A safeguarding adults manager has been struck off for failing to respond to several alerts from Winterbourne View hospital, leaving service users at risk of suffering further abuse.
Brian Leslie Clarke also failed to ensure investigations were conducted in a timely fashion, that service users were interviewed or that the hospital’s manager completed the required paperwork, found a Health and Care Professions Council care and conduct committee.
He also did not arrange a strategy meeting for three months after receiving a whistleblowing alert from a charge nurse at the hospital, Terry Bryan, and failed to make links between these incidents and previous ones that he knew about.
At the time, Clarke was safeguarding adults manager at South Gloucestershire Council, which was responsible for safeguarding adults services for the area covering Winterbourne View. He was dismissed from the role following an internal investigation, sparked by the BBC Panorama programme that uncovered abuse at the hospital in May 2011.
Committee chair Nicola Bastin said: “Although the panel does not feel able positively to conclude that there would have been no further abuse even if Mr Clarke had not defaulted in the respects found, nevertheless in failing to discharge his duties…opportunities were missed to remedy the failings at the hospital and it inevitably follows that the service users were left at risk of suffering further abuse.
“As a very experienced and senior safeguarding practitioner Mr Clarke clearly knew what was required…The panel has seen limited evidence of insight on the part of Mr Clarke into the extent and nature of his failings.”
Safeguarding manager’s failings
Among the committee’s findings against Clarke was that:-
- He failed to ensure an investigation was conducted into three alerts, in March 2009, of a service user being assaulted and injured during restraint by hospital staff, waiting until August 2009 to ask the hospital to undertake an internal inquiry.
- In two cases, in 2009, he failed to follow up on the outcomes of investigations carried out at his request by social workers into alerts of patients being verbally abused at the hospital and of a support working pulling a patient’s hair.
- In January 2011, he failed to follow up on the results of a safeguarding investigation by a social worker which recorded allegations of patients being hit by staff and of wishing to speak to the police urgently; the investigation had been prompted by a safeguarding alert raised by NHS Plymouth in November 2010.
- On seven occasions, from 2008-11, he failed to ensure that the hospital manager provided minutes from safeguarding meetings in a timely fashion, with minutes either not produced at all or delayed by seven to 19 weeks.
- He waited three months to convene a safeguarding meeting after receiving charge nurse Terry Bryan’s whistleblowing email about mistreatment of patients at Winterbourne View in October 2010, a response the panel said was “slow and ineffective”; there was also no evidence that the meeting, in January 2011, linked Bryan’s allegations with other safeguarding incidents, including the contemporaneous safeguarding alert from NHS Plymouth.
Clarke, who qualified as a social worker in 1990, did not attend the hearing, which took place this week, nor was he represented at it, but he did provide a statement to it. The evidence against him came from South Gloucestershire’s former head of service (operations), who was Clarke’s supervisor when in post, and its former head of strategy and commissioning, who conducted the internal investigation into his conduct. The panel found both to be credible witnesses.
It concluded that Clarke’s failings were so serious that he had to be removed from the register, and that a suspension was inappropriate because there was no evidence that he had any insight into his failings or taken action to remedy them.
Serious case review found ‘ineffective’ safeguarding response
The serious case review into the abuse at Winterbourne View concluded that the response of safeguarding agencies was “ineffective”.
Forty safeguarding alerts were made concerning Winterbourne View patients from October 2007-April 2011: 27 allegations of staff to patient assaults, 10 allegations of patient to patient assaults and three family-related alerts. But in only 19 cases were service users who were the subject of alerts seen by the police or social workers with the other 21 largely left to Castlebeck to investigate.
The review found that social workers and other safeguarding staff treated these as discrete incidents and failed to identify a pattern of concern at the hospital; they also relied too much on Winterbourne’s management to honestly report the facts concerning referrals, but this did not happen.