Serious Case Review into Winterbourne View details litany of failings

A damning independent review into the abuse uncovered at Winterbourne View Hospital has sharply criticised its operator, NHS commissioners, a local authority, the police and regulators.

The SCR was commissioned by South Gloucestershire’s multi-agency Safeguarding Adults Board after an undercover reporter working for the BBC’s Panorama programme revealed abuse of adults with learning disabilities and autism at the hospital.

The review, conducted by adult safeguarding expert Margaret Flynn, called for greater investment in community-based care in a bid to reduce the need for in-patient admissions in units such as Winterbourne View.

It said practices such as ‘t-supine restraint’, where patients are laid on the ground with staff using their body weight to restrain them, should no longer be used.

The review also called for notifications of concern, including safeguarding alerts, hospital admissions and police attendances to be better co-ordinated and shared by safeguarding organisations.

Castlebeck, which ran Winterbourne View, was meanwhile heavily criticised for a catalogue of failings in its management procedures.

The company acknowledged that there was insufficient senior management oversight of the hospital and that staff’s use of physical restraint did not reflect the training delivered.

The Flynn Report concluded that the apparatus of oversight across sectors was “unequal to the task of uncovering the fact and extent of abuses and crimes at Winterbourne View”.

Its findings included:

  • NHS commissioners believed that they were purchasing a bespoke service for adults with learning disabilities and autism. There was no overall leadership among commissioners. They did not press for, nor receive, detailed accounts of how Winterbourne View Hospital was spending the weekly fees on behalf of its patients. Even though the hospital was not meeting its contractual requirements in terms of the levels of supervision provided to individual patients, commissioners continued to place people there. Families could not influence the placement decisions. There was limited use of the Mental Capacity Act 2005, most particularly concerning adults who were not detained under the provisions of the Mental Health Act 1983. Although some commissioners funded advocacy services, Winterbourne View Hospital controlled patients’ access to these.
  • The whistleblowing notification was not addressed by Winterbourne View Hospital nor Castlebeck, irrespective of the fact that it was shared with Castlebeck managers with responsibility for the hospital. Although connections were made in terms of safeguarding and patient safety, the inter-organisational response to the concerns raised by the whistleblowing email was ineffective.
  • The volume and characteristics of safeguarding referrals which were known to South Gloucestershire Council Adult Safeguarding were not treated as a body of significant concerns. South Gloucestershire Council Adult Safeguarding had only an edited version of events at Winterbourne View.
  • The existence and treatment of other forms of alert that might cause concern confirmed the complexity of safeguarding adults from both local authority and regulatory perspectives i.e. had both been aware of: patients’ limited access to advocacy; notifications to the Health and Safety Executive; the hospital’s inattention to the complaints of patients and the concerns of their relatives; the frequency with which patients were restrained and the duration and authorization of these; the police attendances at the hospital; and the extent of absconding; then both may have responded appropriately in terms of urgency and recognition of the seriousness.
  • The role of the Care Quality Commission as the regulator of in-patient care at Winterbourne View was limited since light-touch regulation did not work.
  • On paper the policy, procedures, operational practices and clinical governance of Castlebeck were impressive. However, Winterbourne View’s failings in terms of self reporting, attending to the mental and physical needs of patients, dealing with their complaints, recruiting and retaining staff, leading, managing and disciplining its workforce, providing credible and competency based training and clinical governance, resulted in the arbitrary violence and abuses exposed by an undercover reporter.

The report’s recommendations included:

  • Investment in preventing crises;
  • A commissioning challenge concerning ex-Winterbourne View Hospital patients;
  • Outcome based commissioning for hospitals detaining people with learning disabilities and autism;
  • Rationalising notifications of concern;
  • Establishing Registered Managers as a profession with a code of ethics and regulatory body to enforce standards;
  • NHS commissioning organisations prioritising patients’ physical health and safety; and
  • Discontinuing the practice of t-supine restraint in hospitals detaining people with learning disabilities and autism.

Other key findings were that:

  • Fundamental principles of healthcare ethics such as respect for autonomy, beneficence and justice were absent at Winterbourne View;
  • Castlebeck was not starved of funds – Winterbourne View had a turnover of £3.7m in 2010;
  • Castlebeck was able to build a hospital for adults with learning disabilities and autism in South Gloucestershire without any negotiation with South Gloucestershire Council’s Department of Community Care and Housing, local agencies, or the regulator at that time, the Healthcare Commission;
  • Hospitals for adults with learning disabilities and autism “should not exist but they do”. While they exist, they should be regarded as high risk services. They require more than the standard approach to inspection and regulation. “They require frequent, more thorough, unannounced inspections, more probing criminal investigations and exacting safeguarding investigations”;
  • Winterbourne View patients were uniquely disadvantaged. “Their concerns and allegations were dismissed as unreliable, the consequence of mental incapacity or their mental health status, or their desire to leave”;
  • There was an urgent need to draw to a halt the practice of commissioning hospital places for adults with learning disability and autism and “to begin the complex task of commissioning something better”;
  • The families of patients had no experience of being regarded as partners, deserving of trust and respect, or even of collaborating with Winterbourne View staff;
  • There were examples of individual patients and their families being threatened with the improper use of mental health legislation;
  • The only relationship South Gloucestershire Council Adult Safeguarding had with the hospital was as its local safeguarding authority. It commissioned no places there and supported none of the patients financially. It received 40 safeguarding alerts between January 2008 and May 2011 but treated them as discrete cases.
  • The council acknowledged that its safeguarding policy and procedures were “inconsistently applied and their investigation and management of referrals were sometimes poor.” The authority did not challenge the hospital’s failure to produce reports nor some of the decisions of police colleagues. When Adult Safeguarding received a whistleblowing email, this was forwarded to the Care Quality Commission;
  • The council’s expectation that the hospital would honestly report the circumstances concerning all allegations of abuses and crimes was “misplaced”.

Peter Murphy, chair of the Safeguarding Adults Board for South Gloucestershire, said: “This is a detailed and far-reaching report and a vital blueprint for action and debate on the care and safeguarding of vulnerable adults.

"The organisations which make up the Safeguarding Adults Board, including South Gloucestershire Council, the NHS, Avon & Somerset Police and the Care Quality Commission, deeply regret the shocking events at Winterbourne View Hospital.”

Murphy said the organisations fully accepted the findings and recommendations, and were determined to ensure such events did not happen again in the area.

He added that Flynn’s report pointed towards a national policy debate “with far wider implications for the health and social care system.”

David Behan, Chief Executive of the Care Quality Commission, said: “There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn’s thorough and comprehensive report.”

Behan said the CQC would respond fully to all the report’s recommendations in relation to its work.

A copy of the report is available here. 

Philip Hoult