- As care co-ordinators working under the Care Programme Approach (CPA) to monitor the care and progress of people placed at Winterbourne, on behalf of primary care trusts (in some cases commissioning with local authorities). Though most co-ordinators were nurses, a substantial minority were social workers.
- As safeguarding staff from South Gloucestershire Council responding to some 40 alerts relating to Winterbourne View from October 2007-April 2011.
- When a hospital fails to produce a credible safeguarding investigation report within an agreed timeframe, the host safeguarding adult board should identify remedies (SCR, p131).
- Care co-ordinators must have the right mix of skills to challenge providers or should be adequately supported to do so. This should include not taking explanations and reassurances at face value and following up information of concern far more robustly (NHS review, p66).
2) Failure of safeguarding agencies to piece together a pattern of risk from discrete cases
- Agencies must have a shared safeguarding objective and effectively share information (SCR, p130)
- Hospitals for adults with learning disabilities and autism require frequent, more thorough unannounced inspections, more probing criminal investigations and exacting safeguarding investigations (SCR, p136)
- Commissioners should clarify the roles of care co-ordinators in mental health and learning disability specialist placements and ensure there are consistent thresholds for communicating information from care co-ordination teams to the commissioner (NHS review, p68)
- Commissioners should ensure that clinical commissioning teams have access to clinical expertise (p69)