Independent expert details hundreds of incidents of restraint and dozens of assaults on patients by staff at private hospital.
Randeep Ramesh
The shocking catalogue of abuse at a care home first exposed by a TV investigation has been laid bare in a damning report.
The owners of Winterbourne View, health regulators, local health services and police were all criticised for failing to act on increasing warning signs of institutional abuse by staff at the care home.
The 150-page serious case review by Margaret Flynn, the chair of Lancashire's Safeguarding Adults Board, details hundreds of incidents of restraint and dozens of assaults on patients at the private hospital at in Hambrook, south Gloucestershire. It comes after 11 former members of staff at Winterbourne View admitted offences against patients.
The report, released on Tuesday, said Castlebeck, the company that owned the care home in Hambrook, south Gloucestershire, "took the financial rewards without any apparent accountability". Although Winterbourne View was supposed to assess, treat and rehabilitate patients, the report says most of the staff were "unregulated support workers".
"There was a focus on the use of restraint. It is not clear how the hospital's structures and processes were preparing patients to return to their homes or localities of origin," it says.
Flynn recommended that NHS-funded services should ban staff from sitting on people with learning disabilities to restrain them and prioritise the health and safety of such patients.
There appeared to have been evidence that something was amiss at Winterbourne View. The report found Avon and Somerset police were aware of 29 incidents at the home between 2008 and 2011, and South Gloucestershire council received 40 "safeguarding alerts" but the local authority's expectation that the private hospital would "honestly report" the allegations was "misplaced".
It also emerged that a whistleblower had contacted the council about abuse at Winterbourne View, but nothing had been done - in the erroneous belief that the regulator, the Care Quality Commission (CQC), was investigating the improper treatment.
Winterbourne View was exposed by BBC1's Panorama last year when an undercover reporter recorded secret footage of patients being abused by carers. The video appeared to show vulnerable residents being pinned down, slapped, doused in water and taunted. The footage of the treatment caused a national scandal.
Since the allegations were first broadcast, the home's owner, Castlebeck, has closed Winterbourne View and two other residential homes following concerns raised by the CQC.
Peter Murphy, chairman of south Gloucestershire's Safeguarding Adults Board, said that on behalf of the organisations that made up the board - including the council, the NHS, Avon and Somerset police and the CQC - he wished to "convey our deep regret for the events that took place at Winterbourne View private hospital".
"In particular, I would like to express our regret to the hospital's patients and to their families, friends and carers.
"Winterbourne View hospital should have been a safe place for them to be treated with care and compassion. But the hospital's owners, Castlebeck Care Ltd, failed to provide that care.
"Instead it left vulnerable adults in the hands of poorly trained and poorly supervised staff, who dealt out torment and abuse to those entrusted to their care.
"Many of those staff have now been subject to criminal proceedings and this should send out a clear and powerful message - that where employees engage in this kind of criminal behaviour they will be held to account."
Murphy said the board accepted the recommendations of the report.
"Many of those improvements are already in hand and our shared objective must be that events such as this never again occur in south Gloucestershire."
Murphy said the report had national ramifications.
"It examines in detail the underlying 'root cause' issues that underpin the existence and purpose of hospitals such as Winterbourne View and the nature and quality of care provided," he said.
"In this respect, the findings of the report and its recommendations point towards a national policy debate with far wider implications for the health and social care system.
"The board is encouraged by early recognition of this in the June publication of their own interim report by the Department of Health. A final report is promised which will incorporate the findings and learning available from today's serious case review report."
David Behan, chief executive of the CQC, 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 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 in-patient assessment and treatment of services."
Tuesday's report was published as campaigners warned that another care home scandal like Winterbourne View could happen again unless the government takes action.
Mencap and the Challenging Behaviour Foundation warned that moving people hundreds of miles away from their families increased the risk of abuse taking place.
The two charities said a report they had compiled, Out of Sight, detailed several serious cases of abuse and neglect of people with a learning disability in institutional care.
They said they had received 260 reports from families concerning abuse and neglect in institutional care since the Winterbourne View scandal was exposed.
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