Four deaths in 27 days - and questions still remain

Now, 26 years later, they are the subject of a major police investigation.

The deaths occurred at the psychiatric unit of Darlington Memorial Hospital, which at the time was pioneering an informal approach to treatment amid staff shortages.

The unit's problems were compounded by a fifth unnatural death, eight months later.

The first four deaths were followed by an internal inquiry, but this produced few results.

The case was taken up by local councillor Chris Binney, who was also a member of Darlington Community Health Council and, as a firefighter, had been called to the scene of the fourth death at the hospital, that of elderly patient Jonathan Longstaff, who burned to death in his bed in the psychiatric unit.

Mr Binney was uncomfortable with certain aspects of the internal inquiry, especially as he had discovered a mysterious Biblical reference to starting fires near the victim's bedside.

He called for an independent inquiry, which would be headed by Manchester barrister Harold Day.

The Day Inquiry took six weeks and cost the then princely sum of £7,000, but its full, unabridged report, which at the time was believed to be highly critical of the hospital management, was never made public.

Even so, the abridged version makes damning reading, as it concluded with the recommendation that the head of the psychiatric unit, Dr Eric Burkitt, be replaced. He was, within days, but this only excited greater anger among his colleagues, who felt he was being made the scapegoat.

Also heavily criticised was the Memorial's administrator, George Beckwith.

The Day Inquiry said it was "appalled by his administrative complacency".

Mr Beckwith, who died in 1988, was given a "resign or retire" ultimatum by the hospital authority two years later, because of an unrelated matter - although it was clear that the "complete failure of administration from top to bottom" during the scandal contributed to the ultimatum.

Perhaps more sinister was the Day Inquiry's finding that a patient's notes and a letter had been "removed or mislaid" by the hospital, and were only made available to the inquiry after it had finished its work.

These notes referred to an unnamed patient who had been on the ward at the time that Second World War veteran Mr Longstaff burnt to death.

The fire was ascribed to Mr Longstaff dropping a match while lighting his pipe - the report concluded that it was a little known fact that he smoked.

But the missing letter showed that the unnamed patient had set fire to a hospital ward on two occasions prior to June 1971.

The missing notes showed that in the hour following Mr Longstaff's death - the second death of a patient that day, as, earlier, George Charters had stolen a hospital vehicle and gassed himself - the unnamed patient became "increasingly restless" and he started saying how "he would like to start a fire".

He was then transferred to Winterton Hospital.

It is clear from reading The Northern Echo's coverage from 25 years ago that the psychiatric unit was itself a deeply troubled place. The day after the fifth patient died, it was reported that a male nurse had been suspended because the police were investigating allegations of "unlawful sex with a female mental patient".

So it would appear that the 2001 police inquiry has to decide whether the deaths were a tragic coincidence, whether they were the result of mismanagement and staff shortages - or whether there was something more sinister afoot in the Cogwheel Psychiatric Department