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Institutional deaths

analysis of patient deaths (Thomson,
1998). This gap has not yet been filled by
the work of advocacy and self-advocacy
groups, which has concentrated on lived
experiences and life stories (Atkinson et
al, 1997; Mitchell et al, 2006).
This needs addressing. Much can be
learnt from asylum historians who have
made deaths central to their descriptions
of patients’ lives and assessments of
different clinical arrangements and
governance regimes (Cherry, 2003).
Although access to patient records is
problematic for ethical reasons, there are
sources to support investigations into
deaths at local and national levels.
Death was an important topic for record
keepers of 19th and 20th century asylums. It Neglected grave at Calderstones cemetery: around 1,200 people who lived in this institution
was common practice to compare monthly for people with learning disabilities are buried here
and annual totals and contrast death rates
between facilities. This statistical analysis We discussed our preliminary findings and speak to the distinctly 21st century
was often supplemented by detailed with other researchers. Once prompted to concern to explain and avoid premature
Edmund Evans Illustrated London News/Wikimedia Commons: Royal Earlswood Hospital; Evelyn Simak/geograph.org.uk: Norfolk memorial; Pathways Associates CIC: Calderstones
accounts of individual cases, including an consider institutional deaths, they and unnecessary deaths. We suspect far
assessment of the care received and provided testimony (based on oral too many people have died without
praise or blame for particular staff. histories as well as documents) relating to concern being registered and protections
Regarding mental health, historians have suspicious deaths at other facilities before put in place to safeguard others.
not only discussed deaths and death rates and after the creation of the NHS. This conclusion is not only an
(Reaume, 2000) but also drawn attention to Numbers of deaths suspicious enough indictment against past services but
those that involved violence to the self and/ to initiate an inquest were small. shows a worrying, persisting legacy.
or others and/or neglect by staff (Shepherd However, the total number of deaths from Historians as well as practitioners and
and Wright 2002; Shepherd, 2014). all causes was large. We argue historians advocacy groups need to start to correct
should be first noting the fatalities – many the neglect of this important topic. n
Cover-ups? of young people – and then asking serious
We found examples of such cases among questions about them. Jan Walmsley is an independent researcher
the records of the Royal Western Counties Once we became alert to concerns about who specialises in projects related to the
Institution, a long-stay hospital for people inpatient deaths, we realised there had been history of learning disabilities
with learning disabilities at Starcross in periodic official interest. Reports into Ely
Devon (held at Devon Heritage Centre). Hospital, Cardiff (HMSO 1969) flagged the Pamela Dale is an honorary fellow
Here, 172 patients (admitted from April issue up but drew few definite conclusions. attached to the Centre for Medical History
1914 to March 1939) died before the end We suspect this gap in understanding at the University of Exeter and a historian,
of 1947. As non-clinicians, we can owes more to a failure to ask questions who has written about institutional care
comment only briefly on the 160 or so than a genuine lack of evidence. Had Sara
deaths attributed to “natural causes”. Ryan not pursued her son’s death with such
Suspicious deaths resulted from a tractor energy, it too would have been recorded This is the last article in our three-part
accident, poisoning, drowning, and falls; as being from “natural causes”, not the series on death and memorialisation in
all were deemed accidents, although some neglect verdict reached by the coroner. institutions
were investigated as possible suicides. It is time for historians to fill this gap

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Forgotten Lives: Exploring the History of into Allegations of Ill-treatment of Patients and and the victorian asylum: attempted self-
Learning Disability. Kidderminster: BILD other Irregularities at the Ely Hospital, Cardiff murder in the age of non-restraint. Medical
Care Quality Commission (2016a) Southern Mencap (2007) Death by Indifference: London: History 46: 175-96
Health NHS Foundation Trust. Quality Mencap Thomson M (1998) The Problem of Mental
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Care Quality Commission (2016b) Learning, Department of Health Policy in Britain c1870-1959. Oxford:
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Cherry S (2003) Mental Healthcare in Modern Townson L, Ingham N, Ledger S, eds (2006) University of Bristol (2013) Confidential Inquiry
England: the Norfolk Lunatic Asylum/St Andrew’s Exploring Experiences of Advocacy by People into Premature Deaths of People with Learning
Hospital, 1810-1998. Woodbridge: Boydell Press with Learning Disabilities: Testimonies of Disabilities (CIPOLD)
Emerson E, Baines S (2010) Health Inequalities Resistance. London: Jessica Kingsley University of Bristol (2018) Confidential Inquiry
and People with Learning Disabilities in the UK. Reaume G (2000) Remembrance of Patients into Premature Deaths of People with Learning
Learning Disability Observatory Past: Patient Life at the Toronto Hospital for Disabilities (LeDeR)
Gladstone D (1996) The changing dynamic of the Insane, 1870-1940. Don Mills, Ontario: Walmsley J, Welshman J (2006) Introduction. In:
institutional care: the Western Counties Idiot Oxford University Press Canada Community Care in Perspective: Care, Control
Asylum, 1864-1914. In: Wright D, Digby A, eds. Ryan S (2017) Justice for LB. London: JKP and Citizenship. Basingstoke: Palgrave Macmillan
From Idiocy to Mental Deficiency: Historical Shepherd A (2014) Institutionalizing the Insane Wright D (2001) Mental Disability in Victorian
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www.cl-initiatives.co.uk Community Living Vol 32 No 2 | Winter 2018 27