They spoke out after the publication of a serious case review (SCR) into the “appalling and systematically brutal” abuse that took place at Winterbourne View, a private hospital near Bristol, which provided “assessment and treatment” services for people with learning difficulties.
The SRC found that physical assaults on patients by staff dated back to at least 2008, while there were 379 records of staff physically restraining patients in 2010, and 129 in the first three months of 2011, which the SCR described as “extraordinary, excessive and… dangerous”.
There was frequent over-use of medication to control patients, who “lived in circumstances which raised the continuous possibility of harm and degradation”, while the authorities failed to realise that “absconding patients, the concerns of their relatives, requests to be removed and escalating self-injurious behaviour” were evidence of a “failing service”.
The abuse was finally exposed by an investigation by the BBC’s Panorama in May 2011, after a reporter secretly recorded patients being assaulted by care staff. Winterbourne View has since been closed by its owner, Castlebeck.
The SCR report, by safeguarding expert Margaret Flynn, said such hospitals should not exist, but as they do, they need “frequent, more thorough, unannounced inspections, more probing criminal investigations and exacting safeguarding investigations”.
Instead, South Gloucestershire council received 40 “safeguarding alerts” between January 2008 and May 2011, but failed to spot a pattern of criminal abuse.
Patients from Winterbourne View attended a local accident and emergency department 76 times between the same dates, often demonstrating signs of “considerable visible, physical and quantifiable violence”, and yet the department failed to raise a single alert with the council.
Flynn also concluded that social care regulators had proved “unequal to the task” of uncovering the abuse at Winterbourne View.
She said that the “low cost, light touch” approach of the Care Quality Commission (CQC) had not worked, although Castlebeck was “primarily responsible and accountable for the neglectful and inhumane treatment”.
Andrew Lee, director of People First Self Advocacy, said he and other people with learning difficulties were expressing fears that “something like Winterbourne View will happen again”, so “politicians need to make sure that it actually does not”.
He called for MPs to debate CQC’s failure to halt the abuse, or even order an inquiry to “look at whether CQC failed in its duties”.
He said he was opposed to the “light touch regulation” practiced by CQC and called for the watchdog to “get tough around regulation”.
But he also called for parliament to examine the SCR structure itself, and said he doubted whether the report’s many recommendations would be implemented.
He said: “I fear it will be left on a shelf again. I am sure we will get a lot of politicians saying this should never happen again. It will be a bit like a broken record.
“If something like this was happening in the NHS, everybody would be up in arms, but because it is social care it is pushed by the wayside.”
He pointed to previous cases of institutional abuse, which had seen similar inquiries and recommendations, including Longcare in Buckinghamshire, Budock Hospital in Cornwall, Orchard Hill in Sutton, and the long-stay hospital scandals of the late 1960s and 1970s.
Lee said: “They said they would improve on these kinds of cases. What makes this report so different? I am very worried that people will carry on being abused.”
He said that, if such cases were to be prevented, social care would need to be funded just as generously as the NHS.
And he said that more needed to be done to make complaints procedures more accessible, and called for more people with learning difficulties to be involved in inspecting services, through the “experts by experience” programme pioneered by CQC’s predecessor, the Commission for Social Care Inspection.
Lee said: “People with learning difficulties will talk to other people with learning difficulties more freely about their experiences and they are more likely to come out with what is really happening because they know they will be believed if they are speaking to their peers.”
The SCR was published as the last of 11 former members of Winterbourne View staff pleaded guilty to offences of ill-treatment under the Mental Health Act.
They will all be sentenced at a later date, but the Crown Prosecution Service made it clear that it was treating the offences as disability hate crimes, and so would be asking for tougher sentences under section 146 of the Criminal Justice Act.