Learning From Serious Case reviews

1. Learning From Serious Case reviews Geoff Baines, Director of professional Practice, Quality and Safety Karen Anderson, Safeguarding Consultant February & March 2014

2. Winterbourne View Panorama TV show 31 May 2011 Shocking abuse Filmed January- March 2011 18 people there at the time Panorama told Social Services about it on 13 May 2011 Images available on www.bild.org.uk/news-and-whats-on/winterbourne-view/

3. Winterbourne View Run by Castlebeck Care Ltd A Hospital Assessment and Treatment service 23 other units in England Opened in 2006 51 people in total had been there Now closed

4. Government review Many Strands: Police Investigation Care Quality Commission Serious Case review Castlebeck Care internal review NHS Review NHS Assurance process

5. Police On bail while investigated Evidence used from the TV programme 11 sentenced for 38 charges 6 jail terms 2yrs to 6 months for ill treatment 5 suspended sentences plus up to 200 hrs unpaid work

6. Serious Case Review - Some Findings Led by South Gloucestershire Council Report available -www.southglos.gov.uk/wv 40 safeguarding alerts were made between October 2007 and April 2011 27 allegations of assault on residents by staff 10 reports of patient on patient assaults 3 reports concerning family members of patients Only 19 incidents resulted in visits by police or social workers All of the indicators for abuse were present but not collated

7. Some Findings High levels of restraint 379 reported incidents of restraint in 2010 129 reported incidents in the first 3 months of 2011- There was 78 recorded incidents of admissions to A&E – minor injuries, self harm and epilepsy There was no alerting system in place within the hospital to identify repeat admissions from winterbourne view

8. Some Findings The Primary Care Trust scrutinized the case files of 20 Winterbourne View Hospital patients. Some patients had a multiplicity of physical health problems and it is not known whether or not these were treated or monitored. Castlebeck Ltd contracted with a Local GP Practice for general medical services Dental problems were extensive

9. GP Support TheMental Health Commission noted good practice with GP arrangement GP Initially provided weekly visits to the service with General access within the building denied, use of a side/visitors room - later patients escorted to surgery. No safeguarding alerts raised – concerns reassured by explanation provided from clinical staff.

10. Learning …. Denied access to all areas should be challenged and is a risk Where there is a private GP contract and patients from out of area , avoid being isolated from multiagency working Professionals relied too heavily on the information provided by Winterbourne alone – share your information Safeguarding procedures were not followed which reduced detection Sharing information or concerns between agencies avoids referrals being dealt with in isolation and shows the big picture – supports prevention early intervention and quality.

11. Learning … Be wise to safeguarding being multiagency – as well as the Local Authority would you know if the NHS commissioner or CQC is involved? If they are – Serious Incident reporting could pick this up. Information was not shared and therefore not collated so that quality and safety improvement could not be addressed in the commissioners contract – individual vs institutional abuse Safeguarding protection plans can still be important even where the Police find no evidence to undertake a criminal investigation

12. Dentistry • The Serious Case review found Dental problems were extensive • Behaviour linked to pain, both self injurious and aggression not well assessed at the service • One patient had a full extraction over 12 months • Others visited specialist hospital dentist • Emergency treatment provided for a non accidental injury

13. Dentistry Featured in BBC Inside Out , West. 2012

14. Learning • Dentist not happy with the explanation provided by staff of the injury • Recorded consistent with severe blow/blows • Police were involved and reported their view that it was understandable in self defense • This remained unchallenged as was the view of Police • Did not lead to any further multiagency safeguarding process

15. Learning…. Clarity of role of Police – securing evidence, and safeguarding safety Multiagency procedures prioritise Police investigations but should not defer to Police decisions alone Safeguarding can be effective through protection plans and reducing risk Risks when relying upon internal investigations by providers or their own explanations - need to be scrutinised

16. Learning…. Listening continually to the experience of people and their families is essential. – as also highlighted in the Health Care commission investigation into Budock Hospital in Cornwall and the Francis Report.