Lessons from Winterbourne View Hospital: Failures in Patient Care

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Winterbourne View Hospital exposed serious issues of neglect, abuse, and regulatory failures in patient care. The hospital ignored patient complaints, lacked accountability, and failed to address concerns raised by a whistleblower. Regulatory inspections were ineffective, and compliance with standards did not prioritize patient well-being. The ownership structure also raised concerns about prioritizing profits over patient care.

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What has Winterbourne View Hospital taught us? Margaret Flynn and Vic Citarella July 2013 Open University

The BBC exposed assaults and neglect Undercover care: the abuse exposed May 2011, was hard to watch it showed adults with learning disabilities, autism and mental health problems being badly hurt Staff, including nurses and managers, ignored what was happening No-one asked questions about dangerous, painful and illegal ways of restraint

The complaints of patients and their families were ignored Patients had no ways of asserting or protecting their rights Patients had no voice Patients complaints were not addressed Relatives complaints were not addressed One family told the police about the physical restraint of their relative

Whistleblowing didnt work The whistleblower was a nurse. He told: (i) Castlebeck (Teeside) Ltd (ii) the CQC twice and (iii) the BBC about what was happening to patients at Winterbourne View Hospital

Regulation did not work Inspectors looked at policies, procedures, care plans, nursing plans, complaints and incident reporting They did not visit often Winterbourne View Hospital told them that things were fine Inspectors do not look at the model of care practice

Compliance with essential standards did not help patients and their families Regulation did not take account of: - the experience of patients - the service model and how it fits with policy and guidance - the numbers of staff and their qualifications - staff turnover/ use of agency staff - concerns which have a long history

There are high risk services The company that owns Winterbourne View, Castlebeck, is itself part of a group called CB Care Ltd, which is itself owned, via Jersey, by Swiss-based private equity group Lydian, backed by a group of Irish billionaires. The process of private equity ownership is that all the money gets whipped out by the bankers and offshore owners as soon as possible. So while CB Care makes healthy operating profits these disappear in interest payments, leaving the group with hefty annual losses and liabilities exceeding assets by 14 million The Care Quality Commission confirmed that for private providers there is no provision to require insurance under the Health and Social Care Act. So while private equity owners scoop up the profits, it looks like taxpayers could end up having to pay for private care fiascos. Private Eye, Passing the Beck , No. 1327 16-29 November 2012, p31

What about the Care Quality Commission, adult safeguarding, the Health and Safety Executive, the Mental Health Act Commission or the First Tier Tribunal, Mental Health? They did not join up obvious sources of information There was no common purpose shaping action They were not critics They did not take action when there was no Registered Manager They did not know what an Assessment and Treatment service should look like What they did, did not not connect with patients concerns or those of their families

The CQC said nothing about commissioning What is world class about place-hunting? If people need help in a hospital in a mental health crisis this should be for a short time only NHS Commissioners had told Castlebeck that they would buy places at Winterbourne View Hospital NHS Commissioners did not ask about (i) the benefits for individual patients (ii) the hospital s record in making patients lives better (iii) the hospital s record in doing what Inspectors had recommended

The CQC was out of touch with what former patients and their families wanted Relationship centred support in their own localities Staff who understand people s histories and hopes for the future Recognition that working with people with troubled histories can be hard emotionally Staff with positive experiences of working with people with learning disabilities and autism Staff to have good role models and effective managers Patients and families want their views and experiences to be acknowledged Commissioners who know what they are buying Money for hospitals to be transferred to their communities

So what do we want from the CQC Inspectors? A readiness to listen and engage More of what happened after the BBC s broadcast i.e. a 4 day review of Winterbourne View Hospital which involved meetings with patients, relatives, staff, the acting Manager and Regional Director; a focus on patients care and welfare, their safeguarding, the management of medicines, the hospital employees, complaints and records for example; and observations An understanding of the service s contacts with and concerns of: the police, A&E services, adult safeguarding, H&S Executive, the MHA Commission and the First Tier Tribunal, Mental Health and professionals responsible for reviewing how patients needs are met

Customised inspections that Accept that there are high risk settings e.g. where patients are locked in/ at risk of being restrained/ removed from familiar networks Are frequent and take time and ask How well is the purpose of this service being met? Engage with patients and their day to day experiences, their relatives and advocates, the Registered Manager, Responsible Person, commissioners and lay inspectors Start with a concerned nosiness e.g. How do you explain the absence of complaints since 2009? Include inspectors who know when to support improvement by working with owners, safeguarding and commissioning personnel; and when to use their powers to make things happen - enforcement