Royal Commission into the Hospital for Insane, Kew (1924)

In May 1923, a young and inexperienced Ellery was appointed as a junior medical officer at the Kew Asylum. Nine months later, he was transferred to the adjoining but separate institution known as Kew Cottages as its medical officer.^[1] Appalled at the conditions he witnessed there, he endeavoured to make improvements in the institution and the treatment of its patients. For example, owing to the extant health risks, he sought to destroy bug-infested furniture, much to the displeasure of his superiors and colleagues.^[1]

Ellery's attempts at improving conditions at Kew Cottages were seen by the general medical staff as a threat to the comfort of their settled routines.^[2] Nurses and attendants met informally, together and separately, in order to elicit from one another information which could be formed into the basis of a complaint of cruelty and maladministration against Dr Ellery. They did so not out of concern for the interests of the patients, but with a view to displacing Dr Ellery from his position.^[3] An anonymous letter was sent to the Inspector-General of the Insane, Dr W Ernest Jones, setting out these complaints, and the nurses and attendants wrote to the secretary of the Victorian Branch of the Hospital Employees' Association, requesting that the association press Dr Jones to conduct an inquiry. He did so in August 1924, finding no evidence to substantiate the allegations.^[1]

In July 1924, the Prendergast ministry had been elected in Victoria, and had strong ties to the Hospital Employees' Association.^[1] Moreover, members of the press and politicians received information leaks regarding the matter.^[4] The new government had instituted three royal commissions in its short tenure, and with that, Ellery became the first psychiatrist in Australia to have his activities examined by a royal commission.^[1]

The royal commission was held between 5 and 19 November, 1924. The association was represented by Mr F. Brennan, and Ellery was represented by future prime minister Robert Menzies.^[3]

The royal commission was specifically charged with inquiring into the truth or otherwise of a number of allegations made against Dr Ellery, being that he:

1. Extracted teeth from patients without good and sufficient cause in front of other patients, and allowed nurses to do the same.
2. Catheterised a number of male and female patients solely for the purposes of demonstrating the appropriate technique to the nurses, the patients having no medical requirement for such a procedure.
3. Gave medically unnecessary injections of apomorphine, bacillus coli vaccine, and glucose solution, to a number of patients in unsuitable conditions in respect of hygiene, privacy, and decorum.
4. As a result of his maladministration, subjected patients to undue hardship from cold or wet conditions, and subjected some crippled patients to open-air bathing at times or in circumstances calculated to inflict undue hardship or suffering or to endanger health.
5. Permitted or required patients to remain unduly long in unclean or wet clothing or conditions.
6. Permitted improper or indecorous intermingling of male and female patients.
7. Permitted female patients to be inside the male dormitory unattended and in sight of male patients or otherwise in an indecorous or undesirable manner.
8. Brought intoxicating liquor into the institution, or permitted other persons to do so, contrary to regulations.
9. Told female staff members improper or indecent stories.

Additionally, the commission was required to make a finding as to whether there was any evidence of a conspiracy on the part of the staff against Dr Ellery.^[3]

Kelley found that the tooth extractions, catheterisations, and injections were conducted with good and sufficient cause. However, he found that Ellery should not have extracted teeth in front of other patients, nor allowed nurses to extract teeth from patients. He also found that it was inappropriate in all circumstances to catheterise patients for demonstration purposes, although this practice was known and endorsed by Ellery's superiors, who considered it his duty to provide demonstrations of and training regarding certain medical procedures to nurses on request.^[3]

The allegations regarding the wet and cold conditions of the institution and the clothing issued to patients were found to be caused by circumstances not within Dr Ellery's responsibility, and, in any case, a state of affairs well preceding his appointment. The allegation regarding open-air bathing was found to be an appropriate and temporary arrangement during bathroom renovations, however Ellery was criticised for not arranging curtains for the protection of bathing patients. No evidence was put forth to substantiate the allegations relating to male-female intermingling and the presence of intoxicating liquor. The allegation that Dr Ellery told female staff improper or indecent stories was not proved because of a lack of evidence and the unavailability of the person to whom the stories were allegedly told.^[3]

Kelley, however, made criticisms of Dr Ellery which did not arise directly from the allegations, but which were rather "cognate matters". Such criticisms include that he should not have used chloroform to subdue a patient unwilling to undergo an otherwise legitimate and proper blood test, and that he should not have force-fed a patient solely for the purpose of demonstrating the appropriate technique to nurses.^[3]

Kelley said that there was insufficient evidence for him to find the existence of a conspiracy within the meaning of the criminal law, however, he found that:

1. There was an agreement amongst the staff to give accounts of certain events which were helpful to the furtherance of the complaints.
2. None of the staff present during the events complained of made known any complaint at the time of its occurrence.
3. Some time after all of the relevant events, informal meetings were held amongst staff in order to discuss and formulate allegations to be made against Dr Ellery.
4. The attitude of the nurses and attendants through the course of the royal commission changed from "more or less unconcern for the patients to a vigorous attack on Dr Ellery".
5. Attendants O'Grady, Roper, Myers, McDuff, and Sheehan all gave untruthful evidence to the commission, concocted to further the effect of their complaints against Dr Ellery, and did so knowing, due to their long service, that Dr Ellery was not responsible for many of the matters complained of.
6. There was no evidence whatever of any act of cruelty wilfully and deliberately practised by Dr Ellery on any patient.
7. The complaints were motivated by animosity and intended to displace Dr Ellery from his position.^[3]

The Argus reported on 27 November 1924 Ellery's "vindication" at the royal commission.^[5] However, the impact of the commission on Ellery's life was substantial. Despite his supposed exoneration, he was left with significant legal expenses which were not paid by the government. Following the royal commission, Ellery was transferred to Sunbury Asylum, a relatively rural location at the time.^[4]