Winterbourne – The Legacy

16 08 2013

The Journal of Adult Protection has a special issue on Winterbourne View published (volume 15 issue 4). As it’s so key to safeguarding adults – and the contents have been opened up free. I want to read through a few of the papers over the next week or so and comment on them.

I’m going to start with the paper by Margaret Flynn and Vic Citarella – who wrote the Serious Case Review into Winterbourne View. I’d recommend reading that too, incidently,  it carries a lot of learning.

My initial ‘review’ of the Panorama programme is here. I wrote it the day after it was on television. Obviously, there has been a lot of information and change that we know since then but useful for the context of the time.

Winterbourne View Hospital – A glimpse into the legacy – Flynn and Citarella

The paper starts with some background and explanation of the context of the BBC Panorama Winterbourne View TV programme. We are reminded of the main issues which were raised at the time. Flynn and Citarella raise five points initially

a) Viewing the merciless abuse of power

b) The experiences of the undercover journalist who got a job at Winterbourne

c) The lack of response by Castlebeck and CQC to the whistleblower, Terry Bryan.

d) Staff, including more senior staff, who ignored the culture of violence, abuse and degradation of residents

e) The responses by senior management in Castlebeck and CQC to their lack of action.

The authors give some background into both Winterbourne View and Castlebeck as a provider.

Winterbourne View was a private hospital in South Gloucestershire run by Castlebeck. Before the broadcast of the programme, the BBC, the authors explain, were sent a letter (via a local councillor) which detailed the “systematic mistreatment of patients by staff” The letter also raised the issues which had been brought up by the whistleblower, with the acting manager, on 11/10/10. The same issues brought up by the whistleblower had been forwarded to the local council in Oct 2010 and the council had sent it through to CQC in November 2010.

Winterbourne View closed in June 2011. Nine support workers and two nurses were convicted of mistreatment under the Mental Health Act (1983).

After the programme, CQC inspected other Castlebeck provisions. It closed on Arden Vale – another setting in the Midlands and Castlebeck themselves closed Rose Villa in Bristol.

As the article says

Thus a hospital which undertook to provide a high-quality specialist healthcare service including assessment, treatment and support services to adults with learning disabilities and autism, through the application of the key principles of Valuing People: rights, independence, choice and inclusion was exposed as negligent and cruel.

The paper points to the follow up programme in October 2012 by Panorama which showed a ‘turned around’ Castlebeck apparently yet still evidenced some of the same issues of power and cruelty of language and behaviour that resonated.  The continuing use of illegal and dangerous restraint was not a lesson Castlebeck had, apparently, learnt – despite the flowery language. Words are cheap but changing attitudes, particularly in settings which are not often exposed, is more costly and more difficult.

This is particularly telling

In the Serious Case Review we came across no examples of physical restraint being the intervention of last resort. The practice of wrestling patients to the floor and lying across them occurred on a daily and routine basis and yet was not identified as constituting abuse by any professional

For me, this is crucial. Where restraint becomes routine we are on extremely dangerous and cruel ground. Restraint is not a management method, it is a last resort only if absolutely necessary with checks in place. That was not what was happening in Castlebeck settings.

The paper goes on to explain how few rights the people at Winterbourne had in the face of assault carried out by members of staff. The  comment from the Public Prosecution Unit investigator was

restraint is usually carried out by two or more people so any allegation of improper or criminal conduct is countered by two people’s word against the victim – the victim always unlikely to make a good witness in a criminal prosecution

Now I could divert to a rant about the lack of teeth of adult safeguarding legislation and the difficulties of securing prosecutions but that’s probably best for another day. The prosecution was secured by the BBC camera footage  but it’s a pretty shameful situation when that’s the best that people with learning disabilities and mental health difficulties can rely on for justice against abuse and assault from members of staff in settings where they are supposed to be cared for.

In March 2013 Castlebeck went into administration.

The article goes on to talk about the programmes of action which kicked into place after the transmission of the programme.

There were three questions asked, they say

a) Why did it need an undercover reporter to find this level of abuse?

b) Why were there hospitals for people with learning disabilities and autism still around?

c) With Castlebeck funded by international equity firms – how does this match up with the so-called much trumpeted ‘personalisation’ agenda that we hear about – or is it one service for those with voices and another, poorer, possibly cruel one, for those without?

I’ve asked myself these questions – well, not the second so much but that’s only because, having worked in this area, I knew there were these facilities around so it didn’t come as a surprise to me. Of course the level of embedded cruelty and lack of oversight was a shock. I’ve come across a lot of abuse – unfortunately – in my time in adult social care and mental health – but this embedded level is something I had fortunately not seen and I hope never to again.

A variety of reviews have been undertaken and I won’t list them all but we reach a point where Castlebeck built a 24 bedded hospital in a business park and commissioners paid for it because they needed the service.  Long stay hospitals were closed and commissioning bodies needed somewhere for people in crisis but they didn’t spend a great deal of time considering what the best provision was and where it would be and who would provide it. These beds are expensive but they were there. They were easy to commission  but they were not meant to fall off the radar of those who were paying for the services – nor those who were regulating the services.

CQC had moved to a system of ‘light touch’ regulation which relied on self-reporting from provider organisations. I wrote about this back in 2011.  Commissioners showed little oversight. Cultures of abuse were allowed to develop. Few people knew these services existed. There were many blind spots in the ‘system’ and no one to shine a torch on them. Except there was. There was a whistleblower. And that’s another failing of the system.

Now the Department of Health plans to reduce the numbers of people in long stay institutions ‘like Winterbourne’ but it’s important to remember that Winterbourne wasn’t intended to be a long stay institution. It became one because there were no alternative (or no cost-effective alternative) provisions available to either provide significantly more support at home or to provider support in smaller settings – with better care.

The article looks at the disjointed roles of the CQC and the oversight of the Mental Health Act Commissioner whose report didn’t really ‘go’ anywhere. I hope this is something that will be changing with the movement within the CQC but it’s worth keeping an eye on. An understanding of restrictive practices in care settings is a skilled role to understand and to appreciate and it needs inspectors on the ground who have a good understanding – not just of the Mental Health Act but of the Mental Capacity Act too.

The article picks up on the conclusion that most of the recommendations from the Serious Case Review were accepted but that Castlebeck did not respond to the suggestion that therapeutic support be provided on the basis of people who might be subject to distress exacerbated by their institutionalisation. That sometimes the ‘treatment’ has a cost in terms of mental health (I’d say ‘sometimes’ is being very generous here).

Another recommendation which was not taken up was the banning of restraint in settings like Winterbourne and instead more ways to record and monitor restraint solely as a last resort. My concern – and question – would be who is doing the monitoring to ensure that that’s the case? If it’s the same people who were monitoring Winterbourne, we can retain some concerns.

The authors conclude

The Serious Case Review’s findings buttress a growing concern that adults with learning disabilities and autism have been disproportionately disadvantaged in assessment and treatment settings where they may be subject to violence on an unknown scale. Winterbourne View Hospital has taught us about the arbitrariness of cruelty under the guise of restraint and the lamentable lack of interest of all professionals, most particularly Castlebeck Care (Teeside) Ltd and the NHS commissioners of this service, in ensuring that patients were physically well, protected and safe. Had it not been for the undercover-mediated revelations of the BBC Panorama, then needless human suffering in an unnoticing hospital would have continued.

I’d add a further conclusion which is the first thought I had pretty much – why did it need a TV camera to find this? This is the importance of regulation and monitoring. Internal – by the companies providing the services, local in terms of commissioners and also in terms of regulation.

The other concern I have is that while Winterbourne was a particular situation (although we don’t know how common it is/was), it is not a situation which is exclusive to private care providers or services which provide care to people with learning disabilities.

When the conclusions look at how services are provided to people with learning disabilities, I hope they’ll be future learning to transfer to other sectors which also don’t get much light shined in – like older people with dementia in some of the large residential and nursing settings. When we talk about ‘deinstitutionalisation’ we need to look at the sizes of some of the nursing and residential facilities that exist now and wonder if we meant ‘deinstitutionalisation’ for all –or just for younger people.

As for the article, it’s useful and I’ll try to cover some of the other ones. We all have a lot to learn and we all need to look better.