Mental health trust ignored staff concerns for years before Panorama exposed abuse, finds review

Edenfield Centre experienced unsafe staffing levels for years but reporting of concerns was "actively discouraged", enabling abuse uncovered by BBC in 2022 to happen, concludes inquiry

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Mental health trust leaders ignored staff concerns over the safety of services at a hospital over many years before abuse was uncovered there in 2022, a damning review has found.

Managers, in some cases, reprimanded workers who raised concerns about issues such as unsafe staffing levels at the Edenfield Centre, creating a “toxic” culture that enabled the abuse exposed by BBC Panorama to take place, concluded the inquiry.

These issues went beyond the forensic service hospital itself to the wider Greater Manchester Mental Health NHS Foundation Trust (GMMH), of which it is a part, found the independent review into the trust commissioned by NHS England in the wake of the abuse scandal.

The review, chaired by former NHS trust chief executive and mental health nurse Oliver Shanley, also found that the lack of value placed on patients’ and families’ voices was a significant contributory factor behind what the BBC uncovered.

‘Appalling levels of abuse, humiliation and bullying’

In 2022, Panorama sent an undercover reporter into Edenfield, a low and medium-secure mental health hospital for people transferred from the criminal justice system or with behaviours deemed to put themselves or others at risk.

The programme, which aired in September 2022, showed what the review described as “appalling levels of abuse, humiliation and bullying” from staff towards patients.

This prompted a police investigation, which is ongoing, the suspension – and ultimately, dismissal – of some staff and the closure of the centre to new admissions.

The Care Quality Commission also downgraded GMMH from requires improvement to inadequate overall in 2023, and NHS England placed it in the bottom rung of its recovery support programme, for health bodies with the most serious performance issues.

The Shanley review stressed the highly challenging context of forensic services, where patients, often with extensive histories of trauma, are typically admitted against their will because of the serious risk they pose to themselves or others, in locked services away from loved ones.

‘Unsafe’ staffing

While working in these environments had the potential to be “damaging and destructive”, this was exacerbated at Edenfield by “unsafe staffing levels” dating back years.

From 2019-20 to 2022-23, vacancy rates across GMMH’s adult forensic services – which includes Edenfield – averaged 23%, with a 26% rate among nurses and midwives, while sickness levels, turnover and use of temporary staff were also high.

The review found that 13-hour shifts on Edenfield, sometimes without a break, were “commonplace”, with staff regularly working over 48 hours a week.

It heard that it was not uncommon in Edenfield for a single nurse to hold responsibility for three wards, newly qualified nurses were sometimes the only registered member of staff on a ward and unregistered staff were left unsupported and unsupervised on shift.

Nurses ‘often did not know patients well’

Staff also had to move wards during shift to maintain minimal coverage. Consultants told the review that, as a result, nurses often did not know the patients on their wards well or were not able to attend clinical meetings.

“This had a serious impact upon patient care with, on occasion, poor adherence to their care plans,” the report said.

Recruitment and retention problems “depleted the service of forensic nursing experience”. As a result, staff supervision rates at Edenfield had dropped markedly over the past three years, while few practitioners reported a positive view of supervision or on-the-job support.

The staffing situation had a significantly adverse impact on patient care with the review hearing “numerous accounts” of care tasks not being “safely and reliably completed”.

For example, patients told the review that bank and agency night staff were not responsive to routine requests and often told patients not to bother them or ask someone else.

Staff ‘ignored’ and ‘reprimanded’ for raising concerns

Despite a 2018 report commissioned by the trust finding that forensic staff were struggling with stress and overload and not feeling able to speak up, the review found little evidence that the trust had acted on this.

Edenfield staff who raised concerns about unsafe staffing and care were “ignored” and, in some cases “reprimanded”, the review found.

The report said that “a great many staff, of all professions and levels, were highly distressed when telling their stories”, with several saying the review was the first opportunity they had had to talk about their experience of working at Edenfield.

“Reporting of concerns (such as unsafe nurse staffing levels) was actively discouraged and was described by numerous people as being ‘career limiting’, with staff having an “almost unanimous lack of faith” that anything would change as a result.

Poor leadership behaviours

This issue went beyond the leadership at Edenfield to the wider trust. The 2022 NHS national staff survey found that:

  • 7% of GMMH staff disagreed that the trust encouraged staff to report errors, near misses or incidents, the highest of any mental health trust.
  • 13% disagreed that GMMH treated staff involved in an error, near miss or incident fairly, also the highest of any mental health trust.
  • GMMH had the second lowest score among mental health trusts in relation to staff feeling they had a voice
  • About 15% disagreed that GMMH acted on concerns raised by patients.

Trust leaders were described as engaging in poor behaviour including “shouting, swearing, telling staff to retract incident reports and to withdraw written staffing concerns, over-riding clinicians’ decisions made based on patient safety, and fostering an attitude of intimidation”.

The review also criticised the lack of oversight provided by the trust board, which it said was more focused on GMMH’s expansion and reputation and meeting operational targets than on quality of care.

This led to “insufficient curiosity” about patient and staff experience, with board members visible in few services and Edenfield a particular blind spot.

Leadership changes

In the months following the Panorama programme, the then chair and chief executive of GMMH, Rupert Nichols and Neil Thwaite, left the organisation.

Staff told the review that their interim replacements, Bill McCarthy (chair) and Jan Ditheridge (chief executive), were more visible, with McCarthy being regularly seen at Edenfield. He has since been replaced by a new chair, Tony Warne.

However, several managers who had been subject to HR investigations after being accused of poor behaviour remained in senior roles within the organisation, the review said.

“It is critical that the trust assures itself that those in senior leadership positions now are exhibiting and role modelling the values and behaviours the trust requires, in order to reset and reshape its culture to one which can provide safe services.”


Among its 11 recommendations, the inquiry called for the GMMH board to strengthen the voices of patients and families, and of clinicians, within the organisation, and to develop and lead a culture that made quality of care its “utmost priority…underpinned by compassionate leadership”.

As part of this the board should “develop a clear set of expectations about the values and behaviours expected from all staff”, along with systems for measuring key aspects of culture so that staff and leaders can be held to account.

The review also called on the trust to develop a staff recruitment and retention strategy and develop systems “to ensure that staff are encouraged to speak freely and that they are listened to
when they raise areas of concern or areas for improvement”.

Improvement plan ‘commendable but focused on process’

GMMH is currently working to an improvement plan, issued in July 2023, whose objectives include:

  • Making sure it has enough registered, competent, skilled and experienced staff who feel supported and able to deliver high standards of care.
  • Reducing the use of restrictive practices such as restraint, seclusion and rapid tranquilisation.
  • Enabling leaders to uphold the trust’s values and provide a safe and supportive working environment.
  • Strengthening the service user and carer voice and ensuring it is heard at all levels of the organisation.
  • Fundamentally changing its culture to create a healthy environment that supports the delivery of high quality care, and creating opportunities to empower the staff voice across the trust.

The review said the plan was “commendable” in its breadth and scope though had “disproportionate focus on processes and inputs, with insufficient weight given to the cultural work needed to embed sustainable improvements for patients and staff”.

Apology from trust

In response to the report, GMMH interim chief executive Jan Ditheridge said: “We are truly sorry for the events described in the report. We worked openly and constructively with Professor Shanley and the team during their time at GMMH last year, we take the findings seriously and accept the recommendations.

“We cannot change the past, but we are committed to a much-improved future – one in which all service users and carers feel safe and supported, and our people are able to do their best work.

“Our improvement plan sets out a range of actions that are addressing the issues raised in this report. Many of these actions have been completed but we know there is more to do to ensure all of our communities get high quality and safe care all of the time.

“Service users are already safer, staff are more supported, leadership and governance is stronger, and our culture is getting better – for example, we have recruited more than 350 nurses in the last six months alone, and we have two full time Freedom to Speak Up Guardians [whose role is to enable staff to voice concerns] and a network of new champions appointed, giving our people a voice and clear ways of raising issues and driving progress.

“We are working with the review team, partners, and colleagues to fully implement the recommendations ensuring our service users and their carers are central to everything we do.”

Wider concerns about speaking up

The report’s findings echoed – in stronger language – those of a rapid national review of the safety of inpatient mental health settings commissioned by the government in response to the abuse uncovered at Edenfield.

This review, which reported last year, found that staff did not always feel empowered to speak up when things went wrong and sometimes felt intimidated raising concerns with Freedom to Speak Up Guardians.

Some staff also said that concerns they had raised had not been acted upon, though others were more positive about this and about guardians’ role.

The government has also commissioned the Health Services Safety Investigations Body to carry out a review into mental health inpatient settings, which will report by the end of 2024. 

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