Drugs 'bedlam' at high security hospital: Medication doses reviewed after spate of disturbances involving patients. Rosie Waterhouse reports

LIFE on Herons and Elms wards at Ashworth high security hospital was reminiscent of Bedlam while the patients were routinely subjected to massive doses of drugs. But once the medication was suddenly reduced, it became even worse, according to senior nursing staff.

The side effects from the medication distorted patients' behaviour and led to heightened aggression, violence and some vicious assaults on other patients and staff. The withdrawal symptoms when the doses were reduced caused them even greater distress.

John Fillis, branch chairman of Unison, which represents nurses, ancillary and clerical staff, said: 'Staff on Herons ward are constantly under pressure and have been victims of numerous horrific assaults. Elms ward is even worse.'

One staff nurse from Herons ward related a nightmarish account of the daily routine: 'The disturbances on the ward were a minimum of two a day. Patients were assaulting the staff and each other or causing self injury. They were damaging windows, throwing furniture around or anything else they could get their hands on. Staff . . . were on constant overtime because others were off with injuries or with stress.

'Then the medication regime changed after the staff raised their complaints . . . Patients were having convulsions and epileptic fits . . . The patients were desperate and would do anything to get more medication. They would attack and assault and run riot to get more drugs. It was bedlam before, but it was terrible after that'.

At Ashworth, near Liverpool, there are about 60 female patients on four women's wards and a mixed ward. In 1992, the nurses became concerned about the medication doses being prescribed by one consultant psychiatrist, Dr Peter Gravett, who was the responsible medical officer in charge of three wards - Herons, Elms and Laurels.

After consulting a prominent local pharmacist the nurses claimed patients were being prescribed drugs far in excess of the maximum doses recommended by the British National Formulary, the standard reference book for all prescribing doctors and pharmacists. A highlighted section of the BNF states: 'In some patients it may be necessary to raise the dose of an antipsychotic drug above that which is normally recommended. This should be done with caution and under supervision'.

The nurses compiled a list of the doses of medication given to each of the 19 patients on Herons ward, based on their daily drug cards in July 1992.

The hospital has confirmed there was a violent disturbance on Laurels ward as recently as last Wednesday night, when patients demanded more medication and had to be locked in their rooms overnight to keep them under control.

Chlorpromazine, the first of the neuroleptic drugs, was one of the main antipsychotic drugs prescribed, but not the only one. In order to assess and compare the doses of a combination of drugs, to check the appropriate BNF level, the 'Chlorpromazine equivalent' is an approximate guide. The nurses showed the full list of medication prescribed for each patient to a pharmacist, John Donohue, chairman of the Liverpool Pharmaceutical Committee, who was shocked by what he saw. 'The doses were grossly in excess of those recommended in the BNF,' he told the Independent. 'Some were three, four and even five times the doses recommended at that time for long-term use. These medicines are powerful tranquillisers which . . . can have some very unpleasant side effects,' he said. 'One of the common side effects is the development of a condition which closely resembles Parkinson's disease. Some of the side effects may be permanent.' Malcolm Lader, professor of clinical pharmacology at the Institute of Psychiatry at Maudsley Hospital, London, said: 'There is also a risk of adverse effects on the heart, increasing the risk of sudden death'.

Fifteen of the patients were prescribed antipsychotics although at least 11 were at that time diagnosed as personality disordered and one or two were 'mentally impaired'. Mr Donohue said: 'Anti-psychotic drugs such as these are not licensed for the treatment of personality disorder . . . The information I have received . . . suggests that for some patients (the medicines) were not used in the treatment of an illness but as a means of controlling the women's behaviour by keeping them sedated.'

In January 1993, Susan Machin, a social worker on the men's wards and one of the Ashworth Five whistleblowers who gave evidence to the Blom-Cooper inquiry in 1992, heard of new problems and arranged a meeting in London with Charles Kaye, chief executive of the Special Hospitals Service Authority. Also in January 1993, a team from the Mental Health Act Commission paid a regular visit to the hospital, including Herons and Elms wards. It, too, reported 'grave concern' about the 'over-medication'.

In April 1993, the authority set up an 'independent external advisory group' to review services for women patients at Ashworth. Its report was never published. Instead the authority drew up an 'action plan'. In November 1993, a psychiatrist from another ward was instructed to reduce the medication levels on Elms and Herons wards. Witnesses have told the Independent the doses were cut to BNF levels. The hospital will confirm only that medication levels have been 'reviewed' as part of the action plan.

On 1 December, Dr Gravett, also one of the Ashworth Five whistleblowers, was moved to care for male mentally ill patients - also part of the action plan, according to a spokeswoman. Asked if Dr Gravett wished to comment on the allegations of over-medication, the spokeswoman said: 'There is no comment from Dr Gravett.'

On reducing doses of antipsychotic drugs the BNF states: 'Withdrawal of anti-psychotic drugs after long-term therapy should always be gradual and closely monitored to avoid the risk of acute withdrawal syndromes or rapid relapse.'

Following a number of sudden deaths of patients at Broadmoor special hospital and elsewhere, the medical profession began to suspect the deaths were caused by high levels of medication. In December 1992, the Royal College of Psychiatrists convened a panel of clinicians and pharmacologists to review the use of high doses of antipsychotics. And in October 1993 the college published guidelines aimed at restricting the use of high doses.

Asked why Ashworth had refused to publish the findings of the 'independent external advisory group', the spokeswoman said: 'The document is not published as it is an internal management document. The information arising from it led to an action plan being drawn up. The action plan is being actively implemented at the moment. Part of the action plan is to review medical staffing and the consultants now in post are assessing the needs of women patients along with other members of patients' care teams and the medical staff. The review does include looking at the levels of medication. It will also ensure the medication is suitable for each individual patient.'

(Photograph omitted)