The Winterbourne View scandal provides "a case study in institutional abuse", which went unchallenged because of substantial failings by managers, commissioners, regulators and safeguarding agencies.
That was the damning verdict of a serious case review into the scandal, published today, which called for hospital placements for people with learning disabilities and autism to be radically reduced and to be subjected to much greater levels of scrutiny.
The review, by adult protection expert Margaret Flynn, reserved its harshest criticisms for Castlebeck Ltd, which ran the hospital near Bristol, but said the company's failings went largely unchecked by the Care Quality Commission, NHS commissioners, police and South Gloucestershire Council, in its safeguarding capacity.
"The apparatus of oversight across sectors was unequal to the task of uncovering the fact and extent of abuses and crimes at the hospital," it said.
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Commissioners should ensure people with learning disabilities and autism receive community support and only receive in-patient care when absolutely necessary;
Commissioners should ensure they have up-to-date knowledge of hospital services including serious incidents and safeguarding investigations;
All registered care providers should advise staff in their contracts to whom they should whistleblow and the response they should receive from their employer;
Commissioners should ensure all hospital patients with learning disabilities and autism have unimpeded access to effective complaints procedures;
The government should consider banning the use of the "t-supine restraint" of patients in assessment and treatment units, in which they are lain on the ground and staff use their body weight to restrain them;
Hospitals for adults with learning disabilities and autism should be regarded as "high-risk services" and subject to more frequent and thorough inspections and safeguarding investigations.;
Conditions for abuse
The SCR was triggered by last May's BBC Panorama programme that screened undercover footage of patients being abused and humiliated with apparent impunity by a group of support workers. Eleven former staff are facing jail for the abuse.
The review found that many of the conditions under which the abuse occurred were present from 2008, including the use of restraint by untrained staff, a lack of professional input or patient advocacy and the limited ways in which staff worked with patients.
It found that "professional standards and codes of practice had no bearing on patient care" as Winterbourne View became largely "led" by its biggest staff group, the unregulated support workers, despite the presence of a team of 13 learning disability nurses. Training was "skewed towards restraint practices with nothing about working with patients".
The review was scathing about the Castlebeck's management of Winterbourne, saying there was "little evidence of senior executive oversight" and a lack of professional leadership from the registered manager. The hospital went without a registered manager for two periods during 2008-11, of seven and 18 months.
The company failed to respond adequately to "unprofessional behaviour" by staff, written complaints by patients, escalating self-harm and the "continued and harmful use of restraints" - of which there were 379 incidences recorded in 2010 and 129 in the first three months of 2011. This approach culminated in its failure to take action when charge nurse Terry Bryan blew the whistle on poor practice at the hospital in an email to managers in October 2010.
Commissioners found wanting
Despite being set up as an assessment, treatment and rehabilitation centre for people with learning disabilities and autism, the review said Winterbourne "strayed far" from this purpose, for which commissioners as well as Castlebeck were to blame.
Primary care trusts placing people at Castlebeck did not set performance targets for the company or effectively check the progress of patients despite being charged an average of £3,500 a week for places. Reviews were "ineffective and did not bring to light either concerns about the quality of assessment and treatment or detail of abusive practices.
Commissioners failed, with council partners, to develop the family support and prevention services that would have removed the need to place people at Winterbourne. Strategic health authorities also did not effectively performance manage PCTs in their commissioning of placements for this client group.
Safeguarding staff failed to spot pattern
The response of safeguarding agencies to incidents was "ineffective", with evidence that South Gloucestershire Council's safeguarding practice was more effective in other cases than in relation to Winterbourne View.
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.
Inadequacy of light-touch regulation
The review also concluded that institutions such as Winterbourne were "ill-suited" to the "light-touch" regulatory model employed by the CQC, which was "over-reliant on self-assessment" and did not specify how providers should meet prescribed outcomes for service users.
The SCR said "closed establishments" such as Winterbourne would benefit from a more prescriptive approach, which specified best practice in terms of inputs and processes, such as staffing and models of care, as well as outcomes.
"Such services require more than the standard approach to inspection and regulation," it said. "They require frequent, more thorough, unannounced inspections, more probing criminal investigations and exacting safeguarding investigations."
In response, Castlebeck said it was "committed to learn the lessons from the serious case review" and was "working hard to ensure its model of care was fit for the future".
The CQC has published its own management review into its role in the Winterbourne View case, including its failure to respond to whistleblower Terry Bryan's reports of ill-treatment of service users at the hospital. Chief executive David Behan promised to "respond fully" to the SCR's recommendations for the regulator.
South Gloucestershire Safeguarding Adults Board chair Peter Murphy - who is also the council's director of adult social services - said the board fully accepted the findings and was "determined to ensure that events such as this never occur again in South Gloucestershire".Mithran Samuel is Community Care's adults' editor.
Background to Winterbourne View case