Winterbourne View Hospital Serious Case Review

South Gloucestershire Council has published its Serious Case Review into Winterbourne View Hospital, after all eleven previous employees of the facility, charged with the ill treatment of patients with learning disabilities, pleaded guilty. The Review details key findings on how problems at the care home came to be overlooked by the local authority.

The Winterbourne View case came to the attention of Avon and Somerset Police after the broadcast of a BBC Panorama programme in May 2011. The documentary contained shocking undercover footage of abuse and humiliation carried out by a team of carers who were supposed to be safeguarding the well-being of residents.

As well as the resulting investigation and speedy closure of Winterbourne View, the broadcast led to severe criticism of England’s care regulator, the Care Quality Commission (CQC), as it emerged that a whistleblower had sought to alert the authority to the situation at the facility but no action had been taken.

Notable failures the Review found include that: there ‘was no overall leadership amongst commissioners’, who continued to place individuals at the facility regardless of service failures or the concerns of relatives; that the volume of safeguarding referrals ‘were not treated as a body of significant concerns’; and that patients had limited access to advocacy services, meaning there were not enough forms of alert in place.

However, the Review, written by chair of Lancashire County Council’s safeguarding adults board, Margaret Flynn, also criticises the role of the CQC for ‘light-touch regulation’, as well as care provider Castlebeck, for the service failing to reflect the company’s policies and procedures on paper.

The safeguarding adults board chair Peter Murphy comments: “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. We fully accept the findings and recommendations of the report, and are determined to work together to ensure that events such as this never again occur in South Gloucestershire.

“We are very grateful to Margaret Flynn for her analysis, which has gone much further than a typical event-focussed enquiry. In this respect, its findings and recommendations point towards a national policy debate with far wider implications for the health and social care system.”

In response, chair of the CQC Dame Jo Williams welcomes the findings of the Review and states: “Winterbourne View was a watershed moment for CQC. We did not respond as we should have and we have taken steps to put things right. Among other things, we set up a specialist team to deal with whistleblowers and systems to make sure every such contact is followed up. Before Winterbourne View we were receiving about 50 whistleblower contacts a month; now we get more than 500. This information is vitally important in helping us to identify poor care.

“This Serious Case Review sets out failings across a number of organisations at individual or organisational level that contributed to the events at Winterbourne View. As Margaret Flynn notes, we have been honest about the areas where the CQC fell short, and have made changes as a result. We carried out an urgent and thorough internal review to strengthen our processes and to ensure that we are better placed to play our part in protecting people in vulnerable care situations. Following this review, we have adopted 13 recommendations for improvements to systems and working practices.”

Winterbourne View’s former owners Castlebeck also issued a statement welcoming the Review’s findings:

“The actions towards people with learning disabilities by former members of staff at Winterbourne View Hospital were both wholly unacceptable and deeply distressing for all concerned and we are truly sorry this happened in one of our services.

“The criticisms that have been directed at the health and social care sector in general, and particularly those that were directed at our organisation and are highlighted in this report have been listened to and are actively being addressed. We believe we have responded in a way that demonstrates our resolve to ensure that the events of Winterbourne View will not be repeated.

“Our operational management structures have been reviewed and revised, those structures will be underpinned by the launch of a new Strategy for Quality that helps us to move towards a model of care reflective of the recommendations contained within the DH Interim Report and any further policies and guidance that they issue. Castlebeck is emerging as one of the few providers in the sector that have moved to ensure that we embrace and can demonstrate our transparent approach to all sections of our policy, procedure and practice.

“In the 15 months since those events we have made significant changes within our organisation that include extensive changes to Board membership, all new operations structures, strengthened clinical governance and increased staff training and development. These improvements and others are part of an on-going and widespread development programme to ensure we provide safe, high quality, person centred care.”

Avon and Somerset Constabulary confirmed the final plea yesterday, 6 August, when the eleventh individual Michael Ezenugu pleaded guilty to two charges of ill-treatment, making up a total of 38 charges made under Section 127 of the Mental Health Act 1983: the ten other people charged are named as Wayne Rogers, Graham Doyle, Alison Dove, Jason Gardiner, Charlotte Cotterell, Holly Draper, Kelvin Fore, Sookalingun Appoo, Danny Brake, and Neil Ferguson.

Head of CID, detective chief superintendent Louise Rolfe’s statement reads as follows:

“I wish to acknowledge the support and patience of the victims and their families throughout our inquiry. We were shocked by the Panorama programme as many people were. The voice of the victim has been central to our investigation into this case.

”The investigation has always been about the criminal actions of eleven individuals working at Winterbourne View. The Serious Case Review which will be published tomorrow will consider all other concerns regarding this hospital.

”The eleven individuals abused the trust of victims and that of their relatives and friends. They have all pleaded guilty to criminal offences of ill treatment and neglect as detailed within the Mental Health Act.

”Had it not been for the actions of individuals who raised concerns about the neglect and cruelty suffered by the victims at Winterbourne View, this wholly unacceptable behaviour would have continued unchecked.

”We now await sentencing which will bring the criminal justice process to a final conclusion."

Ann Redropp, head of the CPS Complex Case team, also writes: “Safety and security, and the ability to live free from fear and harassment, are fundamental human rights. The kind of offending that took place at Winterbourne View undermined these rights in an appalling and systematically brutal way.

”The CPS has treated these as Disability Hate Crimes, which we regard as particularly serious. Disability Hate Crimes are based on ignorance, prejudice and hate. Disabled people can be victims of crime due to their perceived vulnerability, particularly where there is an unequal relationship, such as where the perpetrator is the victim’s carer. At Winterbourne View, people who should have been able to trust their carers had that trust cruelly and repeatedly abused.

”The CPS will invite the Judge to consider exercising his powers under Section 146 of the Criminal Justice Act 2003 when passing sentence.”

Dame Jo Williams released a statement following Avon and Somerset Constabulary’s announcement, in which she apologised for the regulator having failed to act “quickly enough”, while looking to reassure families with loved ones in care that steps have been taken to ensure the same mistakes are not made again:

“Following a thorough internal review, we have made changes to strengthen our processes and to ensure that we are better places to prevent abuse.

1. We have made it easier for people to raise concerns with us and we have set up a specialist team to deal with whistleblowers and to ensure that we follow up all allegations. All inspectors have received additional training in this.

2. In response to this case, inspectors have made unannounced inspections of 150 services for people with learning disabilities and where we found concerns, we have already taken action.

3. We recognise that hospitals like Winterbourne View are high risk institutions. We will respond swiftly and appropriately whenever concerns are raised.”

Reacting to this week’s announcements, Mencap chief executive Mark Goldring voiced concerns that other adults with learning disabilities might be similarly vulnerable as those of Winterbourne View, saying: “We fear that unless the government commits to a strong action plan to close large institutions and develop appropriate local services for people with a learning disability, there is a very real risk that another Winterbourne View will come to light.”

While Martin Green, chief executive of the English Community Care Association (ECCA), comments: “The Serious Case Review on Winterbourne View Private Hospital has identified that every bit of the system failed the people it was supposed to support and protect. Every single one of us must learn from this case, and there are some clear lessons for care providers, commissioners, and the regulator.

"We sincerely hope that this terrible incident will lead to systemic change, and the lessons learned will ensure that no other service user, ever has to be subjected to this type of unacceptable abuse.”