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37 years ago a wise mentor got me, as a student MH nurse, to read all the reports from Ely, Normansfield et al. The elements are consistent with all subsequent recent reports from acute settings; inward local cultures, islands of tolerated behaviours, cliques, "strong" personalities not questioned, nurses acquiescing, "everyone knew" but nobody said outside the changing room and pub gossip, places run for and by staff with no service user access to power, forgotten outposts of the NHS conveniently ignored by higher echelons, local managers not wishing to peer too closely in case they see something they have to act upon...…….