“Murder,” “deaths,” “negligence,” “unethical and medical malpractice”—Australian Court Upholds Findings that “Deep Sleep Treatment” is a Psychiatric Horror

It read like a horror movie script but it was a 279-page Australian Federal court judgment about a psychiatric hospital called “Chelmsford” and a lethal drug and electroshock (ECT) combo known as “Deep Sleep Treatment” (DST) practiced there. The November 25, 2020 decision roasted two former DST practitioners—one a deregistered psychiatrist—who had attempted to sue a publisher of a book that included a chapter on DST which is linked to 48 patient deaths in the 1960s-70s.  The doctors protested the book resurrecting and quoting from a two-year New South Wales government Royal Commission inquiry held 30 years ago into their dangerous practices, the findings of which were scorching.

The nightmare for many former patients at Chelmsford was re-lived when Dr. John Gill and Mr. John Herron challenged the book that, essentially, re-hashed the Royal Commission findings and other reports.  It didn’t really add anything new or of value to the story. But Dr. Gill in particular took umbrage with it. His wife testified in the defamation trial that in their discussions about the book, Dr. Gill said words to the effect that it “makes it seem like I am a criminal.”[1]

It’s understandable given that Chelmsford hospital and DST are renowned as one of the darkest episodes in Australian psychiatry’s history. Indeed, one former Chelmsford nurse who testified in this year’s proceedings, accused the main proponent of DST, the late psychiatrist Harry Bailey of the murder of a patient.[2]

DST involved a drug-induced coma using, largely, barbiturates and while patients were unconscious, electroshock treatment (ECT) was administered.[3] The latter was done without administering patients muscle relaxants or anesthesia as is done with general ECT. The manner in which it was delivered in Australia differed to that used in other countries such as the U.S., UK and Canada.

Due to efforts spearheaded by Citizens Commission on Human Rights (CCHR) in Sydney, NSW, DST was banned under the NSW Mental Health Act in 1983. CCHR is a mental health industry watchdog, established by the Church of Scientology in 1969 to investigate and expose psychiatric violations of human rights, and Chelmsford exemplified some of psychiatry’s worst violations.

CCHR was registered in Australia around 1974 and worked with a Chelmsford hospital nurse and whistleblower, the late Rosa Nicholson, to expose DST in the late 70s.  Rosa was instrumental in collecting evidence against the treatment, leading to it being stopped in 1979.

In a damning indictment, the Australian Federal court NSW Registry judge, Jayne Jagot, delivered a scathing rebuke to the applicants in the defamation suit. As was submitted to the judge, “due to the Royal Commission and its findings, these matters form a notorious part of the medical and social history of New South Wales. The applicants have sought to use the vehicle of this litigation, in effect, to prove that the Royal Commission did them a serious injustice by accepting a ‘Scientology [CCHR] version of events.’”[4]

Ironically, there was only one version of the events—that which CCHR, former DST patients and their families and medical experts conveyed: DST was a highly dangerous practice that should never have been used.  Indeed, as one veteran Sydney journalist told me in 1985 when he investigated DST, he could not find “another side to the story” to support its use.

The Royal Commission’s findings had run about 4,000 pages and close to two million words in a 12-volume report.  The findings were reaffirmed with the 2020 judgment:

  • Nearly 300 witnesses testified, including patients, nurses, Chelmsford doctors and senior bureaucrats.
  • Harry Bailey was the main instigator of DST, but committed suicide in 1985 immediately prior to a lawsuit that would have inevitably found against him in favor of the patient suing.
  • Bailey falsified as many as 17 death certificates.
  • 24 DST patients died between 1963 and 1979 with another 24 committing suicide within a year of release.
  • The NSW Department of Health was criticized for neglecting to carry out proper checks at Chelmsford and for failing to properly investigate the deaths.

Judge Jagot stated: “The evidence about the dangers of DST is overwhelming and that fact ought to have been recognized as such by any reasonable medical practitioner with detailed knowledge of the treatment in the 1960s and 1970s.” Further, “The conclusion which must be drawn on the evidence is that DST should never have been performed at all at Chelmsford. To subject patients to it …was unethical, grossly negligent and involved sustained medical malpractice….”[5]

As further detailed in the judgment:

  • Patients recalled being “semi-conscious while given ECT with feelings including burning hot metal being placed on their temples, feelings of dying with a patient’s mind and body going into a great painful darkness, being held down while begging and screaming for the electricity to stop.”[6]
  • One nurse and matron recalled: “On one occasion in my presence, Dr [Ian] Gardiner [psychiatrist] administered a series of ECTs until the patient’s body lifted off the bed so that they were balancing on the back of their head and the heels of their feet and the patient screamed. When this occurred, the nurses had to hold the patient down. I concluded from the physical reaction of the patients when this happened that they could still feel pain.”[7]

As stated, Dr. Bailey was the principal proponent of DST at Chelmsford.  Former psychiatrist, Mr. John Herron, provided ECT to Dr. Bailey’s patients. He then prescribed DST to his own patients using the same procedures as Dr. Bailey. Dr. Gill treated six patients with DST using a modified version of some of the drugs involved but with the basic barbiturate components being the same.[8]

According to the judgment, “By the 1960s a person in Dr. Bailey’s position should have known that he was perpetrating on vulnerable people an experimental treatment based on an outmoded form of therapy which involved a high risk of serious complications and death…He should have known that what he was doing fundamentally contradicted the first principle of medical practice to do no harm…The depths of Dr. Bailey’s disgraceful conduct could not be more plain from the expert evidence….”[9]

Psychiatric “Help” Causes Harm

Further covered in the judgment were the following astounding facts, made worse because the state health authorities ignored them for years, but for CCHR and Barry Hart, a former Chelmsford patient, bringing this to their attention, and forcing action: 

  • The patients at Chelmsford subjected to DST were dosed with barbiturates to a level of deep unconsciousness.
  • The barbiturates used involved a small gap between sedating and fatal
  • “Many patients suffered complications during DST (unsurprisingly given its risks). According to the medical records…they suffered pneumonia and respiratory distress, bedsores, high temperatures, cyanosis, breathing difficulties, vomiting, aspiration of dark stomach fluid, distended abdomens and bladders, and serious blood pressure issues.”[10]
  • Many patients also had distressing memories of being shackled to the bed; patients recall naso-gastric tubes being inserted, choking as liquid was passed through it, and being in such discomfort as to try and tear the tube out.[11]
  • While under DST the patients were given ECT. Oxygen, muscle relaxants and anesthetic were not routinely given to patients being administered ECT despite these being standard requirements at the time.[12]
  • A former Chelmsford Hospital matron (head nurse in charge), Julie Bothman, expressed concern that administering ECT this way could cause “fractures, damage to soft tissue from severe seizures, and pain due to the lack of anesthetic….” [13] She testified that every DST patient was given ECT unless the doctor specifically ordered to the contrary. ECT was performed every day by Mr. Herron or Dr. Gardiner using an “ECT machine [that] did not have a regulator on it … which meant that the doctors were unable to regulate the amount of voltage released by the machine and the duration of the shock.”[14]
  • “The fact that Mr. Herron performed ECT on sedated patients without the routine use of anesthetic, muscle relaxants and oxygen, when these were standard requirements, immediately calls into serious question his medical and ethical judgment.” [15]
  • None of the patients were informed about the dangers associated with DST and thus were not in a position to give informed consent to the treatment.[16]
  • The hospital admission sheet was filled out by the receptionist, who sought to have the patient sign a consent to ECT. There was no consent form for DST.[17]
  • There was a standardized treatment sheet involving a cocktail of drugs to be used for DST. This treatment sheet was used for all patients irrespective of their age, weight or physical condition.[18]
  • Matron Bothman also said that “before and since I worked at Chelmsford, I have never seen barbiturates prescribed in such large quantities, or in the same combinations” and that she was instructed by Dr. Bailey and nursing staff at Chelmsford to sedate DST patients to “a deep level of unconsciousness where they only responded to pain.” She could not “recall any occasion when I observed Dr. Bailey physically examine a patient at Chelmsford before the commencement of Sedation Treatment,” and “Dr. Herron’s patients were not always physically examined at prior to the commencement of sedation.” [19]
  • Doctors were not regularly on duty or present at the hospital, despite the high risk of the treatment.
  • Patients were aware of being in the DST ward but were unable to move or speak, hearing moaning and screaming from other patients, seeing bodies strapped in beds around them as if in a morgue, experiencing foul and putrid smells, and while partially sedated saw other patients being subjected to ECT.[20]
  • The therapy was always reported to involve a high level of risk of death and serious complications.[21]
  • Lightening out of DST caused patients to suffer serious hallucinations. One patient recalled hallucinating people with their arms cut off and blood spurting across the room. Another hallucinated rat crawling across the room and her children being taken away from her in wagons. Patients emerged from DST confused, distressed, disoriented and weak, sometimes unable to walk or bathe without assistance and some having suffered severe weight loss. Some patients experienced convulsions and seizures on lightening out of deep sedation. Some patients felt trapped or imprisoned during their recovery from DST believing (wrongly) that they were locked into Chelmsford. [22]
  • No amount of nursing care at Chelmsford could make the procedure safe and justifiable.[23]
  • Many patients reported continuing problems after DST including long and short-term memory loss, changes in personality, anxiety, depression, respiratory issues, sleeping issues, learning difficulties and migraines. Some patients felt the treatment took away part of their life and is something they have spent their lives struggling to overcome. [24]

 Patients’ Testimony Vindicated

The Royal Commission, held between 1988 and 1990, had been unique because, as confirmed in the recent judgment, patients testified about their recollections of receiving the violence of electroshock while they were meant to be in a “comatose state.” Justice John Slattery, who headed the Commission, accepted their evidence as true.  So did Judge Jagot three decades later.

Yet Gill and Herron “made wide-ranging attacks on the credibility of witnesses,” according to Judge Jagot’s findings, including patients, “blaming their unreliability on their pre-existing psychiatric conditions, sedatives they were given as part of DST, and their subsequent involvement with the Chelmsford Victims Action Group, as well as noting the effect of adverse publicity about Chelmsford on their thinking. These allegations do not confront the reality of DST and the harm that it was capable of causing and did in fact cause. None of the applicants’ criticisms undermine the essential thrust of the evidence—that for no sound medical reason and without their informed consent patients were subjected to a dangerous ordeal that many found terrifying and traumatizing.”[25]

Judge Jagot also opined: “I consider the evidence of former patients of Chelmsford who underwent DST and their relatives discloses that the treatment involved a most serious form of abuse of vulnerable persons.” Further, “Even if the patient had been fully informed of the nature of the treatment (which, despite the self-serving evidence of the applicants and Dr Bailey to that effect, is inherently unlikely as the patients would have had to be informed in clear terms of a real risk of serious long-term harm and death), nothing could have prepared them for the trauma that the evidence indicates DST inflicted on many patients.” [26]

Doctors’ Responsibility Re-Affirmed

Gill and Herron deferred to Dr. Bailey as the expert, trying to distance themselves from any responsibility for the damage DST caused and to lay any blame largely upon him. But as Judge Jagot made clear: Dr. Gill, who was co-owner of Chelmsford, “de facto controlled Chelmsford on behalf of its owners. As the person with such de facto control, Dr. Gill had ultimate oversight of the treatments offered at Chelmsford and responsibility for ensuring that the treatments offered could be provided in a safe and appropriate manner.” DST “could never be provided in a safe and appropriate manner at Chelmsford and Dr. Gill, given his medical training, should have known this from the moment he understood the nature of DST.”[27]

Judge Jagot continued: “Dr Gill was a general practitioner with the power to decide what treatments could be provided at Chelmsford (even if that power was one to be exercised in consultation with his fellow part owners).” Both Herron and Gill “were not entitled to suspend their independent medical judgment merely because Dr Bailey was a well-known psychiatrist and an apparently charismatic figure. From their medical knowledge they must have known that DST was highly dangerous and by the 1960s and 1970s was well outside the bounds of mainstream psychiatric practices.”[28]

It didn’t end there, with such findings as:

  • “While Dr Bailey and Mr. Herron were primarily involved in administering DST at Chelmsford the evidence also satisfies me that Dr. Gill bears responsibility for the negligence, unethical conduct and medical malpractice involved in the administration of DST at Chelmsford.”[29]
  • “Dr. Gill personally administered DST to six patients, one of whom died. Given my conclusions above, this fact alone is sufficient to mean that Dr. Gill was negligent and engaged in unethical conduct and medical malpractice.”[30] 
  • “The fact that Dr. Bailey and Mr. Herron were specialists and Dr. Gill was a more junior (in years of experience) general practitioner does not absolve Dr Gill of responsibility for permitting a highly dangerous treatment for which there was no justification from being provided in the hospital over which he had de facto control. Dr Gill was obliged by his ethical and professional duties as a medical practitioner to ensure the other owners knew what was happening and to ensure it ceased….”[31]

The “applicants” were critical of any messenger exposing the lethal effects of DST and Judge Jagot also rejected their claims, noting their submissions consistently identified “any discrepancy in a person’s version of events over time as evidence that the person is a liar or fantasist.” They explained away evidence as “a result of the adverse influence of publicity and the Chelmsford Victims Action Group, and otherwise mischaracterize any material that does not fit with the applicants’ worldview of a false narrative (the so-called ‘Scientology version of events’) unfairly perpetrated on them over decades.” (Emphasis added)[32]

The horror show kept being exposed throughout the trial, and not even children escaped it.

Children Couldn’t Escape Abuse

Herron administered the lethal practice to teenagers.  According to the judgment Herron’s “extraordinarily cavalier attitude to the use of DST despite its known risks is exposed by the fact that he subjected children to the treatment. The applicants have not sought to explain how it could have been thought appropriate by Mr. Herron to render a child unconscious for an extended period through the use of barbiturates.”[33]

Cases were cited, including a 13- and 14-year-old. “How he could have thought that subjecting a child to this dangerous unproven treatment was appropriate is not apparent.”[34]

Psychiatric “Treatment” Kills Patients

A significant number of patients died while under or immediately after the administration of DST in circumstances where it should be inferred from the evidence that DST caused their deaths, the judgment stated. “Mr. Herron and Dr. Gill continued to administer DST despite knowing of the deaths and took none of the steps that would have been necessary at the time to investigate the cause of death and suspend or cease the treatment if the cause could not be mitigated.”[35]

The evidence was also clear that:

  • Given that it was a small private hospital they could be expected to know of every death under DST from the time of their involvement with Chelmsford.
  • Herron said in his affidavit that he was “aware at the time that sedation patients had died.”
  • Gill was present after a patient, Ann Bennett, died and was aware of the death of his own patient, John Adams, but in any event, it would be inferred on the evidence that given his role at Chelmsford and involvement with the hospital he would have known of each of the deaths from 1972 onwards.
  • Herron and Dr. Gill continued to use DST despite the number of deaths it caused. Mr. Herron continued until 1979.[36]
  • “Mr. Herron accepted during the Royal Commission that 26 people had died during or immediately after DST and that DST was a significant contributing factor to their deaths but, in this proceeding, said he had changed his mind and did not accept that DST was a cause of these patients’ deaths. It is difficult to imagine Mr. Herron having made any concession at any time unless it was unavoidable on the evidence. No cogent reason for the change in position was apparent other than Mr. Herron’s self-interest in this proceeding.”[37] 

CCHR and Nurse Rosa Nicholson helped get coroner’s inquests re-opened into some of the deaths, including: John Adams, Miriam Podio and Audrey Francis.  Additionally, Sharon Hamilton, a patient of Dr. Bailey’s with whom he had sexual relations—committed suicide and CCHR had her inquest reopened.

Audrey Frances, 66, was a journalist who died in 1976 while undergoing DST.  In the 2020 trial, Herron claimed that she had “demanded” DST.  Judge Jagot rejected this, referring back to the coroner’s inquest: “Nowhere in Mr. Herron’s evidence before the Coroner is there any reference to Ms. Francis insisting on having deep sleep treatment, knowing of the drugs that were proposed to be administered to her or having said that she had done research or read literature about sleep therapy.” Further, “Had Ms. Francis insisted on DST irrespective of the risks (an inherently unlikely scenario), then Mr. Herron would have informed the coroner to that effect. Yet he made it clear to the coroner that it was his recommendation (not Ms. Francis’s insistence) that she be subjected to DST.”[38]

  • Francis was given 3,600mg of barbiturates in a period of about 36 hours—more than double the dose associated with severe toxicity.[39]
  • “ Herron admitted during cross-examination that Ms. Francis had an elevated risk of mortality because of her weight and physical condition: He was therefore clearly conscious that subjecting her to a treatment such as DST, which puts strain on the body including reducing respiratory function, would increase that risk.”[40]
  • “Given the risks of death and serious complications associated with DST and the availability of safer and better alternative treatments,” Judge Jagot was “unable to accept any suggestion that Mr. Herron complied with these obligations. Rather, he decided to subject Ms. Francis to an experimental treatment involving serious risks of harm for which there was no indication and despite safer and proven to be efficacious alternatives being available. This was gross negligence, unethical and medical malpractice.”[41]
  • “Mr. Herron’s self-serving and inconsistent evidence over the years leads to the conclusion that he signed the death certificate to avoid a coronial inquiry into Ms. Francis’ death when, on the evidence, the actual cause of death was DST.”[42]
  • “For the reasons already given it was grossly negligent, unethical and medical malpractice for Mr. Herron to subject Ms. Francis to DST. She died from the treatment which given its serious risks and her physical condition was not outside the reasonably expected range of outcomes for her.”[43] “I am satisfied that DST caused the death of Ms. Francis,” Judge Jagot said. [44]

John Adams, a 25-year-old, had to be resuscitated while under DST at Chelmsford and died a week later in Hornsby Hospital after his transfer from Chelmsford. He was Dr. Gill’s patient who initially used Dr Bailey’s pro-forma treatment sheet for Mr. Adams’ first treatment with DST. CCHR, using information from Rosa Nicholson, was able to get an inquest into Adams’ death through information provided the then NSW Attorney General, Frank Walker.  Judge Jagot’s judgment stated:

  • “In subsequent admissions of Mr. Adams, Dr. Gill used Lethidrone, an opiate antagonist, in conjunction with Tuinal (and sodium amytal) to allow drug addicts to withdraw quickly, while sedated. There is no evidence that Dr. Bailey or Mr. Herron used this combination of drugs. Dr. Gill appears to have come up with the combination on his own without any research or consideration of the potential for drug interactions….Dr Gill’s treatment modification of the polypharmacy used in DST was itself experimental.”[45]
  • Based on testimony in the Royal Commission, “ Gill’s own evidence is that the DST he gave to Mr. Adams at Chelmsford contributed to his death.” [46]
  • And in a further damning recognition, the judgment stated: “There seems to have been no recognition by Mr. Herron and Dr. Gill that they were involved in something ‘calamitous and catastrophic,’” as one expert in the case, Professor Gordon Parker, described, it.[47]

Dr. Gill rightfully received a lion’s share of criticism as he did from the Royal Commission, which had made severe comments about Dr. Gill, including:

  • “Gill was a most unsatisfactory witness. He was prepared to lie when the occasion demanded it. He ultimately continued his delusional attacks on innocent people in the witness box in the face of clear evidence he was wrong. He was prepared to indulge himself in the falsification or removal of records if his interests were threatened.”[48] 
  • A doctor who spoke in defense of Dr. Gill’s reputation this year agreed “that he did not know of any doctor other than Dr. Gill who thought other than that the medical treatments at Chelmsford were discredited and dangerous. He agreed that the Royal Commission made serious adverse findings against Dr. Gill and that the Royal Commission report received significant publicity. He accepted that it is notorious within the psychiatric community in Australia that the practice of DST at Chelmsford, including by Dr. Gill, involved the mistreatment of vulnerable patients by the provision of dangerous, non-evidence-based treatment, being DST, and said he suspected this was the view held by the medical community generally. He agreed that Dr. Gill’s behavior at Chelmsford was part of a deeply shameful aspect of the history of psychiatry.”[49]

In summary, it was alleged in court that “by their conduct, Mr. Herron and Dr. Gill materially contributed to (that is, caused) the death of many patients at Chelmsford from DST. They were integral parts of a system or pattern of conduct that enabled the administration of DST and ECT at Chelmsford to continue.”[50]

The judgment drew on the expert testimony given in support of DST being dangerous. Most of those doctors had given testimony to the Royal Commission or made earlier comments about DST’s serious, lethal risks.  However, two psychiatrists that testified had nothing to do with the early history or exposure of DST or stopping it; in fact, one had not even finished medical school at the time.

But the expert evidence made it clear that the first principle of medical practice was at all times to “do no harm.”[51] It’s a policy still ignored by many psychiatrists in the mental health industry today.  While deep sleep treatment is disavowed now as part of psychiatry’s armory, electroshock treatment is still used and causes as much damage as it did as part of DST. It’s still given patients without their consent—despite the United Nations identifying this practice as torture.

Ultimately, Judge Jagot determined: “I have no difficulty in characterizing the conduct of Dr. Bailey and Mr. Herron and Dr. Gill as gross negligence.” [52]

That could well be extended to other psychiatrists practicing dangerous “therapies” under the guise of mental health care today.

CCHR, along with DST survivors, especially the late Barry Hart, who was key to the Chelmsford Hospital expose, journalists, lawyers, legislators and their staff, were tenacious in putting pressure on the NSW government to investigate how the practice could have continued for as long as it did, while the death toll kept rising. This culminated in the NSW Royal Commission and reforms to Australia’s mental health system. The Chelmsford doctors/psychiatrists would have preferred to have it otherwise. Yet, as Judge Jagot determined, John Herron’s “continued insistence to the contrary merely confirms his determination to be vindicated at any cost for what he perceives as the injustices wrought upon him by the Church of Scientology, his patients, and the Royal Commission.”[53]  The injustice wasn’t against the perpetrators of a barbaric “treatment,” but against its victims.

A special note must be made about Rosa Nicholson. Her story has never been fully told; the author of the book upon which the defamation suit was based, had theories about her work but, ultimately, missed the mark. The findings in the current case were a vindication of Rosa and CCHR members who battled for more than a decade for justice for the DST victims. Judge Jagot quoted that the “exposure of psychiatric abuses inside Chelmsford was arguably Scientology’s finest moment in Australia,” which, in turn, is due to CCHR and Rosa’s efforts.[54]

The credit for this finest moment exposing and stopping such a psychiatric atrocity, is shared by former patients and their Chelmsford Victims Action Group who represent one of the most tragic and egregious examples of psychiatry running amok to violate their Hippocratic Oath to “do no harm.”

References from the 2020 judgment

[1] Point #147 in the judgment.

[2] Points 59, 88

[3] Point 212-218

[4] Point 4

[5] Point 3

[6] Point 469

[7] Point 85

[8] Point 211

[9] Point 465

[10] Point 470

[11] Point 469

[12] Point 2

[13] Point 85

[14] Point 85

[15] Point 32

[16] Point 3

[17] Point 212

[18] Point 214

[19] Point 67

[20] Point 469

[21] Point 430

[22] Point 469

[23] Point 43

[24] Point 469

[25] Point 144

[26] Point 468

[27] Point 485

[28] Point 461

[29] Point 482

[30] Point 483

[31] Point 486

[32] Point 5

[33] Point 462

[34] Point 462-3

[35] Point 3

[36] Point 687

[37] Point 33

[38] Points 29-30, 507

[39] Point 510.5

[40] Point 510.4

[41] Point 506

[42] Point 703

[43] Point 513

[44] Point 511

[45] Points 514-515

[46] Point 516

[47] Point 490

[48] Point 152

[49] Point 153

[50] Point 732

[51] Point 413

[52] Point 457

[53] Point 40

[54] Point 14

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