Transforming care following Winterbourne: learning disabilities.

Abstract

British Journal of Nursing, 2015, Vol 24, No 1 © 2 01 5 M A H ea lth ca re L td On 31 May 2011, an undercover investigation by the BBC’s Panorama programme revealed criminal abuse by staff of patients at Winterbourne View Hospital near Bristol, a secure setting for patients with learning disabilities and autism. After its broadcast Winterbourne View closed, with the remaining residents placed in other settings. South Gloucestershire Safeguarding Adults Board began a Serious Case Review (Flynn, 2012). In addition, the police launched their own investigations, with 11 criminal convictions (Department of Health (DH), 2012). The Care Quality Commission (CQC) inspected all hospitals and homes operated by Winterbourne View’s owners (Castlebeck) and conducted a wider ‘health check’, inspecting 150 learningdisability services across England (CQC, 2014a). The Government set up its own review, led by the DH, to investigate the failings surrounding Winterbourne View, understand what lessons we should be learning to prevent similar abuse to explore and recommend wider action to improve quality of care for vulnerable groups (DH, 2012). Drawing on the Serious Case Review (Flynn, 2012), as well as reports from the police, the CQC and the local NHS, the DH review drew the following conclusions: ■ Patients stayed at Winterbourne View for too long and were too far from home—the average length of stay was 19 months and almost half of patients were more than 40 miles away from where their family or primary carers lived ■ There was an extremely high rate of physical intervention—well over 500 reported cases of restraint in a 15-month period ■ Multiple agencies failed to pick up on key warning signs—nearly 150 separate incidents including A&E visits by patients, police attendance at hospitals, and safeguarding concerns reported to the local council— which could and should have raised the alarm ■ There was a clear management failure at the hospital with no registered manager in place, a substandard recruitment processes and limited staff training Anne-Maria Olphert