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Susan Geason Writer Image Blank Spacer image
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    Dark Trance
Dr Harry Bailey & the Chelmsford Private Hospital Scandal

Chelmsford

Introduction

The first warning that something was amiss came in 1967 in a small article in the Sydney Morning Herald about the inquest into the death of a 23-year-old man at a small private hospital in Sydney’s north west. The story concentrated on the coroner’s unease about the amount of discretion given to nursing staff to administer dangerous drugs. It was another eight years before the hospital would again make the news. This time the Herald ran a story about a patient who accused his psychiatrist of giving him electroconvulsive shock there without his permission and claimed that he’d contracted double pneumonia and pleurisy and ended up in emergency in Hornsby Public Hospital. The story went quiet again until 1980, when that patient, Barry Hart, made history by winning a civil case against the doctor and the hospital.

The hospital in question was Chelmsford Private Hospital in Pennant Hills, and the treatment meted out to people with problems as varied as schizophrenia, alcoholism, post-natal depression, anorexia nervosa and drug addiction, was called deep sleep therapy, or DST. The successor to insulin coma therapy, DST had been tried in the US, the UK and Europe before World War II, but had fallen out of favour because of its serious side-effects. It consisted of putting a patient into a drug-induced coma for up to 21 days. The theory was that this induced “sleep” would turn off patients’ brains, that this would short-circuit their problems and they would wake up cured.

At Chelmsford, DST was a one-size-fits-all treatment, with the same regimen of drugs administered to all patients regardless of their size, age or physical condition and without an initial medical examination by a doctor. The drugs were dispensed by the nursing staff from typed treatment sheets signed in advance by the doctors, a practice that was not only dangerous but illegal. This drug therapy was combined with daily electroconvulsive shock treatment (ECT) administered without a muscle relaxant or a physical examination

The man behind the treatment at was Dr Harry Bailey, who had moved into psychiatry from a medical degree at Sydney University in 1952. While studying for his diploma of psychological medicine, Bailey had become a convert to organic treatments of mental illness — that is, psychosurgery and drug therapy — rather than psychoanalysis or the “talking cure”.

Charismatic, extroverted and ambitious, Bailey possessed the knack of winning the support of powerful men, and his rise was meteoric. In 1957, after a 15-month World Health Organization travelling scholarship that took him overseas to study trends in the treatment of mental illness and a stint in the Health Department, he persuaded the New South Wales Government to fund a state-of-the-art neurosurgery unit and make him its director. This Cerebral Surgery and Research Unit (CSRU) was built at Broughton Hall, a voluntary psychiatric and teaching hospital in the grounds of Callan Park, the state mental asylum at Rozelle.

Two years later, at only 37, Bailey was appointed Superintendent of Callan Park. By then, after being starved of funds for decades, this once progressive and well-regarded institution was run-down and grossly overcrowded. Bailey quickly became disillusioned, and after only two years in the job stunned his political masters and galvanised Sydney by going public with allegations of mismanagement, theft and mistreatment of patients at the hospital. The publicity forced the NSW Labor Government to hold a Royal Commission in 1961 and made Harry Bailey a celebrity. The inquiry confirmed most of his allegations, but criticised him for suggesting that the hospital send in bogus patients and doctors to spy on staff and catch them in the act. His former mentors, outraged at the betrayal, forced him to resign.
With no choice but to go into private practice, Bailey set himself up in rooms in Macquarie Street, the local equivalent of London’s Harley Street, in the city. As the hero of Callan Park, he was inundated with patients, and became a celebrity psychiatrist. His clientele ranged from ordinary people referred by suburban and country GPs, to establishment figures and show business personalities. After American R&R troops from Vietnam introduced hard drugs into Sydney in the 1960s, he developed a lucrative sideline in treating drug addicts.

In 1963 Bailey began administering DST at Chelmsford Private Hospital in a special 10-bed sedation ward. He recruited Dr John Herron, a former colleague at the CSRU and now Superintendent at North Ryde Psychiatric Hospital, to come in at night and administer ECT. Dr John Gill, a Wahroonga GP and investor, came on board in 1972 when his family company bought a quarter share in Chelmsford and he took over the day-to-day management of the hospital. Three of the “DST doctors” were now in place. The fourth was Dr Ian Gardiner, an employee of Dr Herron at North Ryde, who was subcontracted in 1973 to give some of the shock treatment.

What exactly was Bailey’s miracle cure? On admission, patients were knocked out with an injection of sodium amytal, which quickly made them compliant, then placed on a regimen of barbiturates, tranquillisers and sedatives that could last up to 14 days. Bailey’s favourite drug was the barbiturate Tuinal. A combination of Amylobarbitone and Quinalbarbitone, it combined fast and slow acting drugs and depressed the nervous system, and had become the suicide’s drug of choice. The drugs were administered regularly in high doses and the ensuing coma caused problems such as deep vein thrombosis, pulmonary embolism (a blood clot in the main artery from the heart to the lungs), pneumonia, heart attack and stroke, sometimes followed by brain damage and/or death.

According to witnesses, the DST ward at Chelmsford had a nightmare quality. The room was darkened, and patients were nursed naked and covered only by a sheet, men and women side by side. For nourishment, they were fed a Sustagen mixture through a tube through the nose. In the early days they were roused to go to the lavatory, but in time Bailey ordered that they be kept sedated 24 hours a day. Initially the patients would be constipated by the drugs, but they would often become incontinent when lightened — that is, when the drugs were gradually withdrawn. During the treatment they urinated in their beds and at least in the early days were often left lying in their own urine for hours.
The nursing staff were supposed to observe the “sleeping” patients closely, taking temperatures, pulses and swabs for infections, and monitoring urine outflow. But as many of the Chelmsford nurses had little or no general nursing training and did not know how to take proper medical observations, their observations were often badly done and poorly recorded. Because they did not examine the patients often enough and missed warning signs, people were injured or died. Patients were also supposed to be turned regularly to prevent bed sores, but one woman reported waking to find her knees stuck together and had the scars to prove it. Most of the staff knew nothing about pharmacology or emergency nursing, and even if they had known how to resuscitate a patient in trouble, the hospital’s emergency equipment was woefully inadequate to deal with it.

If patients failed to respond to DST and ECT, some were also treated to Bailey’s particular brand of psychosurgery, which he claimed was a revolutionary new procedure called a “cingulotractotomy”. It was touted as a last resort: Bailey told one woman’s husband that she would only be good for “the scrap heap” without it. Neurosurgeons Dr Cedric Swanton and Dr John Dowling carried out the operations at St Luke’s or at Prince Henry Hospitals. Bailey was responsible for more psychosurgeries than any other psychiatrist or neurosurgeon in Australia in the sixties and seventies, and it was highly profitable.

Bailey claimed that his form of psychosurgery was an improvement on the leucotomies done elsewhere and that it was successful in 85 per cent of cases. He even claimed it increased some patients’ intelligence. The truth was very different. Fifteen years after her operation, Gwen Whitty had to undergo emergency surgery to remove pieces of metal protruding from her skull. A government inquiry in 1977 placed stringent conditions on psychosurgery, but Bailey circumvented these by sending his patients to a neurosurgeon in the US.

Bailey attended the hospital regularly in the early years, although he often turned up late at night. Later, he refused to come for weeks on end. In an emergency, the nurses called Dr Herron or a local GP. John Adams’s life was saved, temporarily, by an anaesthetist who happened to be visiting the hospital when he ceased breathing. None of the doctors who treated patients suffering from the effects of massive drug overdoses ever questioned Bailey’s clinical judgment or reported him to the Health Department or the Australian Medical Association.

Most of the nurses also kept their counsel. Some did not care about what was happening to the patients; others did not feel qualified to second-guess a doctor’s orders. Others, who had been forced to abandon their training before graduating because they had married, were grateful to have any nursing job at all. The matrons, most of whom were not qualified for the position, kept their mouths shut because they were grateful for the promotion and lacked the confidence and knowledge to challenge the doctors.

But some of the women who worked in the sedation ward knew what was going on. They ignored Bailey’s orders and lowered drug doses or omitted them altogether when they thought a patient was in trouble. Two even found the courage to complain to the authorities about what was happening to patients at Chelmsford — a Nurse “M.” Pett in 1970 and Anna Marie Borner in 1978 — but they were largely ignored. Matron Julie Smith, a highly qualified nurse with both general and psychiatric training, attempted to challenge Bailey and institute some reforms in 1976 but was forced to leave after four months.

DST ceased in 1979. It was not abandoned by Bailey, not was it stopped by the Health Department, whose private hospitals inspectors had mysteriously failed to detect any inadequacies in patient care during their regular visits: it ended because of two internal revolts at Chelmsford, one by doctors, one by nurses. When the psychiatrists who used the general wing of the hospital demanded in 1978 that Bailey go and that DST cease, the hospital owners promised to comply, but Bailey continued to admit patients under Herron’s name. In fact, DST did not cease until February the following year, when Chelmsford nurses refused to nurse any more sedation patients after Dr Gardiner’s patient, Coralie Walker, suffered catastrophic brain damage during treatment. A lucky man in the next bed was discharged unharmed.

At this point, nobody knew exactly how many people had died in Chelmsford, and it looked as if the DST doctors, who had been killing and maiming patients with impunity for 16 years, would  get away with it. But not all their victims were too cowed to fight back. Barry Hart, who had been given DST and ECT against his wishes in 1973 and ended up in emergency in Hornsby Hospital, began a long march to court to sue Dr Herron and the hospital. In 1977 the Church of Scientology, which was waging a worldwide war against psychiatry, joined the campaign against Dr Bailey, armed with hospital records stolen by Chelmsford nurse Rosa Nicholson. Its leader was Jan Eastgate, a young volunteer worker with the Scientology front organisation, the Citizens Commission on Human Rights.

Others joined the campaign along the way. Dr David Maddison, a psychiatrist who had trained with Bailey, broke ranks and given evidence against him at the Carter inquest, to no avail. Lawyers Ted St John and Greg Woods took up Barry Hart’s case against Dr Herron, which finally got to court in 1980, and medical experts Professor Dennis Wade, Dr John Sydney Smith, Dr John Corbett and psychologists Peter Todd and Dr Peter Birrell, found the courage to testify. A number of journalists kept the story in the public eye, particularly Toni Eatts, who started out neutral reporting on Hart v Herron, but eventually joined the campaign.

Some politicians threw their weight behind the victims. Labor Attorney General, Frank Walker, briefed by policy analyst Peter Webb, asked the Minister for Health to investigate Chelmsford in 1978. Labor MP Pat Rogan and Independent John Hatton championed the cause in Parliament, and Rogan’s electoral secretary, Margaret Como, helped organise the campaign for an inquiry from her boss’s office. And finally, crucially, there were the former Chelmsford patients who defied prejudice and conquered shame and came forward and told their harrowing stories.
This is the story of the long and difficult battle to expose the abuses of Chelmsford, to punish the DST doctors, and to get justice and compensation for the victims. It was fought though the bureaucracy, the Parliament, the courts and the media, and continued even after the NSW Government gave in and held a Royal Commission in 1988. For some people it will never end.

This book seeks to debunk the myth that the medical catastrophe at Chelmsford was caused by a single “mad, bad” doctor. Certainly, it would not have happened without Bailey, but he was assisted by the failings of the both the system and individuals. Bailey got away with mass murder because the health bureaucracy was complacent and inept; the laws on the treatment of the mentally ill and the regulation of private hospitals were inadequate and poorly policed; the coronial system was antiquated and badly resourced; and the medical profession was unable or unwilling to challenge a colleague’s clinical practice. In short, Chelmsford was enabled by a systemic failure, aided and abetted by the incompetence, apathy or collaboration of individuals.

The story of Chelmsford is a riveting saga of hubris, greed, cruelty and political ineptitude on the one hand, and suffering, courage, fortitude and determination on the other, but most importantly, it is a cautionary tale.

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