The former admiral seconded to Ashworth Hospital in the wake of the damning Fallon report has his work cut out. Laura Donnelly looks at the options

'The hospital's negative, defensive and blame-ridden culture is so deeply ingrained that we doubt even the most talented management team could turn it around.'

The conclusion of the two-year inquiry conducted by former judge Peter Fallon QC into allegations of pornography, drug abuse, and unsupervised contact between paedophiles and a young girl is stark.

'Ashworth Hospital,' it says, 'should close at the earliest opportunity.'

The hospital's former chair, Paul Lever, who resigned last week in the wake of the report, agreed during the inquiry that Ashworth had reached 'an irretrievable position'.

But Ashworth Hospital will survive because health secretary Frank Dobson has concluded that Ashworth's 'shameful story of confusion, indecision, mismanagement and incompetence' is not enough to warrant closure.

Instead, Mr Dobson is 'considering' a least worst option offered by the review team - the break up of the hospital into 'smaller, physically separate units'. And he wants action now.

New chair Ian Pirie has been seconded from Morecambe Bay HA and given just four months to create a programme to turn Ashworth around.

Mr Dobson hopes 'he will bring to this task the leadership and management skills that he demonstrated as an admiral in the Royal Navy'. But will he end up going down with the ship?

Ray Rowden, former chief

executive of the High Security Psychiatric Services Commiss-ioning Board, believes taking on Ashworth is an inhuman task.

He says: 'If you put St Peter in charge of Ashworth I guarantee he would find himself compromised within 18 months.'

The criticisms levelled at Ashworth centre on its 'dysfunctional' management culture, with senior managers described as 'secretive, out of touch and totally unable to control this large institution'.

Mr Fallon criticises the lack of any 'direct line of accountability' between special hospital trusts, regions, the NHS Executive, the Department of Health and

ministers.

The role of NHS regional offices comes under particular focus.

'The polite fiction that regional chairs and officials are merely advisers and agents of the secretary of state is just that - a fiction.

'The reality is that no sensible chief executive would treat their regional director as anything other than a line manager in all but name.'

Mr Rowden believes that the reduced role of NHS regions, following the creation of the Special Hospitals Services Authority in 1989, was a 'great mistake'.

'It brought the special hospitals into the civil service culture with its primary aim to cover the backs of ministers.'

Mr Rowden welcomes Mr Dobson's 'short-term' decision to make key players in the special hospitals directly accountable to himself. But he criticises the lack of attention paid to mental health at NHS Executive level.

'The Executive does not have a single director on the board who understands the nuts and bolts of mental health,' he says.

Mind, the National Schizo-phrenia Fellowship and Sir Louis Blom-Cooper, whose inquiry into Ashworth eight years ago led to a liberalising of the regime there, agree with Mr Rowden that Ashworth should close.

And even if Ashworth acting chief executive Peter Clarke says the task of creating 'a new Ashworth' is already in hand, an institution known for its troubles will struggle to attract good staff to bring in radical change.

The Fallon report says the most 'compelling evidence of the inadequacy' of Ashworth's doctors came in a note of a telephone conversation with SHSA medical director Pamela Taylor.

It reported that just three of 11 doctors were competent. Others were variously described as lazy, weak, appalling, having a serious drink problem, unstable and out of their depth.

During the inquiry, former SHSA chief executive Charles Kaye admitted that such staff were retained because without them the service would have 'fallen to bits'.

But Mr Clarke says: 'Of those doctors identified as incompetent in the report, only two are still with us. And we have recruited some excellent consultants in the recent past.'

He believes Ashworth can attract new staff by increasing its links outside the organisation.

Ashworth is 'exploring' an alliance with Mental Health Services of Salford trust - from which Mr Clarke was seconded.

He says: 'If the organisation is an isolated and insular institution going about its business in a mediocre way, or worse, it will not attract good people. The process of change has already begun.'

Report of the Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital. Volume 1. Stationery Office.£36.

The mighty are fallen

Those responsible for running the special hospitals were singled out in the Fallon report. It says:

former Ashworth chief executive Janice Miles was 'out of her depth'. She was suspended over her handling of a patient's complaints which led to the inquiry. She later quit.

Former SHSA chief executive Charles Kaye's position would be 'untenable' if the authority still existed under his leadership. His actions were 'at odds with his fine rhetoric about the SHSA's policy of openness... he encouraged a climate of secrecy and suppressed two very important reports'.

Former SHSA chair Anne-Marie Nelson received 'no criticism of her personal actions', but 'if public accountability is to have any meaning then the most appropriate response remains that of resignation'.

Former Ashworth chair Paul Lever 'worked hard to deal with the problems' but 'he still has to be accountable... if he had not already indicated an intention to step down early in 1999 we would have recommended that he do so'.

Former SHSA head of medical services Professor Pamela Taylor was 'well aware of the inadequacies of her clinical colleagues' but 'failed to take rigorous enough action'. She 'attracts our severe criticism'.