AGY-6764 | Royal Commission into the former Chelmsford Private Hospital and Mental Health Services in New South Wales [known as Chelmsford Royal Commission]

Full description

Background

During the years 1962 to 1979 the private psychiatric hospital Chelmsford Private Hospital in North Western Sydney was treating patients with Deep Sleep Therapy (DST), also known as continuous narcosis or deep sedation therapy, under the direction of Dr Harry Bailey. It was during this time that a combination of DST and electroconvulsive therapy (ECT) was used for a wide range of psychiatric and non-psychiatric illness.

DST was first practised as a therapy for the mentally ill in Zurich in the 1920s. It was used as the preferred therapy there until 1953 and was gradually phased out in the 1960s and was only used as a last resort treatment. (1) It was during the Second World War that DST was widely used as a treatment for acute battle neuroses. After the war it was not as popular though it was used with ECT for severe depression with agitation. (2)

Dr Bailey’s theory behind DST was that if you could shut down the brain to such a level of sedation the brain could reset itself relieving the patient from a wide range of conditions that included anxiety, depression, and schizophrenia, as well as obesity and addiction. The procedure was to maintain a patient “(for a period of at least several days) in a comatose or semi-comatose state with sedative and other psychotic drugs.” The outcome was that at least twenty-four patients died and many others suffered permanent physical and psychological damage. (3)

Prior to the Royal Commission being established there were coroners’ inquests and several independent court cases brought against Dr Bailey and a number of doctors that were working at Chelmsford Private Hospital. After a number of expose television broadcasts, editorials and articles together with public outcry from the Chelmsford Victims Action Group and others for an inquiry the government reviewed its earlier decisions and established a Royal Commission. (4)

Establishment of the Commission

On 14 September 1988 the Governor issued a Commission to The Honourable Mr Acting Justice J.P. Slattery as a Royal Commission, ‘to inquire into the following matters in connection with public and private mental health in New South Wales.

1. (a) The administration of, and the provision of treatment (including the provision of nursing or other care) to patients in –

(i) the former Chelmsford Private Hospital;

(ii) any other Hospital in which the procedure known as “Narcosis Therapy” or “Deep Sleep Therapy” were used to a significant degree in the treatment of persons who were patients of the Hospital, insofar as that administration and the treatment were connected with the use of those procedures, whether as part of them or otherwise.

(b) Whether there was any failure (deliberate or otherwise) on the part of any medical practitioner to report accurately to the appropriate authorities the cause or causes of death of a person dying in the course of or soon after treatment at the Hospital, as referred to in sub-paragraph (a), where that medical practitioner became responsible, in the circumstances of the case, for reporting the cause or causes of such death.

(c) Whether there was any failure by the State Government, any instrumentality of it (including the Police Force), or any officer or employee of the State Government or any such instrumentality, to take appropriate and diligent action in connection with the investigation of, or the institution of legal or other proceedings in relation to –

(i) such administration or treatment, as referred to in sub-paragraph (a), or

(ii) the conduct of any medical practitioner in relation to accurately reporting the cause or causes of death to the appropriate authorities, as referred to in sub-paragraph (b).

(d) the psychometric testing conducted by Evan Davies on patients at Chelmsford Private Hospital before or after treatment of such patients by procedures known as “Narcosis Therapy” or “Deep Sleep Therapy” and the contribution of such testing to the establishment maintenance and justification of the said treatment”. (5)

2. Whether there are any improvements that should be made in the regulation and monitoring of the standards of mental health service, whether public or private; and in particular –

(a) The regulation and monitoring of treatments (including the administration of drugs and the performance of psychosurgery), particularly treatments of a new or experimental kind, in order to ensure their efficacy and safety. In your consideration of these matters you should include consideration of the possible role of official organs of the medical community and of the Medical Board of New South Wales, and

(b) The investigation of or taking of other action by the responsible State authorities, including the Complaints Unit of the Department of Health and Government employees, when cases of possible mistreatment are complained of or otherwise arise. (6)

Duration of the Commission

The first sitting of the Commission was held on 4 October 1988 in a court room at the Supreme Court made available by the Chief Justice of NSW. Senior counsel gave an opening address on 10, 11 and 12 October 1988. The inquiry heard evidence for over a total of two hundred and eighty-eight days and the public transcript of the hearing extended to 18,714 pages. The inquiry ranged over a period of almost 25 years for the years 1967 to 1987. Two hundred and ninety seven witnesses gave evidence which resulted in five hundred and twenty two exhibits that included lever arch folders, files and extensive series of documents. (7) The last day of the public hearings and closing address was given on 10 July 1990.

The commission covered all aspects of the use of DST and ECT at the Chelmsford Private Hospital and included “professional standards, nurses, treating doctors, referring doctors, death, death certificates, drug regimes, other hospitals, legislation, epidemiological studies, records, psychological techniques”. It also looked into the interrelated relationships with other government departments including Health, Attorney General, Police and the State Coroner. (8)

The report was originally to be completed on or before 31 August 1989 but the Letters Patent were varied on 31 August 1989 extending the Commission to 31 May 1990. (9) A further extension on 16 May 1990 was granted until 20 December 1990. (10) The report on the first term was presented to the office of the Premier on 17 December 1990 tilted Report of the Royal Commission into Deep Sleep Therapy while the report on the second term was presented on 21 December 1990. (11)

Assisting Slattery were Mr B.H.K. Donovan Q.C., Mr J.K. O’Reilly, Mr T.A. Cunningham instructing solicitor and on 14 November Mr C.J. Geraghty. (12)

Findings

The hospital records showed that there were acts of deliberate deception or fabrication to induce voluntary patients into the programme without their knowing what was involved. (13) The Royal Commission “found that informed consent was not given, patient records and death certificates were illegally altered by doctors, and that drugs routinely administered by nurses were all restricted substances which could by law only be supplied by a medical practitioner, dentist or veterinary surgeon.” (14)

“DST as practised at Chelmsford was not acceptable treatment. Communication between referring doctors and specialist left a great deal to be desired with no system of referral, no system of reporting, and no system of aftercare and supervision.” (15)

“The commissioner concluded that events at Chelmsford were deplorable, and found evidence of fraud, obstruction of justice and serious medical negligence. He condemned all the doctors involved but concluded that Bailey was central and that without him there would have been no deep sleep therapy. The New South Wales parliament banned the treatment and enacted stricter regulations governing the admission and treatment of mental health patients.” (16) The commissioner mentioned that the “Royal Commission developed into a Royal Commission of ideas. This was one reason for its length and complexity”. (17)

Electronic Recordkeeping System

The Royal Commission used a full-text retrieval software called STATUS. The electronic retrieval system was first designed in 1970 to hold legislation for the United Kingdom Atomic Energy Authority. “Lewis Pape, an academic from the Australian National University, returned from the United Kingdom with a copy of the STATUS software and interested the Attorney General's Department in its use. The Department, in consultation with the Advisory Committee, decided to use STATUS as its retrieval system, partly because of its ‘portability’ between different computers.” (18) The system worked on a four-level base structure of chapter, article, paragraph and word.

The Commission titled this database the Chelmsford Hospital Royal Commission Transcript Enquiry System. This enabled Commission staff to carry out an electronic search of the transcript. They had no need to maintain an extensive and unmanageable index. (19) The Enquiry System contained five individual databases which covered the transcript, submissions, documents, the report (not complete) and supporting documents for the second term.

Endnotes
1. Report of the Royal Commission into Deep Sleep Therapy, Vol. 3: DST and ECT, 1990, p.9.
2. ibid., p.14.
3. Position Statement 34 Deep Sleep Therapy June (2009) The Royal Australian & New Zealand College of Psychiatrists https://www.ranzcp.org/files/resources/college_statements/position_statements/ps34-pdf.aspx (accessed 1 October 2015).
4. Report of the Royal Commission into Deep Sleep Therapy, Vol. 1: Introduction, 1990, pp.7-9.
5. NSW Government Gazette, No. 124, 22 December 1989, p.11019.
6. NSW Government Gazette, No. 145, 16 September 1988, p.4831.
7. Report of the Royal Commission into Deep Sleep Therapy, Vol. 1: Introduction, 1990, pp.13-15.
8. Loc. cit.
9. NSW Government Gazette, No. 92, 1 September 1989, p.6363.
10. NSW Government Gazette, No. 65, 18 May 1990, p.3895.
11. Final Report of the Royal Commission into Deep Sleep Therapy, Vol.1 – 12 Term 1, 17 December 1990 and Report of the Royal Commission into Deep Sleep Therapy, Vol.13 – 14B Term 2, 21 December 1990.
12. Report of the Royal Commission into Deep Sleep Therapy, Vol. 1: Introduction, 1990, p.9.
13. ibid., p.57.
14. Walton, M. 'Deep Sleep Therapy and Chelmsford Private Hospital: have we learnt anything?' Australian Psychiatry, Vol. 21 Issue 3 (2013), pp.206-212.
15. Report of the Royal Commission into Deep Sleep Therapy, Vol. 5: The Experts, 1990, p.211.
16. Stephen Garton, ‘ Bailey, Harry Richard (1922-1985)’, Australian Dictionary of Biography, National Centre of Biography, Australian National University, http://adb.anu.edu.au/biography/bailey-harry-richard-12162/text21793(accessed 1 October 2015).
17. Report of the Royal Commission into Deep Sleep Therapy, Vol. 1: Introduction, 1990, p.21.
18. G.W. Greenleaf, A.S. Mowbray and D.P. Lewis, Australasian Computerised Legal Information Handbook, http://www2.austlii.edu.au/cal/guides/retrieval/handbook/index-4.html#Heading90 (accessed 1 October 2015).
19. Report of the Royal Commission into Deep Sleep Therapy, Vol. 1: Introduction, 1990, p.11.