I'VE been writing a lot about mental health lately on our Breaking the Silence blog as well as for the magazine One in Four.
This has largely involved helping people tell their stories of mental distress.
Posts by Suzie Grogan about her family history and Deerbaby who wrote about a fleeting moment etched on her memory inspired me to find out more about an institution I mentioned in our recent carnival of blog posts about mental illness.
And I've discovered half a story. It's the sort of story the me of 15-20 years ago would have jumped on. I may still do that. Perhaps I could pull a more in-depth report together.
But I never knew that in Feb 1969 24 patients died in a fire there.
They were locked in, despite a previous change in the law that said patients shouldn't be. Most of the patients died from smoke inhalation.
An accident investigation found no night staff had been trained in fire evacuation procedures for at least 20 years despite urgent calls for such training six years earlier. There was a delay of 10 minutes between a nurse first noticing smoke and calling the fire brigade. The report also found that staffing at the hospital was "on the low side".
I'm thinking I'd like to go to my home town and see the local coverage that followed, track down relatives of people who died and see what they remember of what happened and what action, if any they took after the fire.
The 24 patients who died were described as elderly women. Things were said to be made worse by the age of the building, referred to in the Hansard report of questions on the subject in the immediate aftermath as “Constructed 14 years before the Indian Mutiny,” and by the fact that women patients were routinely locked in their ward at night.
Staffing was also questioned after the event – only two qualified nurses and a junior to oversee almost 100 severely mentally ill women, some of whom couldn't move from their beds.
Questions were asked in the House of Commons about the fire and fire reporting was reviewed in the wake of the tragedy.
I find this fascinating.
And I think I'd like to know more.