Regulator finds catalogue of failings at Bristol centre exposed by television documentary

Winterbourne View, the learning disabilities hospital exposed by a BBC Panorama programme earlier this year, was guilty of “a systemic failure to protect people [and] to investigate allegations of abuse,” the health watchdog for England, the Care Quality Commission, has said.

The alleged abuse of patients revealed by Panorama’s secret filming at the Bristol assessment and treatment centre has led to an investigation by the commission of all services run by Castlebeck Care, Winterbourne View’s owner, and the arrest of 12 people (BMJ 2011;342:d3482, doi:10.1136/bmj.d3482).

The commission has admitted that it failed to act quickly enough after Terry Bryan, a senior nurse at the hospital, first drew its attention to what was happening some in December last year, some six months before the Panorama programme was aired, on 31 May.

In a new report on the scandal the commission lists a catalogue of failings at Winterbourne View, which was closed down in June. In all, it says, it failed to meet 10 essential standards with which care providers must comply. These included a failure to protect its patients against risk, “including risks of unsafe practice by its own staff,” and failure to report serious injuries and incidents where patients went missing.

The report also says that some staff members were too ready to use restraint rather than considering alternatives. In addition, the hospital recruited staff with no background in care services; references were not always checked; and training and supervision were inadequate.

The report was a “damning indictment of the regime at Winterbourne View,” said the commission’s director of operations, Amanda Sherlock. “It is now clear that the problems were far worse than were initially indicated by the whistleblower,” she said.

The commission had effectively been misled by the hospital, she said. “If we had been told about all these things, we could have taken action earlier. We will now consider whether it would be appropriate to take further legal action.”

It was not true that the commission had failed to act on the whistleblower’s warnings, she added. It was aware of the concerns raised but believed that local agencies were dealing with them.

But Ms Sherlock accepted that the commission should have contacted the whistleblower directly—and this omission would be one of the issues to be looked at in an independent serious case review into the role of all responsible agencies.

In addition, the commission is planning a programme of random, unannounced inspections of all 150 learning disabilities establishments around the country that are similar to Winterbourne View.

It has also completed its review of all 24 locations owned by Castlebeck Care, the results of which will be published at the end of the month. It has already expressed concern about three of these: Arden Vale in Meriden, West Midlands, Croxton Lodge in Melton Mowbray, Leicestershire, and Rose Villa in Bristol. A number of staff from Arden Vale and Rose Villa have been suspended.