A Serious Case Review providing lessons to be learnt
On 31st May 2011 news broke of abuse of adults with learning disabilities and autism being carried out at the Winterbourne View Hospital, provided by Castleback Limited. Panorama in their documentary “Uncover Care: the Abuse Exposed” screened footage showing care workers beating, taunting and bullying those who they were supposed to be taking care of. This abuse had, up until the showing of the documentary, remained unaddressed and unpunished.
In light of the documentary evidence and after investigations were carried out, eleven former workers at Winterbourne have pleaded guilty to 38 charges of ill treatment under the Mental Capacity Act 2005. They are due to be sentenced later at Bristol Crown Court in September 2012.
Due to the seriousness and amount of abuse that was undertaken,South Gloucestershire’s Adult Safeguarding Board commissioned a Serious Case Review. The review looked at various providers of care, including Castleback Ltd, NHS South Gloucestershire, NHS South West, South Gloucestershire Council and Avon and Somerset Police, and reviewed the role each played during the Winterbourne scandal. Mangers of the organisations, their staff, clients and even families of those in care were interviewed and conclusions were made as to the failings of the organisations.
Dame Jo Williams, the Care Quality Commission (the regulator of care homes and hospitals in England) chair has said of the investigations:
“A recurring theme running through all these reports is that the important job of preventing abuse is not just a matter for CQC; good care starts with providers and their staff, relies on effective commission and safeguarding procedures, and is informed by the views of people who use services and their families. We must all work better to ensure people are protected from abuse”
The review found the management procedures in place were seriously below standard and matters were often left unresolved. 13 recommendations have been listed in order to ensure this kind of scandal and footage are never publicised again. They focus on how the organisations can respond to concerns of whistleblowers in order to safeguard those in care.
These recommendations include:
1) Greater investment in community based care; this will reduce the need for in-patient admissions at assessment, treatment and rehabilitation units such asWinterbourneViewHospital;
2) The need for outcome based commissioning for hospitals, whereby the results and outcomes that the services are intended to achieve are focused on as opposed to the services themselves;
3) Follow up action plans when services are not meeting government standards;
4) The discontinuation of t-supine restraint, whereby patients are laid on the ground with the staff using their body weight to restrain them; and
5) Notification of concerns procedures to be improved: better co-ordination, safeguarding of adults and police attendance.
CQC Chief Executive David Behan said:
“There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn’s thorough and comprehensive report. I will ensure that the Care Quality Commission responds fully to all recommendations for CQC. We will continue to work with other organisation to improve communications and sharing of information to ensure we all protect those who are most vulnerable.”
Clarke Willmott can offer advice and representation on a range of legal issues affecting those in care homes and hospitals, including clinical negligence, inquests, mental capacity and community care law. Public Funding (Legal Aid) may be available.
For more information please contact John Boyle .