This chapter aims to bring together components of asylum life—the law, the leadership, staff, patients and public—to create a broad picture about what happened when things went wrong: accidents, injuries, escapes and suicides. There are drawbacks, in that much of the material is necessarily anecdotal with inconsistencies and contradictions. However, cases provide enough evidence to identify repeated patterns of attitudes, behaviours and decision making, from which conclusions can be drawn. The Board of Control indicated that it knew about asylum rough handling, but it did little to try to remedy the situation. Despite their rhetoric of good intentions, the asylum leadership frequently rationalised or denied maltreatment, thus failing to secure the most humane conditions for patients.