Mr Walton, 20, a sex offender admitted to the hospital five years earlier, had been told to clean the toilet as a punishment for making sexual advances to a patient.
The morning after his seclusion, he was found dead in the side ward, his legs dangling over the side of the bed, his pyjamas dangling round his ankles. Neither the post-mortem examination nor the inquest was able to pinpoint how or why he died. An inquiry by Tony Barsted, the chief nursing officer, was partial and inadequate and had a 'disabling effect' on an investigation, the Blom- Cooper report said. 'Had Sean Walton not died, the incidents of the snooker cue and seclusion would have remained unknown to the public. The whole sequence of events . . . was symptomatic of the pattern of patient life on Firs Ward in the late 1980s.'
Two years later, another patient, Geoffrey Steele, 36, who was seriously mentally disturbed and suffered hallucinations, was found with multiple bruises in a shower room. He had been beaten up by two staff after dropping some crockery in the ward kitchen.
The subsequent actions of Colin Sheeran, a nurse, and Robert Keith, a nursing assistant, who were found responsible for bullying and bruising Mr Steele, were 'designed to protect themselves from discovery'. The behaviour of Muriel Dunnigan, the nurse in charge who failed to report the incident, smacked of 'defensive, unprofessional manoeuvering', the report said.
Complaints against Brian Johnson, the hospital's general manager, for not holding an internal inquiry or mounting any proper investigation of the Steele incident, were upheld.
Gillian Darnell, a young patient with a personality disorder, claimed she was repeatedly sexually assaulted for several months in 1985 by Peter Williams, a nurse who had, she said, threatened to give her a lethal injection and set fire to her father's house if she ever talked to anyone about the incidents. Hospital administrators and managers refused to hold an investigation into her allegations, despite the existence of several witnesses.
Mr Williams denied the allegations and did not know why Miss Darnell had made them. 'When on the ward with her, we did have a good working relationship, although she was totally besotted with me,' he said. The Blom-Cooper inquiry concluded Mr Williams had a case to answer, and an inquiry has now begun.
The fourth case examined by the committee of inquiry was that of Gary Harrington, who hanged himself in his room in May 1990, three years after being admitted to Ashworth.
Despite being an obvious suicide risk, with no close friends and spending much of the time alone in his room, the hospital had no plan for his care or rehabilitation. It was three and a half hours before anyone bothered to tell Mr Harrington's mother of his death. There were no formal procedures for informing relatives of patients' deaths.
'His death was a tragedy, made more tragic by the predictability and preventability of a deliberate act of self-destruction. The response of the hospital management fell short of acceptable standards,' the report said.
The seven Ashworth nursing staff suspended from duty yesterday pending disciplinary hearings over accusations of gross professional misconduct are: Tony Barsted, aged 50, the chief nursing officer; Norman Bell, 39, a charge nurse; Wayne Dolan, 29, an enrolled nurse; Muriel Dunnigan, 43, a charge nurse; Colin Sheeran, 34, John Griffiths, 35 and Robert Keith, 43, all nursing assistants. The last three of these are also accused of assault.
Joseph Silvester, the medical director at Ashworth, and Brian Johnson, the hospital's general manager, have been relieved of their responsibilities and moved to other posts.
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