Last summer, a couple of months before she died, Georgina Robinson had an odd conversation with her brother, Julian. They were driving home to their parents’ house together and they started talking about Georgina’s work, helping the mentally ill at a small specialist centre in Torbay in south Devon.
She had always seemed to be happy there but now it was obvious that something was wrong, but she wouldn’t say what. That was pretty typical. Georgina always did play things rather close to her chest. But Julian kept prodding and digging, and Georgina started to admit that she had had enough, she wanted to leave. And when Julian prodded her a little more, trying to find out why, she suddenly blurted out something that still rings in his memory today.
“It’s a dangerous place, Julian,” she said. “It’s a dangerous place to work.”
But Georgina Robinson did not leave. She had just bought a house with her boyfriend and she couldn’t afford to stop working, so she went back to the Edith Morgan Centre in Torbay and, two months later, on September 1 1993, she was attacked by a patient, who seized her from behind and stabbed her a dozen times in the neck and chest. She died five weeks later in intensive care. She was 27.
Georgina has been buried now near her parents’ home in Fairford, Gloucestershire, and the patient who killed her has been convicted of manslaughter and sent to Broadmoor secure hospital, but the case is not closed. Georgina’s family have started asking questions, her former colleagues have been banging on their managers’ doors, the local press and the coroner have been digging into the truth, and this month a formal inquiry, led by Sir Louis Blom-Cooper, began to gather evidence about her death. All of them want to know the same thing: what makes the Edith Morgan Centre such a dangerous place to work?
The answer to that question is awaited with some anxiety in the office of the Secretary of State for Health, Virginia Bottomley. For the Edith Morgan Centre is no ordinary unit. It was launched in 1986 as the flagship of the fleet of units which have been established in hospitals over the past decade to support care in the community for the mentally ill. Torbay’s status was captured in a report by the Health Advisory Service, which said that it was recognised as “a national leader in the change to a community-based service… Torbay is regarded by the Department of Health as a pioneering health authority, and its policies are being promoted as an example of good practice which others might follow.”
This tribute was published in the autumn of 1991, just as Georgina Robinson was starting work at the Edith Morgan Centre. But the truth was that she was walking into the sort of situation that is the classic heart of horror stories – a lethal threat which is allowed to flourish because it is ignored or denied by those who should control it. It is one of the cruelest ironies of her death that her killer was moved by a hatred of these very people – the managers of mental health services – and he attacked Georgina only after he had tried and failed to kill the person whom he held to be ultimately responsible for them, the Prime Minister.
From the start, Georgina knew there was something wrong. Everyone warned her that there was trouble at the centre. It had been open for only five years, but in that short time it had already tumbled from its place of pride at the head of the new policy of community care. Ten patients had committed suicide in less than 12 months, the local coroner was demanding action, and staff were heading for the door. The health authority had commissioned two different reviews which had both produced a string of recommendations and both agreed, among other things, that the Centre was storing up trouble by failing to provide a separate unit to care for those who suffered from serious long-term illnesses.
And in saying this, the two reviews were echoing an alarm that had first started to ring more than 15 years earlier, when the 1974 Glancy report had looked forward to the future of community care across the country and warned: “There are already some indications that District General Hospital Psychiatric Departments are less able to manage persons suffering from severe personality disorders… Within the restructured service, the problems of the management of the small number of highly behaviourally disturbed and difficult patients will be exacerbated.”
Glancy’s warning had gone largely unheeded in 1974. And in Torbay, in 1991, the warnings of the two local reviews went unheeded again. The result was that the Edith Morgan Centre was struggling to deal not only with the post-natal depression of new mothers or the addiction of adolescents, but also with the bizarre and occasionally violent lives of profoundly damaged psychotics who were being tipped out of the locked wards of the old mental hospitals. But Georgina Robinson knew little of this. She walked into the centre with no experience at all of mental illness or its management.
Georgina’s skill was occupational therapy. It had been her mother’s idea. Georgina had always been optimistic and even-tempered, she was the sort of person that always had a lot of friends – at school in Gloucestershire, there was a little gang of them who were known to one and all as The Girlies – and she was also quite artistic. She used to sing folk music in student bands and play the violin. So her mother had suggested that she should combine all her talents in one job – as an occupational therapist, using art and activity and her easy-going personality to heal the sick. She’d spent three years training and then a year in a general hospital before choosing to work with the mentally ill, because she thought it would be more demanding.
It was, and soon she discovered that staff were labouring under a problem that was more immediate and more troublesome even than the volatile mix of patients. The Edith Morgan Centre was an architectural disaster.
The worst problem was that the nurses and therapists could not see the patients. On the ground floor, all the treatment rooms and little workshops were tucked into corners at right angles to the main corridor. Upstairs, on the first floor, it was even worse: the bedrooms and bathrooms were laid out on a “racetrack” model, scattered around a four-sided corridor which meant that there was always a corner to interrupt the line of sight. To aggravate the problem, the doors had no grilles or windows through which staff in the corridors could see what was happening inside. The nurses told Georgina that you’d need to be psychic to know what the patients were doing in this place.
Patients came and went around the building. Nurses ran up and down stairs trying to track them. In the middle of the ground floor, there was a wide open lobby which was unaffectionately known as the Airport Lounge. For patients, it was a big, empty, soulless place which could feel threatening and cold. For staff, it was another part of the observational nightmare – everybody who was anybody was likely to walk through it and there was no way of knowing whether they had a right to be there or not.
All the staff grumbled about the building, and Georgina soon discovered its most wretched results. One woman who had been weighed down with depression took herself upstairs, disappeared into the maze of little rooms, found a bathroom, ran a bath and drowned herself her in it. Another woman slipped into a bedroom where no one could see her and hanged herself. While some took advantage of the building’s misshapen structure, others damaged themselves with its inappropriate features – beating their foreheads against the square corners of pillars, slashing their arms with the glass slats in the ceiling vents, strangling themselves on nylon window cords.
The nurses asked for more staff, and some were provided but since the building made their job so hard, it was not enough. There were more reviews. The Mental Health Act Commission came and reported a catalogue of worries, drawing attention once more to the building’s disastrous design, and warning, too, of the lack of leadership from doctors and managers. The Health Advisory Service came and reported the same concerns, provoking the health authority into commissioning a further report from a Strategic Review Team, which reported more worries, provoking the health authority into commissioning a further report from the same team. But nothing was done about the building.
Meanwhile in London, the design flaws of the Edith Morgan Centre became part of a running battle between the Department of Health and a small cluster of specialists who were trying to warn them that health authorities all over the country were constructing units which were as bad or even worse. The most persistent voice belonged to a young town planner named Neil McDougall, who had resigned from the Bath district health authority in 1988 when they commissioned a new building for the mentally ill which he believed was threatening and unfriendly for patients.
McDougall dedicated himself to persuading the Department to develop a prototype model building for the mentally ill from which local authorities could work. He fired off a steady volley of letters to Ministers and reports to MPs, detailing the history of his argument, warning of the dangers which ill-designed buildings presented to patients and staff. The mental health charity MIND joined him in complaining that the Department was failing to provide a lead. Ministers agreed that McDougall had a point and encouraged him to meet with their own specialists.
The minutes of one of these meetings, in the Spring of 1992, record that McDougall began by asking what had happened to the Department’s review of a relevant report from the Social Services Committee, announced in 1985. The officials replied that seven years later the review was still under way and that “this was a complicated area which required much more time.” McDougall went on to argue “that the Department of Health should issue definitive guidance in respect of the planning of mental illness services” and that “a prototype adult acute mental illness unit should be built as an example of a good building” . But the officials replied that they “considered that a design solution appropriate for all situations could not be specified as a standard solution.” So, despite Neil McDougall’s four-year campaign, nothing was done.
That spring, McDougall wrote to the chairman of the Parliamentary Select Committee on Health, Nicholas Winterton, warning that: “It is disappointing and perhaps ominous that, despite all the effort that has been made by the Department of Health in preparing guidance, there is no proven prototype design which can be demonstrated as an appropriate building for the future.”
And in Torbay, events were, indeed, becoming ominous. Georgina began to discover that the blind spots in the building invited not only suicide but also attacks by violent patients on others. That summer, a woman patient was quietly drying her hair in one of the bedrooms when a male patient who had gone upstairs without being noticed, simply walked in and started beating her. Then two of the staff were attacked: a male nurse had his skull fractured by a young paranoid schizophrenic who attacked him as he was arriving for work; a woman nurse was seized in an upstairs room by another schizophrenic who tried to strangle her and was stopped only by the intervention of another patient. Hospital unions demanded more staff, but got none. Georgina and her colleagues were now angry and frightened.
There had been plans for a new policy to protect them. The Health and Safety Executive had started the ball rolling three years earlier when they had written to the Torbay district health authority in October 1989 to remind them that “the district should produce a policy on violence to staff” and detailed the different points it should cover. It had taken more than a year, but by the early spring of 1991, the authority had finally produced a seven-page policy, laying out the training and procedures and practical measures which would be brought in to protect staff from violence. But in April 1991, the old health authority had been replaced by a new NHS Trust, which promptly threw out the entire policy on the grounds that it was pious and unrealistic.
Fifteen months later, in June 1992, the new Trust finally produced its own version . It was less than a third of the length of the original and it omitted many of the protections which the staff had wanted. So the staff rejected it. The result was that nearly three years after the Health and Safety Executive first set the ball rolling, there was still no agreement on how vulnerable staff should be trained and protected.
In the wake of the two attacks on staff in November 1992, one of the managers took up the cause. Carole Heatly, the business manager of the mental health directorate, wrote to her boss, Hilary Cunliffe, to report the attacks. There was nothing immediate that could be done about the building, but, in a letter dated November 25 1992, she pressed once more for effective training: “I feel very strongly that the Trust has an obligation to support and protect staff from unprovoked acts of violence and that this could be achieved by providing the appropriate training. This, of course, would involve an element of cost but I think it would be money well spent. If we do not provide this as an organisation, it is only a matter of time before a member of staff takes legal action against us. Are we prepared to run this risk any longer? Or is there any way that funds can be made available to help protect staff by training them in control and restraint?”
Carol Heatley explained that her own training budget allowed for only £15 per person per year, whereas the training she was suggesting would cost £90 per person. She added that this was not needed for all staff. “There are a group of staff who are particularly vulnerable – untrained staff, female staff and all those who work in Extra Care…” The Trust said they would look for a “cost-effective solution” and, in the meantime, they would find extra places on a course at a local hospital. But there was no extra money and no blanket training for the vulnerable staff.
Eight days later, in the early hours of the morning on December 3 1992, a male patient ran to a nursing auxiliary to report that a paranoid schizophrenic had tried to strangle him in one of the upstairs bedrooms. The auxiliary, a woman of 60, called down for help and then realised that there had been another patient in the same bedroom. She tip-toed into the room, saw that all was quiet, turned and suddenly found herself thrown to the ground by the schizophrenic who kneeled on her back and started trying to snap her neck. Other patients dragged him off but not before the auxiliary had suffered broken ribs and a chipped elbow. She was a friend of Georgina’s. She never worked again.
In London, Neil McDougall was still trying to persuade the Department of Health to design a safe and therapeutic building for the mentally ill. When the Department finally published its Design Guide, three months later in March 1993, he wrote to the Secretary of State, Virginia Bottomley, warning that the Guide was inadequate and urging her to reject its suggestion that potentially violent and dangerous patients could be dealt with simply by occasionally locking them into a special seclusion room. “I view it as highly improbable that this form of provision would create an appropriate environment for the care of people who present disruptive or dangerous behaviour associated with mental illness, or contain the necessary standards of observation, safety and access to facilities.” He cited the Edith Morgan Centre as an example of bad design and offered to meet a minister to explain the point.
That was in June. That same month, a new patient arrived at the Edith Morgan Centre. His name was Andrew Robinson. He was a severe paranoid schizophrenic with more than 15 years of mental illness behind him including episodes of violence. In 1978, he had been sent to Broadmoor without limit of time for attacking a girlfriend, but he had been released less than three years later. Since then, he had been “cared for in the community”, living alone, failing to take his medicine, hitting peaks of paranoia, being pulled back into hospital and back onto his medicine, before being sent out on his own again to repeat the cycle. He was, in other words, exactly the sort of dangerous and disruptive patient whose care had occupied so many reports and provoked so many entreaties by Neil McDougall.
Some of the nurses did not like Andrew Robinson. He had been to the Edith Morgan Centre before and he was one of the very few patients who actually spooked them. It was nothing they could put their finger on – on the face of it, he was a well-educated chap – but there was something in his manner which was most intimidating. He was detained under section three of the 1983 Mental Health Act, which meant that for the safety of himself and others, he was not allowed to leave the building without permission, but he often did and went wandering in the town. They could hardly stop him because most of the time, they didn’t know where he was, any more than they knew where any patients were in their maze of a building.
That summer, Robinson was busy writing a long treatise about his suffering at the hands of psychiatrists whom he blamed for his ruined life. At the beginning of August, he took the completed manuscript to a little printing shop in Torquay and asked them to type it up for him. When the shop staff read through the collection of roughly scribbled notes, they found that Robinson had produced a manifesto of violence, explaining the legitimacy of mass murder and, in particular, of the murder of the Prime Minister, John Major. The printing shop were so worried that they called the police, who said there was nothing they could do if no crime had been committed. So the shop’s owner called the Edith Morgan Centre and warned a senior member of staff that one of his patients was talking about some serious violence. The shop was advised to refuse to type the manuscript. But nothing was done about Robinson. And now he was getting ready to explode.
By this time, Georgina was sure that she wanted to leave the Edith Morgan Centre, but she also wanted to stay with her boyfriend with whom she was living 20 miles away, in Exeter. She needed to work to help pay the mortgage which they had taken out on their home. So she stayed and did her best to do her job and to keep her worries to herself. But that summer, they started to bubble over, first in her sudden outburst to her brother Julian as they drove back to Gloucestershire one weekend, and then to her older brother, Cliff.
She told Cliff exactly what was troubling her, in the hope that he could help – because Cliff is an architect who has studied the design of medical buildings. One Sunday afternoon, on a visit home, Georgina sat down with him and drew the building for him, urging him to show her how it could be improved. Cliff could see the problem and the two of them spent several hours sketching out solutions on sheets of paper on the table in the kitchen. On paper, they could change it, but in reality, Georgina went back to work, to the same old building with the same old blindspots and the same shortage of staff and the same dangerous mix of patients.
In August, the NHS Trust finally agreed a new policy on the protection of its staff from violence. They said it was more realistic than the version which had been produced with the old health authority more than two years earlier. It was also significantly weaker. It cut staff and their unions out of the picture: they would have no right to see the records of incidents and no right to discuss the counter-measures. It refused to admit that shortages of staff might encourage more violence. It slashed the commitment to train all staff and refused to make any individual manager responsible for safety. Even now, in its watered-down form, it was not circulated to the staff.
In London, Neil McDougall threw one more paper grenade at the Department of Health when the Secretary of State rejected his request for a meeting with a minister and offered him another meeting with the same official whom he had already met three times in the course of five years of letter-writing. “I am not altogether convinced that presenting my work once again will be a productive use of his or my time,” he wrote. Once again, he rehearsed his arguments, citing the expert reports which supported his position, pleading for action over the dangerous buildings. On August 23, he received a two-line reply from the head of the NHS Estates Policy Group, thanking him for his letter and informing him that his comments had been noted.
Six days later, Georgina was upstairs in the Edith Morgan Centre, talking to a woman patient in one of the bedrooms that was hidden from general view by the design of the building. She was sitting on the bed with her back to the door. Andrew Robinson was outside in the corridor and he was carrying a knife. Nobody saw him.
For the last ten days, the tension had been building inside him. On one of his trips into Torquay, he had bought himself a knife with a five-inch blade and walked back with it unobserved into the Edith Morgan Centre. On August 28, he had set out for London to find the Prime Minister. Staff at the Centre had given him permission to go into Torquay for the day, but when he failed to return at night, they had no idea where he was. Nothing had been done to retrieve him. In London, Robinson had prepared himself overnight and then found his way to the House of Commons, only to discover that the Prime Minister and other MPs were away for the summer recess. He had returned to the Centre on August 31, his three-day absence unexplained, his plan to register a spectacular protest against his treatment still alive in his mind.
By September 1 he had decided to kill a doctor and now he was padding around the building with his knife, looking for Dr Montera, who had been responsible for admitting and sectioning him two months earlier. He couldn’t find him. Turning unobserved along the four-sided corridor, he saw a bedroom door hanging open, spotted the young woman talking to a patient, guessed she must be a nurse or a doctor, stepped up behind her, wrapped his arm around her chest and stabbed her deeply in the neck.
Georgina screamed and tried to pull free, but he caught her and pulled her backwards stabbing her again and again, while the woman patient cried for help. By the time the other staff appeared from the far reaches of the building, Georgina was lying on the floor and Robinson was standing over her, soaked in blood with the knife on the floor at his feet. The police came and took him away and, in the car, he told them he was sorry he had attacked Georgina. “She got between me and the system,” he said.
It was only later, after Georgina had lingered in intensive care and finally succumbed to a collapse in her lungs, that her family began to discover the risks which she had been running in her work. And the more the family dug, the more angry they became, as they uncovered the history of inaction not only in Torbay but in health authorities throughout the country. Georgina turned out to be only one of more than 40 patients, staff and members of the public who had died at the hands of violently disordered individuals who had been released into the community and treated in buildings which offered neither the security nor the facilities which they needed.
In the wake of the attack on Georgina, the South Devon Healthcare Trust ordered an immediate review and invited Sir Louis Blom-Cooper to send them a report. They also finally circulated staff with their watered-down policy on defending them against violence. The local coroner who had first sounded the alarm about the Edith Morgan Centre in 1989 repeated his urgent call for a special secure unit for those whose illness made them too dangerous to live in the community. In a preliminary report on the Centre, Sir Louis Blom-Cooper, reported that the building was so badly designed that it was “seriously prejudicial to effective mental health care”. He said it should be modified immediately and eventually replaced.
The South Devon Healthcare Trust say they have always been concerned with the safety of their staff and patients, that they have taken every reasonable step to protect them, and that their safety record is no worse than that of comparable units. Staff say their complaints have been ignored for years. A group of social workers from the Community Mental Health Care Team wrote to Sir Louis-Blom Cooper: “We feel we have been voicing these concerns for years to no avail. In South Devon, mental health concerns are not a high priority with management and the communication difficulties with the Health Service have exacerbated these problems.”
Since Georgina’s death, five more patients from the Edith Morgan Centre have committed suicide. One of them, Stephen Hext, did so by jumping from the roof of a car park 12 days after he had warned doctors that voices in his head were telling him he was about to die by jumping from the roof of a car park; he had slipped out of the Centre without the knowledge or consent of the doctor who was in charge of him. Twice in the last month, police in riot gear have been called to the Centre to deal with patients who have become violent and uncontrollable. On one occasion, they removed a man who had started to smash up his room, only to have to return him later because there was nowhere else to keep him.
On March 22, as Andrew Robinson was sent off to Broadmoor without limit of time – for the second time in 15 years – Georgina’s parents, Wendy and Rob, stood outside Truro courthouse and read a statement. “What concerns us now,” they said, “is that something is done permanently so that Georgina can rest in peace knowing that psychiatric patients, those that care for them, and the general public are protected and informed of the dangers of certain mental illnesses. At present, this is not the case.
“Everyone is affected by the current Government approach to psychiatric care, and everyone is still at risk from dangerous mentally-ill people. We don’t want any more victims like Georgina.”
