Care home firm ‘put its profits before patients’

Health regulators, police, social services and the NHS were are all heavily criticised in the independent report for failing to spot the warning signs about the treatment of patients at the Winterbourne View care home.

The serious case review was published after the final member of staff accused of abusing patients at the home in Hambrook, South Gloucestershire, pleaded guilty.

A total of 11 former staff have admitted between them 38 charges of either neglect or ill treatment of people with severe learning difficulties.

The shocking catalogue of abuse at the hospital only came to light when whistleblower Terry Bryan, a senior nurse at the home, contacted BBC1’s Panorama.

Their undercover five-week investigation, broadcast in June last year, recorded secret footage of patients being abused by carers. The video showed frail and confused residents being forcibly pinned down, slapped, soaked in water, trapped under chairs, taunted and having their hair pulled and eyes poked.

Dr Margaret Flynn, who wrote the 150-page serious case review, said her findings could be the “tip of the iceberg” and said care at Winterbourne View had become “institutional abuse”.

Her report detailed hundreds of incidents of restraint and dozens of assaults on patients and warned that had it not been for Panorama the scandal may never have come to light, despite enough warning signs over the preceding three years for the authorities to have investigated further.

Senior managers at Castlebeck, which ran the care home, ignored internal reports of the excessive use of restraints and injuries to patients, as well as the concerns of its own staff.

The 24-bed Winterbourne View had an annual turnover of £3.7m and was regarded as Castlebeck’s best performer financially.

The home was exclusively funded through contracts with local authorities and the NHS and charged on average £3,500 a week per patient.

Castlebeck did not provide any documents to Dr Flynn’s report to show how this money was spent on the severely disabled residents.

“Castlebeck appears to have made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation,” she said.

Dr Flynn’s report records the failure of the healthcare watchdogs – the Healthcare Commission and the Mental Health Act Commission, until April 2009, and their successor the Care Quality Commission – as well as social services, the NHS and police to act on concerns raised at Winterbourne View.

South Gloucestershire Council received 27 allegations of abuse by staff to patients, 10 allegations of patient-on-patient assaults and three family-related alerts.

Avon and Somerset Police recorded nine carer-on-patient incidents, five patient-on-patient incidents, three patient-on-staff incidents, and 12 other incidents.

Between January 2008 and May 2011 residents attended accident and emergency departments 76 times - yet no medics alerted the authorities with any concerns.

The report detailed that Castlebeck recorded a total of 379 physical interventions during 2010 and 129 for the first three months of 2011.

“Unwittingly, the hospital has become a case study in institutional abuse,” Dr Flynn said. “It is shocking that the practice of restraint on a daily, routine basis was not identified as constituting abuse by any professional.

“Although ‘person-centred’ care, participation and empowerment characterise national policy priorities, these were alien to the experience of Winterbourne View and their families.

“Their silencing was scandalous. Regardless of the eloquent first-person accounts and the concerns of their families, the experience of Winterbourne View patients was ignored.”

Staffing levels and training were poor and the hospital often relied on agency workers to fill the gaps, with two migrant workers even arrested by the UK Border Agency.

Whistleblower Terry Bryan went public after his own senior managers and the Care Quality Commission (CQC) ignored his email detailing his concerns.

After the Panorama broadcast Castlebeck closed Winterbourne View and two other residential homes.

The serious case review has led to those blamed for failure vowing that it would never be repeated.