South Gloucestershire Council

Published: 04/09/2012

South Gloucestershire’s multi-agency Safeguarding Adults Board (SAB) today publishes the independent Serious Case Review into the events at the Winterbourne View private hospital.

The review was commissioned by the SAB following the disclosure last year of the abuse of adults with learning disabilities and autism at the 24-bed private hospital owned and operated by Castlebeck Ltd.

Prepared by independent adult safeguarding expert Margaret Flynn, the review shows that the abuse at Winterbourne View Hospital resulted from serious and sustained failings in the management procedures of Castlebeck Limited.

It also identifies where other organisations’ systems and procedures fell short in commissioning patient care, and in reviewing and safeguarding the wellbeing of patients before and during their stay at Winterbourne View hospital.

Recommendations include a call for greater investment in community-based care in order to reduce the need for in-patient admissions at assessment, treatment and rehabilitation units such as Winterbourne View Hospital.

The report highlights the need for outcome-based commissioning for hospitals detaining people with learning disabilities and autism and says that the use of ‘t-supine restraint’ — in which patients are laid on the ground with staff using their body weight to restrain them – should be discontinued at such units.

The report also calls for notifications of concern, including safeguarding alerts, hospital admissions and police attendances, to be better co-ordinated and shared amongst safeguarding organisations to allow earlier identification of potential problems and earlier action to be taken.

SAB chair Peter Murphy said: “This is a detailed and far-reaching report and a vital blueprint for action and debate on the care and safeguarding of vulnerable adults.

“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.”

David Behan, Chief Executive of the Care Quality Commission, said: “There is much for all the organisations involved with Winterbourne View to consider in Margaret Flynn’s thorough and comprehensive report. I will ensure that the Care Quality Commission responds fully to all the recommendations for CQC. We will continue to work with other organisations to improve communications and sharing of information to ensure we all protect those who are most vulnerable.”

Andrew Havers, Medical Director of NHS Bristol, North Somerset and South Gloucestershire Primary Care Trusts, said: “Many of the systems that could have prevented the shocking abuse of patients at Winterbourne View Hospital failed. One year on, significant measures have been taken by the organisations represented by the Safeguarding Adults Board to ensure better standards of adult protection and improve commissioning across health and social care services for people with behaviour which challenges to reduce the number of people using inpatient assessment and treatment services.”

A copy of the report is available here.