Publication — not a case

The inquiry told to accept every recommendation but one

In 1992 a committee of inquiry into Ashworth Special Hospital made 90 recommendations. The Secretary of State accepted all of them except the one that would have ended seclusion.

NHS mental health · 1990s

What this is

The Committee of Inquiry into Complaints about Ashworth Hospital, chaired by Sir Louis Blom-Cooper and reported in 1992 as Cm 2028. It examined complaints about Ashworth Special Hospital at Maghull, Merseyside, a high-security psychiatric hospital. Its remit covered management, the regime patients lived under, the handling of patients’ complaints and the hospital’s use of seclusion. It was appointed after allegations about the treatment of patients there.

The date of publication, and the period over which the committee sat, are not established in the sources held.

What it records

The committee made 90 recommendations. One of them was to phase out and ultimately end the practice of seclusion.

The Secretary of State ordered the Special Hospitals Service Authority to accept the report and all of the recommendations save that one. The authority was required to deliver an action plan to the Department of Health by 1 September 1992, and a task force was sent into the hospital.

The inquiry also found serious mismanagement, including a failure after 1989 to stop the circulation among staff of “hateful literature” about patients.

All of this is carried in the Fallon inquiry report, Cm 4194, published in January 1999, at paragraph 2.15.35, which is where the 1992 findings sit in the sources held here.

How to read it

Three rules.

First, this is a finding about a hospital’s regime and management, not about any patient or any named member of staff, and it should never be cited as though it settled what happened to one person.

Second, the refusal is the fact worth quoting, and it is not evidence that seclusion continued. Nothing in the sources held says what happened to seclusion at Ashworth after 1992, and this page does not guess.

Third, “accepted all but one” is not “implemented all but one”. An action plan delivered to a department by a date is a document, not an outcome.

The reason it earns a page: seclusion was not challenged here as a dangerous technique. It was challenged as a practice that ought to end, and the challenge was refused at the top of the system. That is the argument a trainer meets in any service that still has a room it uses.

Where it stops

One hospital, one year, England. The report itself was not obtained. No digitised full text of Cm 2028 was located, so the 90 recommendations, the seclusion recommendation and the refusal all rest on the Fallon report’s account of them. The other 89 recommendations are not summarised here, because the sources held do not set out their text.

It is evidence of 1992, not of now. No follow-up, no implementation review and no patient-level finding is offered, and none should be inferred from the fact that the report was accepted.

Sources

Where a service still has a room it calls something else, our physical interventions training works through the alternatives that have to exist before a seclusion policy can change.

Reviewed 20 October 2026.

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