Thursday, April 5, 2012

Winterbourne View - Serious Case Review

In May 2011, the BBC aired an episode of their revered series 'Panorama' which would shock not only the general public, but those who worked daily in care and social services. Winterbourne View Hospital for those with Learning Disabilities became the focus of the media, the law and the world.

Patients were referred from the NHS to the hospital, owned by Castlebeck Care Ltd, under the belief that they would receive appropriate care, assessment and rehabilitation, to allow the service users to return to their normal home life. As the programme documented, a severe amount of abuse was occurring there that was yet to be discovered.

It displayed care workers and nurses at the establishment hitting, slapping and abusing several patients. One carer put a woman into the shower with her clothes still on, and others sat on patients, not allowing them to get up and sometimes even using chairs to perform this act. The serious abuse highlighted the 'appalling standards of care' that were witnessed on the footage.

The Care Quality Commission (CQC) reacted quickly to the broadcast, carrying out four inspections of the premises, suspending all admissions to the hospital and pursuing regulatory action against Castlebeck Care, which resulted in the closure of the unit in June 2011. With a Safeguarding Adults Board assembled through the CQC, South Gloucestershire Council and all involved in the hospital, a Serious Case Review was carried out. This was published on August 7th, 2012.

Written by Margaret Flynn, it detailed several missed opportunities for action to be taken and a lack of appropriate training amongst the many criticisms of this case. It reported how complaints had previously been made by patients of the hospital to staff and family members, none of which has been said to have been believed. Former Nurse at the unit, Terry Bryan, explained the situation to the hospital manager in the first instance. When nothing came of this, Terry wrote to the Care Quality Commission to file a Whistleblower report on the abuse that was happening at the establishment. He eventually took this complaint to the BBC, at which point it was handed over to Panorama.

The review states that the owners, Castlebeck Care had in their policies and procedures 'sufficient rules' on how the hospital was to be managed and the services executed. The criticism of this was that staff did not follow the rules and were not enforced to do so. The staff did not receive sufficient training and managers did not fulfil their duty of care. Communication problems were also noted, the most important being that the hospital did not report injuries adequately, often failing to inform the family of the patient, the NHS service from which they were referred and the CQC.

The clear theme throughout the Serious Case Review and Executive Summary was that more questions should have been asked. The organisations involved included the Safeguarding Staff, the Police and the CQC and greater communication would have made more people aware of the problems at Winterbourne View.

The Lessons To Be Learned from the review were comprehensive and a clear indication of how the services need to operate to eradicate the risk of this type of case in the future. It included making better ways to check with hospitals that their patients with Learning Disabilities had ensured safety. It also states that staff need to listen more effectively to patients, especially those with communication problems. Any patients who are taken ill, or have to go to an emergency department whilst admitted to a hospital must be reported to the relevant bodies and communicated to all involved. And lastly that any patients affected by the experience at Winterbourne View must receive any additional help required to recover from their ordeal.

The Winterbourne View case is one that gained a lot of attention from the media and in turn, the general public. Awareness of the abuse in hospitals has been heightened ever since and this will have a positive effect on the reporting of problems in this area, however there is still much to learn from this incident.

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