Last updated: 27.01.20

Serious Case Review: Winterbourne View (2012)

Local authority: South Gloucestershire Council

What happened?

Adults with learning disabilities and autism living at Winterbourne View hospital were subjected to systematic abuse by members of staff. Most adults living at the hospital were detained under the Mental Health Act 1983.

Terry Bryan, a former nurse at the hospital, reported his concerns to Castlebeck, the provider responsible for the operation of Winterbourne View and the Care Quality Commission (CQC). His concerns were ignored, leading him to contact the BBC in 2011, who sent in an undercover reporter to work in the hospital. During this time, the undercover reporter filmed staff subjecting patients to serious harm and abuse which was shared and, subsequently, a Serious Case Review (SCR) was conducted.

Using the evidence collected by the undercover reporter, South Gloucestershire Council were duty bound to hold a SCR and enable the closure of the service. 

What went wrong?

Contributory factors to the abuse and neglect identified by the SCR were:

  • Lack of accountability: Castlebeck, who were responsible for running the hospital, failed to provide sufficient oversight of the service and accountability for running the service safely.
  • Neglect to check suitability of services: NHS South of England funded and placed patients in the service without checking the service was safe.
  • Lack of efficient record keeping: Patients attended accident and emergency 78 times, though the hospital had not recorded the high number of attendances in a short period of time.
  • Lack of justification for actions: Primary Care Trusts had noted extensive use of physical restraint and sedatives without justification. This information was not shared with the Safeguarding Adults Board (SAB).
  • Poor safeguarding systems: Between January 2008 and May 2011, 40 safeguarding alerts were reported to the Safeguarding Adults Board though no action was taken, which reflected poor safeguarding systems.
  • Failure to respond to reports: CQC failed to respond to the reports made by Terry Bryan, as assumptions were made that Castlebeck and the SAB were responding appropriately.
  • Lack of belief of complaints: Patients had complained to their families, staff, manager at the hospital and other professionals, though were not believed.

Actions for improvement

Following the findings of the SCR, the following improvements and actions were taken to reduce the reoccurrence of events at Winterbourne View:

  • Where possible people with learning disabilities and autism should be supported in the community. This promotes control and empowers adults with support needs whilst improving their visibility to services. The Transforming Care programme (2015) and Building the right support (2015) support the improvement and development of improved community care services for adults with learning disabilities.
  • When an adult is hurt, ill or known to the police, the organisation that has funded their placement must be informed.
  • Increased unannounced inspections by the CQC to gain a better, realistic view of a service.
  • Improved responses to reports of abuse received by CQC, improved responses and partnership working with organisations.
  • Improved communication channels between organisations and alerting procedures to allow for early interventions where abuse and neglect is suspected. Improved commitment to share information where there are concerns.

Read the full report here.