Chelmsford Private Hospital Royal Commission 1988–90 

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Chelmsford Private Hospital Royal Commission 1988–90

Conducted over two years from 1988-1990, the Royal Commission into Mental Health Services, otherwise known as the Chelmsford Royal Commission, examined mental health services in New South Wales. The commission, chaired by Justice John Slattery, specifically focused on the practices of the Chelmsford Private Hospital psychiatric institution from 1963 to 1979, where director Dr Harry Bailey administered barbiturates to patients as part of his Deep Sleep Therapy (DST) program.[1] Over 1400 of these treatments were administered to 1115 patients over the course of thirteen years; the deaths of approximately twenty-seven patients were associated directly with Dr Bailey’s actions during their stay at Chelmsford in Pennant Hills.[2] A further twenty-four patients committed suicide the same year as undergoing DST, with hundreds of others reporting negative side effects such as brain damage.[3]

The DST treatment involved the continuous administration of a barbiturate cocktail to patients, sending them into a coma-like state for two- to three-week stretches. This continuous sedation could lead to problems with the bowels and lungs, as well as longer-term effects from the high quantities of drugs. DST was prescribed by Dr Bailey for complaints ranging from lower back pain, anorexia nervosa, skin problems to pyromania. Often the therapy was combined with electroshock convulsive treatments. As the patients were unconscious, many did not know that this second treatment was occurring.[4]

A number of coronial inquests into the deaths of patients at Chelmsford were undertaken prior to the Royal Commission.[5] The first of these took place in 1967 under NSW Coroner Leonard Nash. The coroner found that Bailey’s reasoning for his treatments seemed medically sound and he was not responsible for the ill effects that led to the death of Ronald Carter, who had died of virulent and rapid pneumonia following DST.[6] Ten other inquests were held at the Glebe Coroner’s Court between 1967 and 1988; five finding the cause of death directly related to DST treatment, and five findings of suicide of persons who had been recently treated at Chelmsford.[7]

Despite the significant number of inquests connected to Chelmsford, no actions were taken by the Coroner’s Court to pursue Dr Bailey or his team. The NSW Private Hospitals Branch also showed a lack of attention during inspections of Chelmsford.[8] Bailey’s medical colleagues refused to openly condemn or interfere with his actions, despite numerous complaints from patients and nurses over the experimental nature of Chelmsford’s treatments. This may have contributed to the lack of accountability attributed to Dr Bailey in various coronial inquests.

As Bailey’s professional integrity began to disintegrate, the media seized onto the developing story. The Sydney Morning Herald published sixty-six articles about Chelmsford, using leaked papers smuggled out of the hospital by a nurse. Following a 60 Minutes investigation into the death of patient Miriam Podio, a coronial inquest was held in 1982.[9] This time, the Assistant Coroner Terry Forbes gathered evidence.[10] Bailey appeared again at the Glebe Coroner’s Court and was charged with manslaughter in 1983. Bailey committed suicide in 1985, three years before the Royal Commission began.

Following the Royal Commission, the complaints mechanism for NSW Health was dramatically improved, with strong regulations throughout the medical profession being rigorously applied. The commission also recommended that coroners be immediately informed of any deaths occurring within private psychiatric hospitals. No criminal charges were pursued in relation to the wider medical team at Chelmsford.

Notes

[1] Brian Boettcher ‘Fatal episodes in medical history’, British Medical Journal V.317:1599, published 5 December 1998, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114416/ viewed 20 November 2020
[2] Merrilyn Walton ‘Deep sleep therapy and Chelmsford Private Hospital: have we learnt anything?’ Australasian Psychiatry June 2013 V.21 No. 3. 206–12
[3] E. Wilson, 2003. ‘Psychiatric abuse at Chelmsford Private Hospital’. In Catharine Coleborne and Dolly MacKinnon (eds), ‘Madness’ in Australia: Histories, Heritage and the Asylum (2003, University of Queensland Press, St. Lucia, QLD), 121–34.
[4] Michael Sexton, ‘Chelmsford and the role of the coroner’. Paper delivered at a public seminar ‘Coronial Inquiries’, Institute of Criminology, Sydney University Law School, 10 October 1990, http://www.austlii.edu.au/au/journals/CICrimJust/1991/12.pdf viewed 24 February 2021
[5] Merrilyn Walton, ‘Deep sleep therapy and Chelmsford Private Hospital: have we learnt anything?’ Australasian Psychiatry June 2013 V.21 No. 3. 206–12
[6] Michael Sexton, ‘Chelmsford and the role of the coroner’. Paper delivered at a public seminar ‘Coronial Inquiries’, Institute of Criminology, Sydney University Law School, 10 October 1990, http://www.austlii.edu.au/au/journals/CICrimJust/1991/12.pdf viewed 24 February 2021
[7] Merrilyn Walton, ‘Deep sleep therapy and Chelmsford Private Hospital: have we learnt anything?’ Australasian Psychiatry June 2013 V.21 No. 3. 206–12
[8] Merrilyn Walton, ‘Deep sleep therapy and Chelmsford Private Hospital: have we learnt anything?’ Australasian Psychiatry June 2013 V.21 No. 3. 206–12
[9] Stephen Garton, 2007. ‘Harry Richard Bailey (1922–1985)’. Australian Dictionary of Biography website: http://adb.anu.edu.au/biography/bailey-harry-richard-12162/text21793 viewed 20 November 2020
[10] Michael Sexton, ‘Chelmsford and the role of the coroner’. Paper delivered at a public seminar ‘Coronial Inquiries’, Institute of Criminology, Sydney University Law School, 10 October 1990, http://www.austlii.edu.au/au/journals/CICrimJust/1991/12.pdf viewed 24 February 2021