First one example, the strange fate of Case No. 98 ...	A lobotomy fails to cure a stomach ulcer but acts to get the CVAG spokesperson marched out of the Royal Commission between three policemen when he wishes to explain to the Royal Commissioner that counsel assisting were in reality compromised.

Who Were They ?

Those referred to Chelmsford Private Hospital were people who suffered from stress-related problems caused by bereavement, divorce, post-natal depression, pre-menstrual tension, children with behavioural problems at school, people with weight problems and so on.

For many, the treatment they received at Chelmsford horribly and irretrievably altered their lives. For others, the result of the treatment was death.

Chelmsford exposed the shortcomings of government bodies and, in some instances, their collusion with vested interests. Especially, it is a condemnation of private hospitals. The Director of Public Prosecutions dropped all criminal charges against the Chelmsford doctors.

The following are extracts from the Chelmsford Royal Commission report which investigated the treatment of patients at the Chelmsford Private Hospital in the Sydney suburb of Pennant Hills:

The context for the cases (extracts from the Royal Commission findings)

"The first patients died in 1964. In the second half of 1964, five patients died during DST (deep sleep therapy) and possibly their deaths were also associated with a golden staph epidemic in Sydney. DST made them more susceptible to the infection. Patients died thereafter at an average of one or two a year. Most patients who died were aged in their 20s, 30s and 40s.

Dr Bailey [the doctor then in charge] routinely provided death certificates, for these deaths, which were often false and avoided any coroner's inquest even though, if the facts were known, an inquest should have been held.

Of the 24 deaths which occurred Dr Bailey signed 17 certificates which were probably false.

A large number of patients were treated for complications, these being mainly infections, pneumonia and deep vein thrombosis. The unconscious condition and immobile position contributed to these complications. There was incontinence of urine and faeces... There were restraints used to prevent falling from the bed, fractures and falls, vomiting, skin break-down and metabolism imbalance. At the end of the treatment there were gross visual distortions and hallucinations and severe weakness.

Dr Bailey claimed to have a specialised nursing team looking after patients at Chelmsford but this was not so.

Nurses were given almost no special training and learned any expertise on the job. They were given a wide discretion in the amount of sedative drugs they could administer to a patient and sometimes even these were exceeded, The DST doctors did not usually check on these matters. They did not read the records and relied almost entirely on what the nurses told them. The nurses relied only on clinical observations on the depth of sleep which at times involved levels at anaesthesia and coma.

Although in 1967 there had been a detailed coroner's inquest into the death of Ronald Graeme Carter, no adverse consequences for Dr Bailey flowed from that.

By the mid-1970s, however, the nurses were becoming more concerned about the deaths and complications arising from DST.

[Nursing] Sister Shea committed suicide in 1977 by taking an overdose of barbiturates which she obtained from Chelmsford.

Dr Bailey's behaviour, which had never been stable, and was quite improper in relation to some patients, became worse, leading to his breakdown and admission to Chelmsford in April 1978 after the suicide of one of his patients, Miss Sharon Hamilton, with whom he had been having sexual relations.

Many patients were not told they would receive electroconvulsive therapy. It was clear from the evidence given that many believed the consent form they signed was only a type of entry admission form.

Some patients were treated contrary to their express wishes. Other patients were treated by stealth and deceit. The signature on some forms was obtained by fraud and deceit.

Some were signed by people whose judgement was compromised by drugs. Some patients were even woken up from their DST treatment to complete the authorisation ... some were treated despite the fact they had specifically refused treatment.

The doctors and the nurses who treated patients without the patients,' consent, contrary to the patients' Consent, or on the basis of a consent obtained by fraud or deceit, committed a trespass to the person of each of these patients, and were responsible for an assault on them

The evidence satisfies me [the Commissioner Justice Slattery] that virtually from the beginning of the administration of DST... there was a systematic cloak of secrecy about the treatments, a blanket on the disclosure of information relating to it and a fraudulent cover-up of deaths and other incidents at the hospital."

As coverage made the cases more widely known more public events took place...

1985 A protest meeting outside the office of the then Labor Premier of NSW, Barry Unsworth.

1992 A protest meeting outside the Bar Association office
[The only prosecution carried out in the Chelmsford case was against Ken Crispin, QC, the Chelmsford Victims Action Group barrister who represented them at the Royal Commission. He was prosecuted by the Bar Association, who charged him with professional misconduct. The charge came out of his address to the Royal Commission about the conduct of the former head of the Health Department JD Grimes. Grimes was Permanent Head of the Department of Public Health from 1961 to the end of 1972. While he was in that position 16 patients died in Chelmsford. After a three-day hearing the charges against Ken Crispin were dropped.]

Four of those who died

John Adams: Died in Chelmsford 1977 aged 25 years.

From the notes of a Dr Aders on John Adams:


According to the nurses' statements he was 'grey and pale' about 20 to 30 minutes before the cardiac arrest, sure signs of oxygen deficiency. When Dr Windon intubated him she could establish assisted breathing only after sucking secretions out of the tube. By the time he reached Hornsby Hospital his brain was irreversibly damaged and the Hornsby records merely show the valiant but futile attempts to get him going : The question of extra sedation... Whether they were ordered or not cannot be proven since the treatment sheet has mysteriously disappeared from the record ... action should have been taken 14 hours earlier. On the evidence ... there is no doubt that Mr Adams' cause of death was respiratory failure. This was caused by barbiturate poisoning in association with mechanical obstruction because of secretions. [Dr Gill] was, in my opinion, grossly negligent in his treatment of John Adams.

 

The coroner's verdict of a "medical accident" and --- no negligence" seems to be rather kind to Dr Gill.


Here is part of the Commissioner's conclusion on Dr Gill:

 

Graeme Carter: Died in Chelmsford 1967 aged 22 years.

Coroner Dr Lee:

In his opinion the cause of death was respiratory failure following the ingestion of barbiturates. There can be no doubt whatever that the cause of death was barbiturate poisoning.

The evidence of Sister Stephenson who found Mr Carter dead at 3.40am was completely inconsistent with the continual close monitoring which was essential. Mr Carter was neglected by the Chelmsford staff.

[Graeme Carter's wife] had similar evidence [that he was being neglected] which should have been presented to the coroner and was not.

She had visited her husband to find him unattended. She had demanded that the treatment be stopped or that her husband be transferred. Dr Bailey ignored these instructions and denied them before the coroner.

Had there been full disclosure of the truth of the matter (that the death of the deceased had been caused by barbiturate poisoning) then the outmoded therapy may have been immediately stopped.

Peter Clarke: died in Chelmsford 1974 aged 32 years.

Here is part of the Commissioner's conclusion on Peter Clarke:

I have concluded that the probable cause of Peter Clarke's death was as follows - the combined effect of barbiturates and tranquilisers ingested by him between 16 and 22 February 1974 depressed his central nervous system to such a degree that his breathing and coughing were reduced. [Peter Clarke was rendered unconscious from From February 16 to 22.1

This led to pneumonia. A further severe episode of hypoxia [lack of oxygen] followed his last ECT electroconvulsive therapy] treatment and this led directly to his death.

After consideration ... I have formed the opinion that this material should be directed to the Director of Public Prosecutions for his consideration as to whether any action action should be taken against Dr Herron in respect of the death of Peter Clarke.

Audrey Francis: died in Chelmsford 1976 aged 66 years.

Here Is part of the Commissioner's conclusion:

Dr Herron found it difficult,---if not impossible", to accept the barbiturates given to Miss Francis depressed her respiratory system and thereby contributed to her death.

Dr Herron was confronted with the evidence of Dr Kariks, a pathologist, who stated in his opinion the final cause of Miss Francis's death was "a combination of events".

Dr Kariks spoke of deep sleep Induced by barbiturates ... at the toxic level"...

[Dr Herron] agreed the concentration of barbiturates found in the blood of Miss Francis was within the toxic range and within the potentially fatal range...

Dr Herron seems unwilling or unable to accept the overwhelming evidence of the experts that DST was directly-linked to and responsible for Miss Francis's death.

After consideration ... documentation should be referred to the Director of Public Prosecutions for his consideration of whether any action be taken against Dr Herron in respect to the death of Audrey Francis.*

BUT nothing happened ! The DPP did nothing !

... a continuing story for those effected. Hundreds of patients suffered disability and worse because of the actions of the Chelmsford doctors. And today the details exposed by the 1988-90 Royal Commission are so unfit for the public to know about that they have been locked away in the government archives only to be released to public gaze to the historians of a future generation in NSW.