Week 6 cross examination of psychiatry expert witness Professor Gordon Parker
Update: Closing arguments are listed for 26 – 28 August 2020
Dr John Gill GP, and former psychiatrist John Herron were involved in the deep sleep therapy scandal at the Chelmsford Private Hospital (CPH) in Sydney that was the subject of a Royal Commission in 1989. Gill and Herron are suing HarperCollins Publishing Australia and ABC journalist Steve Cannane for defamation over a 28 page chapter of Cannane’s book Fair Game: The Incredible Untold Story of Scientology in Australia.
On July 8 2020 the trial was adjourned part heard. Cross examination of Dr John Herron resumed on 3 August. Closing submissions are likely to be heard mid August. A judgment is unlikely to be handed down until 2021.
DST – deep sleep therapy at Chelmsford
Deep sleep therapy (DST) is a psychiatric treatment in which drugs are used to keep patients unconscious for extended periods. The height of its use was from the 1930s to the 1960s.
DST was practised (in combination with electroconvulsive therapy (ECT) and other therapies) by Harry Bailey between 1962 and 1979 at the Chelmsford Private Hospital (CPH) in Sydney. As practised by Bailey, deep sleep therapy involved long periods of barbiturate-induced unconsciousness. Wikipedia
Dr Bailey and John Herron had continued the DST until 1979. The Chelmsford hospital was partly owned and managed by Dr John Gill. The court has heard that Dr Gill also had patients that underwent deep sleep therapy at the hospital.
Cross examination of Professor Parker
Professor Gordon Parker is the founder of the Black Dog Insititute, Head of the School of Psychiatry at UNSW and Director of the Division of Psychiatry at Prince of Wales Hospital.
Expert evidence for the defence was given in the form of written reports, which are not available to members of the public. Professor Parker’s report was based on the Chelmsford Hospital records of fifteen DST patients. He was cross examined for two days by counsel for the applicants Sue Chrysanthou. The following represents his responses to challenges to his report.
A high risk therapy
Sue Chrysanthou asked the professor if he was aware of papers on narcosis therapy published by Dr William Sargant in the British Medical Journal in the 1960s and 1970s. (Chelmsford’s Dr Bailey claimed to have based his DST on Sargant’s treatment.) Professor Parker described Dr Sargant as a controversial and ‘polarizing figure’ in British psychiatry who never provided any data on the death rate of his therapy. He added that the sedatives prescribed by Sargant were different to those used at Chelmsford.
Professor Parker gave evidence that DST had an associated risk of death, and safer alternatives, such as antidepressants and ECT, were available at that time. The professor also spoke about ‘polypharmacy’ in the Chelmsford deep sleep therapy where patients were commenced on a standard drug regime that included high doses of barbiturates and psychotropics. He said that Haloperidol was prescribed in DST at nine times the recommended starting dose. Conventional practice was to ‘start low go slow’ in terms of prescribed dosages because different people metabolise the drugs at different rates. Beginning with low doses averted the risk of complications from excessive sedation, some of which could be lethal. While Chelmsford nurses were given discretion to administer a half or full dose of the main sedative drug, he said that because DST included a combination of three different hypnotic drugs, even an anaesthetist would have difficulty modulating the dose to maintain sedation safely.
Early in his cross examination, Professor Parker took issue with ‘a type-written treatment template’ that was found in the majority of files he was given. The unsigned and undated drug sheet was a pre-typed list of prescribed medications with Dr Herron’s name typed underneath. He said that it appeared the template was applied to the DST patients ‘in a procrustean manner; no respect for the age, or the weight of the patients, or whether they had any physical conditions… I cannot think of any circumstance where a complicated, detailed and potentially dangerous procedure, implying multiple medications, would be provided in such a formulaic way.’
Indiscriminate treatment approaches
When questioned about the application of ECT, the professor did not accept Sue Chrysanthou’s proposition that indications for its use were wider in the 1960s and 1970s than they are today. He agreed that he was not aware of any published guidelines at that time but said that he assisted in delivering ECT from the early 70s and that it was used for a narrow range of psychiatric conditions where other treatment strategies had been exhausted. If it was used beyond those, he said, it was for exceptional cases, or by maverick practitioners. He gave the example of certain psychiatrists continuing to use it to treat anorexia nervosa. ‘There’s always been practitioners who have personal views about ECT which are completely unsupported by the scientific literature. That percentage of cavalier practitioners has not changed very much.’
Aside from his misgivings about the risks of DST, Professor Parker identified a number of Chelmsford patients who did not exhibit indications for ECT, such as a patient who presented with alcohol intoxication and depression, and some cases where the diagnosis of depressive disorders was questionable, or where there was no evidence that antidepressant medications had failed. He described the DST therapeutic template being ‘dropped over a patient’ without any reference to the patient’s medical conditions. ‘The whole thing is chaotic, superficial and negligent,’ he said.
Professor Parker also said that it has since been found that ECT carries a risk of causing long term cognitive problems.
Calamitous death toll
Professor Parker gave evidence about the hospital’s failure to conduct a review despite the deaths of DST patients. He said that ‘in any medical setting, if there’s a catastrophic event, such as a patient death, you would expect that a hospital would take that very seriously, you’d want to know exactly what had occurred…’ After several deaths he said that ‘any hospital that practiced with any basic acceptable standard’ would halt the treatment and notify the appropriate authorities for the matter to be investigated. However, DST continued at Chelmsford despite the mounting fatalities, ‘with no notification by the hospital to the health authorities, with internal processes unclear…’
It seemed to me the multiple deaths created something that we’d never had before in Australia, catastrophic and calamitous.
Sue Chrysanthou suggested that the count was more likely to have been twenty-four deaths, and not twenty-six as had been reported.
Professor Parker replied, ‘if it were twenty-four, is it not a catastrophic event?’ He added that the number was ‘totally unacceptable. Even if it were three patients — twenty-four is extraordinary.’
He also mentioned that there was a number of suicide deaths among DST patients following their Chelmsford admissions. (It has been reported as around two dozen, but the figure has not been verified.)
The professor noted that it was evident from the hospital records he examined that one patient did not want ECT and did not sign the consent form until after sedation had commenced. The illegibility of her signature indicated that she was cognitively impaired when she signed. Another file indicated that a patient was not told she was receiving sedation. Professor Parker remarked that these the patients had not given informed consent.
Chrysanthou said that the notion of informed consent was not fully developed in the 1970s and that there was no legislation that required hospitals to obtain consent via consent forms. Professor Parker said that he knew from his work as a junior doctor in the 1960s that large hospitals required any patient undergoing a procedure to sign a consent form. He gave an example that patients at the time needed to sign consent for anaesthetic, and that the level of sedation in DST was equivalent. He added that the use of consent forms was standard and simply ‘good practice’, and that he wouldn’t expect that every standard practice had to be legislated or mandated.
Deficiencies in record keeping
Professor Parker worked in hospitals from 1967 and told the court that he was familiar with medical recording processes from that time. He was also the first psychiatrist surveyor for the Australian Council of Healthcare standards in 1982 and inspected a number of hospitals in that role.
Prof. Parker said there was a major, substantive problem of deficiencies in Chelmsford hospital’s record keeping. Early in his cross examination he laid out what he would accept as an appropriate set of documentation in a patient’s file and repeated his complaints about the lack of such documentation throughout his two days of evidence. The hospital files he’d examined consistently lacked a referral letter, and therefore lacked documentation of reasons for the patients’ admission to hospital. The files lacked a medical history written by a doctor that recorded a diagnosis or any medical conditions or allergies that might be relevant to the treatment; and they lacked records of any physical examination by a doctor prior to commencement of hospital treatment. He said the Chelmsford doctors made no proper progress notes in the hospital file, and there were no final status reports or discharge summaries to be found either.
Professor Parker complained of cases where complications, such as fevers, arose in sedated patients yet there was little or no documentation recording any examination of the patient by a doctor. Nurses’ notes instead indicated that a number of patients were not examined when complications arose, and that Dr Bailey had given instructions by phone to order pathology tests or to change medications. He had not signed off on any such documentation on file.
He said there was no documentation in the patient files in general by Dr Herron except for occasional references in the progress notes when the patients got into an emergency. Professor Parker said that he regarded that ‘as absolutely unacceptable clinical care and competence.’
During one exchange Ms Chrysanthou suggested that referral letters weren’t necessary if Dr Bailey was admitting a patient to the hospital under his own care. Professor Parker disagreed and replied that the doctor needed to record the reasons for a patient’s admission in the hospital file.
Ms Chrysanthou asked, ‘why would he need to do that? It’s his patient. He’s decided to admit the patient, he knows why…’
The professor answered, ‘a hospital involves a team effort. The doctor needs to record things so that staff working in the hospital are aware of the contingencies.’
Chrysanthou said that diagnosis, comorbidities etc. were not matters that the nursing staff needed to know and that only the treating psychiatrist needed to know them.
The professor disagreed and gave examples that a patient might be psychopathic, or have a particular drug and alcohol, or medical condition. ‘You are obliged in your admission history to cover those issues because they may become major management issues downstream’.
Professor Parker said that it spoke to the management of the hospital that admitting doctors didn’t enter proper records in the CPH files or perform proper medical examinations of their patients. He saw it as a management issue that the hospital had lax standards that encouraged doctors to take a cavalier approach, and that to suggest there are records kept elsewhere is not acceptable when certain basic information is relevant to any procedure a patient might undergo at the hospital, such as ECT.
Under reexamination by Tom Blackburn SC, the Professor said that proper hospital records were also important if an emergency situation arose. He said he’d worked as a doctor in hospitals from the late 1960s, and had read and contributed to many patient records, at that time. Based on that experience, he said that the record keeping at Chelmsford was far inferior to that of other institutions at the time.