The Serious Case Review conducted by Margaret Flynn, chair of Lancashire's Safeguarding Adults Board, described hundreds of incidents of restraint and dozens of assaults on patients. 11 former members of staff at Winterbourne View admitted offences against patients and are due to be sentenced on 22nd October. People are also appalled by the fact that it took the Panorama programme to get the home's owner, Castlebeck Care Ltd, to close Winterbourne View and the risk of similar media exposure forced the Care Quality Commission (CQC) to finally close two other residential homes where similar concerns had been raised.
Perhaps the most disturbing conclusion of the Serious Case Review is that fact that the owners of Winterbourne View, various health regulators, local authority health services and police all failed to act on increasingly clear and repeated warning signs of abuse by staff at the care home. Compelling and consistent evidence that something was seriously amiss at Winterbourne View was repeatedly ignored or dismissed by the appropriate authorities.
Avon and Somerset police recorded 29 calls and 9 incidents about the home between 2006 and 2011 but the Flynn report stated that the police tended to believe the ‘professionals’ rather than the concerned relatives making a complaint. South Gloucestershire council received 40 "safeguarding alerts” between January 2008 and May 2011 concerning some 20 different patients which they chose to ignore, trusting that the private provider would diligently investigate the allegations themselves. It also emerged that a whistleblower had contacted the council about abuse at Winterbourne View, but again the local authorities did nothing because they thought (incorrectly as it turned out) that the CQC was conducting its own investigation.
Reaction to the Flynn findings suggests that this was not simply a case of a rogue provider leaving vulnerable adults in the hands of poorly trained and badly supervised staff who tormented and abused those in their care and implies a need for a national policy debate with far wider implications for the health and social care system as a whole. Many of the systems that could have prevented the shocking abuse of patients at Winterbourne View hospital clearly failed and campaigners from Mencap and the Challenging Behaviour Foundation warn that another care home scandal like Winterbourne View could easily happen again. Indeed, those two charities say they continue to receive complaints from families concerned about elderly abuse and neglect in care homes and have logged some 260 reports of suspected abuse in the months since the Winterbourne View scandal was first exposed.
The national charity, Action on Elder Abuse, also maintains that abuse is still occurring and can take a number of forms – physical, mental, sexual, financial or neglect. The World Health Organisation (WHO) has adopted that charity’s definition of abuse: “a single or repeated act or lack of appropriate action, occurring within a relationship where there is an expectation of trust, which causes harm or distress to an older person”. In October 2007, the Mental Capacity Act 2005 came into force partly to prevent abuse of the elderly and vulnerable with the hope that the legislation would make some forms of abuse a thing of the past. It would seem from the Winterbourne View example that we still have a long way to go before we achieve that aim.
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