange sins such as implementing the Blom-Cooper report. Criticism by a public inquiry of this kind is powerful and damaging. Reputations are besmirched and careers may be ruined. Justice demands that anyone who is attacked in such a way should be given the opportunity to defend himself or herself properly.

    Sadly, when dealing with the professionals the report resembles a witch hunt. Undoubtedly mistakes were made and it is right to highlight them, but no attempt is made to mitigate those mistakes. The panelists would no doubt point to the fact that they say “the system” is the real villain of the piece. Unfortunately, they do not explain what that system might be. They select only some individuals for naming and shaming, and yet it is not clear on what grounds these selections are made. They note, in passing, in the report that this same iniquitous authority that could not run a personality disorder unit at Ashworth to save its life (my words not theirs) did in fact run perfectly satisfactory personality disorder units in the other two special hospitals for which it was responsible.

    I drew quite different conclusions from the evidence set out than did the committee. To paraphrase the prime minister's soundbite: the problem is recruitment, recruitment, and recruitment. Yet the greatest legacy of this report will be an even more difficult recruitment problem for forensic psychiatry.

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